Can manipulation make my lower back pain sciatica worse?

In a word, yes.  There are risks with pretty much any clinical intervention, and the risks from manipulation are probably well-known and established, given that there have been manipulative therapists of one type or another around for over a 100 years.

The most common unwanted effect of manipulation is just feeling a bit more sore for a day or so after treatment.  Approximately half of all people will experience this. However most people are happy to tolerate this if they feel better after that initial increase in pain.

At the other end of the spectrum, the most serious side-effects include some pretty horrendous outcomes, but these are exceptionally uncommon, and the risk of these should be hugely reduced by your clinician taking a very thorough case-history (lots of questions about your general health as well as questions about your back), and by undertaking a rigorous examination of your back and related bits (sometimes includes an abdominal examination for instance).

Before we dive into the gruesome details, remember that the chances of these things happening as a result of manipulation are very remote and where possible I’ll give a figure showing the risk.

Ruptured Abdominal Aortic Aneurysm (AAA)

This would be a really really bad outcome, as it can rapidly lead to death. The main artery in your abdomen can develop a weakness in the wall, leading to a bulge in the artery which in a very small number of people can lead to it bursting.  As undergraduates we were taught that the merest hint of an abdominal aortic aneurysm (AAA) was an absolute contra-indication to lumbar spinal manipulation i.e. if you think your patient may have an AAA, don’t manipulate their lower back! 3 in 100,000 deaths are caused by AAA. Note that these are most commonly found in men over 65 years of age.  I could find no records of spinal manipulation leading to rupture of an AAA, so I’m not sure why I even mention it, other than as a nod to my lecturers 30 years ago!

Prolapsed Intervertebral Disc

It is certainly possible to imagine that manipulation of a disc which is hanging by a thread could lead to that disc herniating or prolapsing.  It’s also possible that such a weakened disc may not be causing any symptoms which would give the clinician a warning to go more carefully.  It’s difficult to find any reliable figures for an estimated risk for this, but one researcher puts the figure at 1 in 3.7 million manipulations, another at 1 in 400,000.

Cauda Equina Syndrome (CES)

This is as a result of a prolapsed intervertebral disc.  A large piece of disc bulges/prolapses into the space occupied by a number of nerves (referred to as the Cauda Equina).  Pressure on these nerves causes Cauda Equina Syndrome.  There are a number of nasty effects from this, not least severe pain in the legs, and difficulty controlling bladder and bowels.  The risk of CES subsequent to spinal manipulation is closer to the 1 in 3.7 million figure.

Compare the above figures with the risk of taking Non-steroidal anti-infammatories (NSAIDs) e.g. ibuprofen, naproxen, voltarol, over a long period. Researchers in Oxford claimed that long-term use carried a 1 in 2000 risk of death, and that NSAIDs are likely the cause of 2000 deaths in the UK annually.  Note that this was long-term ingestion of these medications, whereas above we are talking about the risk of a single manipulation.  I’m just trying to give some context.   Perhaps a more appropriate comparison is with surgery for lower back problems.  Laminectomy carries a 1 in 1000 risk of nerve root damage, resulting in lasting nerve pain and a 1 in 10,000 risk of Cauda Equina Syndrome.

If you’re at all concerned about risks, discuss this with your clinician, and there are always other techniques and approaches that can be taken – “there are more ways than one to skin a cat”!  Or, if you’d like to set up a call, just email reception

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