Clinical UM Guideline

This document addresses the use of manipulation under anesthesia of the spine. This document also addresses the use of manipulation under anesthesia of joints other than the knee and shoulder. Anesthesia types may include local, regional, intravenous (IV) monitored sedation, and general.

Note: Please see the following related documents for additional information:

• CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation
• CG-SURG-09 Temporomandibular Disorders
• CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures

Medically Necessary:

Manipulation under anesthesia of the spine is considered medically necessary for the treatment of vertebral fracture, complete dislocation of the spine, or acute traumatic incomplete dislocation (subluxation) of the spine.

Not Medically Necessary:

Manipulation under anesthesia of the spine is considered not medically necessary for all other diagnoses not listed above.

Manipulation under anesthesia of any other joint not listed above as medically necessary, except for the knee or shoulder, is considered not medically necessary.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Spine
When services are Medically Necessary:

When services are Not Medically Necessary:
For the procedure code listed above for all other diagnoses not listed.

Other joints (excluding knee and shoulder)
When services are Not Medically Necessary:
For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Manipulation refers to the use of a variety of manual techniques to adjust the spinal column and joints, improve the range of motion of the joints, stretch and relax connective tissue and muscles, and promote overall relaxation. It can be used in conjunction with anesthesia. With anesthesia, the individual is less apprehensive and the anesthesia allows for reduced muscle tone and protective reflex mechanisms.

Spine

Manipulation under anesthesia of the spine has been proposed as a treatment modality for spinal dysfunction. This procedure is typically performed in one single session. Some chiropractors, with the assistance of anesthesiologists, have also employed this technique to alleviate acute and chronic neck and back pain.

Manipulation under anesthesia of the spine is considered an established treatment option for vertebral fracture, complete dislocation of the spine, or acute traumatic incomplete dislocation (subluxation) of the spine and will not be discussed further. Therefore, this discussion will focus on manipulation under anesthesia of the spine as a treatment of chronic back pain, other musculoskeletal disorders and the pain associated with incomplete dislocation.

As with any treatment of pain, controlled clinical trials are considered particularly important to isolate the contribution of the intervention and to assess the extent of the expected placebo effect. In a case series, West and colleagues (1999) reported on 177 individuals with acute and chronic back pain who had failed prior therapy. The individuals were treated with three sequential manipulations under intravenous sedation, followed by 4 to 6 weeks of further chiropractic spinal manipulation. At the 6-month follow-up, there was a 60% improvement in visual analog scale scores. However, this uncontrolled study cannot isolate the contribution of the spinal manipulation under anesthesia; treatment effect could also be related to the placebo effect, the effect of continued chiropractic therapy, or the natural history of the condition.

Palmieri and Smoyak (2002) evaluated the efficacy of manipulation under anesthesia using a self-reported pain questionnaire in a convenience sample of those undergoing spinal manipulation compared to conventional chiropractic treatment. The pain scales decreased by 50% in those treated with spinal manipulation under anesthesia compared to a 26% decrease in those receiving conventional treatment. The lack of a true control group limits interpretation of this study. Similarly, this literature does not permit scientific interpretation.

In a prospective cohort study of 68 individuals with chronic low back pain, Kohlbeck and colleagues (2005) measured changes in pain and disability for those with low back pain who received spinal manipulation with intravenous analgesia and sedation and compared these to changes in a group only receiving spinal manipulation. Individuals with pain caused by a fracture were excluded. All individuals received an initial 4- to 6-week trial of spinal manipulation, after which 42 individuals received supplemental spinal manipulation under anesthesia and the remaining 26 individuals continued with spinal manipulation without anesthesia. Low back pain and disability measures favored the spinal manipulation under anesthesia group over the spinal manipulation only group at 3 months. This difference narrowed at 1 year. The investigators concluded spinal manipulation under anesthesia appears to offer some improvement in low back pain and disability. However, the investigators noted, “improvements may not endure,” and “the clinical changes observed are not necessarily caused by SMUA and large randomized controlled trials are necessary to determine effectiveness.”

In 2014, Peterson and colleagues reported on 30 individuals with chronic neck pain (n=13) or chronic back pain (n=17) who after receiving conservative therapy without relief had a single session of manipulation under anesthesia. Pain was assessed using a numeric rating scale (NRS) and the Bournemouth Questionnaire (BQ) at 2 weeks and at 1 day prior to manipulation under anesthesia. At 2 weeks and 4 weeks following the manipulation under anesthesia, the Patient's Global Impression of Change (PGIC) (primary outcome measure), the NRS for low back pain/neck pain and the BQ were collected by telephone interview. At the 2 week assessment, 52% of participants reported clinically relevant improvement with 45.5% of participants reporting improvement after 4 weeks. In this study, improvement was defined as responses of much better or better on the PGIC scale. No adverse events from the manipulation under anesthesia were reported. While participants reported improvement at 4 weeks following manipulation under anesthesia, further studies are required with long term outcomes to effectively evaluate efficacy of manipulation under anesthesia for chronic neck or back pain.

Manipulation under anesthesia of the spine may be performed in two general settings; for example, as a closed treatment of vertebral fracture or complete dislocation, or as a form of treatment of the pain associated with incomplete dislocation, that is, subluxation. In the latter setting, spinal manipulation or adjustment under anesthesia is intended to overcome the conscious individual’s protective reflex mechanisms, which may limit the success of spinal manipulation in the conscious individual. While general anesthesia is typically used for the closed treatment of vertebral fracture or complete dislocations, spinal manipulation for the treatment of incomplete dislocations typically uses either conscious sedation or regional anesthesia. A low velocity/high amplitude technique may be used in contrast to the high velocity/low amplitude technique used in the typical spinal adjustment in the conscious individual.

At this time, evidence from the available peer-reviewed literature does not support manipulation under anesthesia of the spine in the absence of vertebral fracture, complete dislocation, or acute traumatic incomplete dislocation (subluxation) as a treatment for pain that is in accordance with generally accepted standards of medical practice.

Other Joints
Manipulation under anesthesia has also been suggested as a treatment for conditions of other joints such as the elbow, wrist, hand, finger, pelvis and ankle. Current peer-reviewed literature includes retrospective chart reviews and single case series. There are no controlled studies or any studies reporting long-term follow-up with outcomes. At this time there is insufficient evidence in peer-reviewed medical literature to establish and support the use of manipulation under anesthesia for other joints such as the elbow, wrist, hand, finger, pelvis and ankle as treatment that is in accordance with generally accepted standards of medical practice.

Dislocation: The displacement of a bone from its normal position, which can be classified as either complete or incomplete. This distinction may be made with imaging studies.

Subluxation: A condition in which the bony surfaces of a joint no longer face each other exactly but remain partially aligned. This is also known as a partial or incomplete dislocation.

Peer Reviewed Publications:

1. Kohlbeck FJ, Haldeman S, Hurwitz EL, Dagenais S. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manipulative Physiol Ther. 2005; 28(4):245-252.
2. Palmieri NF, Smoyak S. Chronic low back pain: A study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther. 2002; 25:E8-E17.
3. Peterson CK, Humphreys BK, Vollenweider R, et al. Outcomes for chronic neck and low back pain patients after manipulation under anesthesia: a prospective cohort study. J Manipulative Physiol Ther. 2014; 37(6):377-382.
4. West DT, Mathews RS, Miller MR, et al. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther. 1999; 22(5):299-308.

Manipulation under Anesthesia

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