Archived Policies - Therapy

Spinal Manipulation under Anesthesia


Effective Date:04-01-2007

End Date:05-31-2008


Spinal manipulation under anesthesia (MUA), in the absence of vertebral fracture or dislocation, is considered experimental, investigational and unproven.


In the appendicular skeleton, manipulation of the patient under anesthesia may be performed as a treatment of arthrofibrosis, particularly of the shoulder (i.e., frozen shoulder) or knee.  In the spine, MUA may be performed as a closed treatment of vertebral fracture or dislocation.  This policy does not address the treatment of vertebral fractures or dislocations. 

In the absence of vertebral fracture or dislocation, MUA performed either with the patient sedated or under general anesthesia is intended to overcome the conscious patient’s protective reflex mechanism, which may have limited the success of prior attempts of spinal manipulation or adjustment in the conscious patient.  In MUA, a low velocity or high amplitude technique may be used in contrast to the high velocity or low amplitude technique that is used in the typical spinal adjustment.  A single session of MUA may be offered, followed by a series of outpatient sessions, or a series of up to five sessions of MUA may be offered, also followed by outpatient sessions.  In some instances the MUA may be accompanied by corticosteroid injections.


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.

Several case series were identified, which included patients with cervical, thoracic and/or lumbar back pain, treated according to varying protocols.  In the largest case series, West and colleagues reported on 177 patients with back pain who had failed prior therapy.  The patients were treated with three sequential manipulations under intravenous sedation, followed by four to six weeks of further chiropractic spinal manipulation.  At six-month follow-up, there was a 60% improvement in visual analog scores.  However, this uncontrolled study cannot isolate the contribution of the manipulation under anesthesia compared to the placebo effect, the effect of continued chiropractic therapy, or the natural history of the condition.  Palmieri and Smoyak reported the results of a comparative trial in which convenience samples of patients with chronic low back pain were chosen to receive either MUA or conventional chiropractic treatment.  Self-reported outcome assessments were used to evaluate changes.  Although there was more improvement reported in the intervention group (50% decrease in pain scale) than the nonintervention group (26% decrease in pain scale), scientific conclusions cannot be drawn from this data due to selection bias, the lack of randomization, inability to isolate the treatment effect of MUA from post-MUA interventions, and small sample sizes.  In addition, as outcomes were only assessed at four weeks post MUA, the duration of the treatment effect is not known.  The authors state there is a need for large-scale studies on MUA.  Other small case series focused on the use of manipulation in conjunction with corticosteroid injections. 

In a 2002 assessment Kohlbeck and colleagues concluded that medicine-assisted spinal manipulation therapies have a relatively long history of clinical use and have been reported in the literature for over 70 years.  However, evidence for the effectiveness of these protocols remains largely anecdotal based on case series mimicking many other surgical and conservative approaches for the treatment of chronic pain syndromes of musculoskeletal origin. 

In a prospective cohort study of 68 chronic low-back pain patients, Kohlbeck et al. (2005) measured changes in pain and disability for low back pain patients receiving treatment with medication-assisted manipulation and compared these to changes in a group receiving only spinal manipulation therapy.  Outcomes were measured using the 1998 version 2.0 American Association of Orthopedic Surgeons, Council of Musculoskeletal Specialty Societies and the Council of Spine Societies Outcomes Data Collection Instruments.  The primary outcome variable was change in pain and disability.  All patients received an initial four to six-week trial of spinal manipulation therapy, after which 42 patients received supplemental intervention with medication-assisted manipulation and the remaining 26 patients continued with spinal manipulation therapy.  Low back pain and disability measures favored the medication-assisted manipulation group over the spinal manipulation therapy-only group at three months.  This difference attenuated at one year.  These investigators concluded that medication-assisted manipulation appears to offer some patients increased improvement in low back pain and disability, and stated that further investigation of these apparent benefits in a randomized clinical trial is warranted.

An updated search of the MEDLINE database was conducted through December 2006. This search failed to identify any additional published studies that alter the conclusions reached above.


Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.



Medicare Coverage:

The information contained in this section is for informational purposes only.  HCSC makes no representation as to the accuracy of this information.  It is not to be used for claims adjudication for HCSC plans.

Medicare (CMS) does not have a national position on this service. It is subject to local carrier discretion. Please refer to the local carrier for more information.


Ben-David, B., and M. Raboy.  Manipulation under anesthesia combined with epidural steroid injection.  Journal of Manipulative and Physiological Therapeutics (1994) 17:605-9.

Aspegren, D.D., Wright, R.E., et al.  Manipulation under epidural anesthesia with corticosteroid injection: two case reports.  Journal of Manipulative and Physiological Therapeutics (1997) 20(9):618-21.

West, D.T., Mathews, R.S., et al.  Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia.  Journal of Manipulative and Physiological Therapeutics (1999) 22(5): 299-308.

Kohibeck, F.J., and S. Haldeman.  Technical assessment.  Medication assisted spinal manipulation.  Spine Journal (2002) 2(4): 288-302.

Palmieri, N.F., and S. Smoyak.  Chronic low back pain: a study of the effects of manipulation under anesthesia.  Journal of Manipulative Physiological Therapeutics (2002) 25(8): E8-E17.

Childs, J.D., Fritz, J.M., et al.  A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation:  a validation study.  Annals of Internal Medicine (2004 December 21) 141(12): 920-8.

Kohl, F.J., Haldeman, S., et al.  Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain.  Journal of Manipulative Physiological Therapeutics (2005) 28(4): 245-252.

Buchmann, J., Wende, K., et al.  Manual treatment effects to the upper cervical apophysial joints before, during, and after endotracheal anesthesia:  a placebo-controlled comparison.  American Journal of Physical Medicine and Rehabilitation (2005 April) 84(4): 251-7.

Fritz, J.M., Whitman, J. M., et al.  Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain.  Archives of Physical Medicine and Rehabilitation.  (2005 September) 86(9): 1745-52.

Spinal Manipulation under Anesthesia.  Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Manual (2006 March 7) 8.01.40.

Policy History:

Archived Document(s):

Title:Effective Date:End Date:
Manipulation Under Anesthesia08-01-201907-14-2020
Manipulation Under Anesthesia06-15-201807-31-2019
Manipulation Under Anesthesia12-01-201706-14-2018
Manipulation Under Anesthesia09-01-201611-30-2017
Manipulation Under Anesthesia06-15-201508-31-2016
Manipulation Under Anesthesia07-01-201406-14-2015
Manipulation Under Anesthesia01-15-201306-30-2014
Spinal Manipulation under Anesthesia06-01-200801-14-2013
Spinal Manipulation under Anesthesia04-01-200705-31-2008
Spinal Manipulation under Anesthesia01-23-200403-31-2007
Manipulation of Spine Requiring Anesthesia, Any Region05-01-199601-22-2004
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