BMJ：脊椎推拿术是否能够治疗颈痛展开激烈辩论

一直以来，关于脊椎推拿术的医学功效存在巨大分歧，近日，刊登在国际著名杂志British Medical Journal上的两篇文中，研究者对于脊椎推拿术治疗颈痛是否该废止进行了激烈的辩论。

脊椎推拿术（Spinal manipulation）一种涉及推拿腰椎、颈椎来减小背痛、颈痛或者其它肌肉疼痛的应用技术，研究者Neil和其同事认为颈椎推拿可能会引发潜在的严重并发症，而且这种技术并不必要以及不太明智。他们提供了一些关于神经血管损伤和颈椎推拿直接相关的证据，这种损伤包括椎动脉破裂和中风。

研究者Neil指出，关于颈椎推拿相关随机试验的询证医学进展只能作为一种独立性的治疗方法，推拿仅仅可以适度地减缓疼痛，假的推拿技术和肌肉放松技术并不能提供长期的缓解颈痛的效应。另外近日一项试验也加强了研究者Neil的观点，试验表明，相比其它物理干预疗法如锻炼，推拿术并不是最好的，而且在临床上也并不一定必须，突发事件及缺乏其独特性最终可以导致，推拿术治疗颈痛终将被废止。

但是研究者David Cassidy和其同事反对Neil的说法，他们表示，颈椎推拿术对于病人治疗非常有价值。他们也提供了证据，证据显示推拿术对于病人治疗颈痛表现出很好的疗效，而且研究者David对于推拿术和中风之间的偶然关系提出质疑。结合近日的随机试验结果，结果中包括推拿术作为颈痛的治疗方法的结果、其它运动干预疗法如锻炼。

然而，研究者表示，病人首选的肯定是疗法的风险和益处，目前并没有一线的治疗方法，相比推拿术，运动疗法并没有表现出过多的安全性和有效性。因此，研究者David总结道，脊椎推拿术不应被废除，应该在其治疗颈痛的移除和害处方面提供更为充足和严格的数据，才能决定脊椎推拿术的利弊。

doi:10.1136/bmj.e3679
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Should we abandon cervical spine manipulation for mechanical neck pain? Yes

Benedict M Wand, associate professor1, Peter J Heine, research fellow2, Neil E O’Connell, lecturer3

Benedict Wand and colleagues argue that the risks of cervical spine manipulation are not justified, but David Cassidy and colleagues (doi:10.1136/bmj.e3680) think it is a valuable addition to patient care Cervical spine manipulation (a high velocity, low amplitude, end range thrust manoeuvre) is a common treatment option for mechanical neck pain yet may carry the potential for serious neurovascular complications, specifically vertebral artery dissection and subsequent vertebrobasilar stroke. The non-superiority of manipulation to alternative treatments, coupled with concerns regarding safety, renders cervical spine manipulation unnecessary and inadvisable. The controversy surrounding the association between manipulation and neurovascular complications is longstanding and not fully resolved, partly because it is difficult to obtain conclusive evidence on rare adverse events. What can be accepted is that the incidence of vertebral artery dissection is low, with estimates between 1 (95% confidence interval 0.5 to 1.4) and 1.7 (1.1 to 2.3) per 100 000 person years in the United States.1 The estimates for stroke resulting from vertebral artery dissection are lower still, ranging from 0.75 to 1.12 per 100 000 person years,2 and many are unlikely to be the result of cervical …

doi:10.1136/bmj.e3680
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Should we abandon cervical spine manipulation for mechanical neck pain? No

J David Cassidy, professor 1, Gert Bronfort, professor2, Jan Hartvigsen, professor3

Benedict Wand and colleagues (doi:10.1136/bmj.e3679) argue that the risks of cervical spine manipulation are not justified, but David Cassidy and colleagues think it is a valuable addition to patient care Manipulation of the cervical spine should not be abandoned. Recently, an international multidisciplinary task force endorsed manipulation as one of several firstline treatments for neck pain, whiplash, and related headaches based on a systematic review of randomised clinical trials of interventions and research on adverse events.1 They also published an original decision analysis model examining drugs, exercise, mobilisation, and manipulation for neck pain, including summary estimates on benefits and harms, and incorporating patient preferences using the standard gamble method.2 Overall, there was no clear winner when the objective was to maximise quality adjusted life. Another systematic review on conservative interventions for acute neck pain found that manipulation, multimodal physical therapy, neck exercises, and drugs (orphenadrine/paracetamol combined) all had significant short term effects on pain compared with placebo.3 In addition, acupuncture and manipulation had significant short term effects on disability compared with placebo. Thus the evidence clearly suggests that manipulation benefits patients with neck pain. Furthermore, a recent high quality trial found spinal manipulation more effective for acute and subacute neck pain, over both the short and long term, than …