To the Editor: 

I read Dr Seffinger's review¹ of the Nee et al article² about nerve-related arm and neck pain with great interest. Cervical manipulation has been controversial for many years, particularly regarding potential complications.^3-7 I believe it is incumbent on all osteopathic physicians and osteopaths to be aware of the risks of cervical spine manipulation, particularly high-velocity techniques, and specifically in patients who present with radicular complaints. 

I am concerned that Dr Seffinger's review of the 2012 article² may lead to some confusion about the indications for use of manual treatment or therapy in various cervical conditions. Nee et al² discuss manual therapy for nerve-related neck and arm pain,yet Dr Seffinger discusses such treatment for cervical radiculopathy,¹ which may be entirely different from the neck and arm pain. In addition, one of the inclusion criteria required pain reproduction during a “neurodynamic test for the median nerve” by wrist extension,² which introduces another variable that is not necessarily related to cervical radiculopathy. This criterion adds more confusion and less specificity to the proposed treatment regarding the indications. In other words, what is the condition that is actually being managed by the manipulation—what the authors² term neural tissue management? It is important for practitioners to be mindful that equal reflexes and normal strength do not necessarily confirm the absence of a serious underlying condition.⁸ 

The causes of neck pain are multifactoral, and regardless of the source of symptoms, the pain may remain localized or refer to the upper limb.⁸ Serious conditions can masquerade as less ominous disorders.⁸ Local muscular, ligamentous, or joint conditions certainly respond well to manual treatments.⁹ However, when disk protrusions compress nerve roots or the spinal cord, manipulation of the spine can become dangerous and counterproductive.^3-7 Known complications from cervical spine manipulation include vertebrobasilar insufficiency or stroke, lateral medullary infarction, internal carotid artery dissection, cerebral infarct, cervical myelopathy, cervical radiculopathy, long thoracic nerve palsy, diaphragmatic palsy, central retinal artery occlusion, cervical fracture or dislocation, epidural hematoma, intervertebral disk herniation, and tracheal rupture.^3-7 In fact, death can result from inappropriate manipulation.^3-7 Therefore, it is essential to determine a specific diagnosis before initiating treatment. 

The use of advanced imaging and electrodiagnosis may be essential in patients who present with radicular features, because such testing can identify compromised neural structures and help guide appropriate management.⁸ The fact that patients treated in this study “safely receive short-term relief” is concerning, because offering manipulation as the initial treatment may delay a complete workup and more optimal long-term care.