A study estimates that over a period of decades chiropractors have utilized spinal manipulation under anesthesia (SMUA) to treat chronic back and neck pain. As an advanced form of manual therapy, SMUA is reserved for the patient whose condition has proven refractory to office-based manipulation and other modes of conservative care.

For spinal manipulation under anesthesia, what remains ambiguous despite existing guidelines is when to move a patient toward treatment. The heterogeneity of primary research and the presence of mostly lower-level evidence pose inherent challenges to clinical decision making.

Moreover, the current SMUA literature and association-based protocol documents are without a corresponding evidence-informed resource that elucidates risk versus benefit. In determining a patient’s candidacy for chiropractic treatment of an acute or chronic musculoskeletal condition, many core principles apply.

These are not unique to clinical decision-making for SMUA. However, the same obligation exists for SMUA as with any modality or intervention being considered. For acute, non-specific low back pain, clinical practice guidelines consistently recommend patient reassurance of good prognosis and educational instruction on self-care and remaining active.

As early patient advancement to SMUA stands apart from the existing literature on patient management, additional risk/benefit issues arise. The concepts that hurt do not always harm and that some patients get better with or without treatment must be given adequate consideration relative to the natural course of an injury.

At times, a patient may be predestined to receive a full complement of therapeutic services and diagnostic tests early on, only to be followed by a treatment option of “last resort” if symptoms remain after a few weeks. As a primer, a new risk classification system is introduced which may serve as a guide for use in clinical practice.

No longer can treatment standards be reliant upon anecdotal reports of satisfied patients, proclamations of the various conditions amenable to SMUA, preconceptions of permanent therapeutic benefit, a philosophy that calls for serial and multiregional treatment applications, and the fact that the procedure has had a historically good safety record.

As health care professionals committed to the public interest, chiropractors who perform or make referrals for SMUA are obligated to remain current and put forth accurate information in the public domain on the state of the evidence, known procedural contraindications/risks, and the conditions and indicators that may predict an adverse or unfavorable clinical outcome.

When chiropractors lack a comprehensive understanding of that information or advocate for the procedure by preference, patients may be unable to make informed decisions about their healthcare options in submitting to appropriate consent. With a new perspective on the evidence for SMUA, this analysis can assist clinicians who are seeking to identify key decision points in care in enhancing risk management strategies and optimizing patient outcomes.