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Spinal manipulative therapy is commonly used for lumbar spine disorders, but case reports have raised concerns it may precipitate cauda equina syndrome. One cohort study suggested no increased risk, although it did not focus on patients with lumbar spine disorders pertinent to cauda equina syndrome, such as disc herniation, stenosis, or radiculopathy\/sciatica.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>\n                      To address this evidence gap, we tested the null hypothesis that there is no increased risk of cauda equina syndrome following spinal manipulative therapy among adults with these lumbar spine disorders compared to matched controls receiving physical therapist\u2013led therapeutic exercise (\n                      <jats:styled-content style=\"fixed-case\">PTE<\/jats:styled-content>\n                      ).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Using a retrospective cohort design, we queried a U.S. research network (\n                      <jats:styled-content style=\"fixed-case\">TriNetX<\/jats:styled-content>\n                      ) including patients aged \u226518\u2009years with a lumbar spine disorder and excluding those with preexisting cauda equina syndrome, incontinence, serious spinal pathology, and recent spine surgery\/injection. Data spanned 2005\u20132025. Patients were divided into cohorts: (1) spinal manipulative therapy administered by a chiropractor or (2)\n                      <jats:styled-content style=\"fixed-case\">PTE<\/jats:styled-content>\n                      without spinal manipulative therapy. Propensity score matching controlled for confounding variables. Outcomes included the risk ratio of cauda equina syndrome (primary), and bladder catheterization and bowel incontinence as additional cauda equina syndrome markers (secondary).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      After matching, there were 34,376 patients in each cohort. Comparing the spinal manipulative therapy cohort to\n                      <jats:styled-content style=\"fixed-case\">PTE<\/jats:styled-content>\n                      cohort, the incidence and risk of cauda equina syndrome did not significantly differ (risk ratio=0.88 [95% CI, 0.43\u20131.79];\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u2009.715). The risk of bladder catheterization (risk ratio\u2009=\u20090.50 [95% CI, 0.39\u2013 0.64];\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u2009.001) and fecal incontinence (risk ratio\u2009=\u20090.50 [0.37, 0.68];\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u2009.001) was significantly lower in the spinal manipulative therapy cohort.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Among adults with lumbar disc herniation, stenosis, and\/or radiculopathy, we did not identify an association between spinal manipulative therapy and an increased risk of cauda equina syndrome.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/pmrj.70071","type":"journal-article","created":{"date-parts":[[2026,1,3]],"date-time":"2026-01-03T10:53:44Z","timestamp":1767437624000},"page":"723-734","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Chiropractic spinal manipulative therapy versus physical therapist\u2010led exercise and the risk of cauda equina syndrome in adults with lumbar disc herniation, stenosis, or radiculopathy"],"prefix":"10.1002","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4714-1076","authenticated-orcid":false,"given":"Robert J.","family":"Trager","sequence":"first","affiliation":[{"name":"Connor Whole Health University Hospitals Cleveland Medical Center  Cleveland Ohio USA"},{"name":"Department of Family Medicine and Community Health Case Western Reserve University School of Medicine  Cleveland Ohio USA"},{"name":"Department of Biostatistics and Bioinformatics Clinical Research Training Program Duke University School of Medicine  Durham North Carolina USA"},{"name":"Department of Orthopaedic Surgery Duke University School of Medicine  Durham North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4175-3135","authenticated-orcid":false,"given":"Anthony N.","family":"Baumann","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation University Hospitals Cleveland Medical Center  Cleveland Ohio USA"},{"name":"College of Medicine Northeast Ohio Medical University  Rootstown Ohio USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9494-6558","authenticated-orcid":false,"given":"Romeo\u2010Paolo T.","family":"Perfecto","sequence":"additional","affiliation":[{"name":"Department of Biostatistics and Bioinformatics Clinical Research Training Program Duke University School of Medicine  Durham North Carolina USA"},{"name":"Department of Orthopaedic Surgery Duke University School of Medicine  Durham North Carolina USA"},{"name":"Department of Whole Health Roseburg VA Health Care System  Roseburg Oregon USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4941-3645","authenticated-orcid":false,"given":"Christine M.","family":"Goertz","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery Duke University School of Medicine  Durham North Carolina USA"},{"name":"Duke Clinical Research Institute Duke University School of Medicine  Durham North Carolina USA"},{"name":"Robert J. 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