No increased risk of spinal cerebrospinal fluid leak after spinal manipulative therapy: A retrospective cohort study

Spinal cerebrospinal fluid (CSF) leaks, a rare but debilitating condition, have been described following spinal manipulative therapy (SMT) in case reports. However, the nature of the potential association between SMT and CSF leak is uncertain, and symptoms such as neck pain or headache may reflect preexisting leaks rather than effects of SMT.

To test the hypothesis of no significant association between SMT and spinal CSF leak, comparing chiropractic SMT recipients to matched controls undergoing physical therapist-supervised therapeutic exercises (PTE).

We searched a health-records-based U.S. dataset (TriNetX, LLC) for adults with spinal disorders receiving an index event of (1) SMT or (2) PTE without SMT from 2005 to 2024, excluding those with preexisting CSF leaks and related conditions, using propensity matching to minimize confounding. Our primary outcome was the risk ratio (RR) of spinal CSF leak occurring within 2-month follow-up. A secondary composite outcome included the diagnosis of spontaneous intracranial hypotension in addition to the primary outcome.

After matching, 89,042 patients remained per cohort. There was no significant association between SMT and spinal CSF leak incidence or risk compared to PTE (both cohorts: 0.03% [95% confidence interval: 0.02%-0.04%]; RR = 0.85 [0.49-1.49]; p = .572). Adding spontaneous intracranial hypotension to the primary outcome yielded similar results.

The present findings suggest chiropractor-administered SMT does not increase the risk of spinal CSF leak in adults with spinal disorders relative to PTE. Although our analysis focused on chiropractor-delivered SMT, the findings could plausibly apply to SMT delivered by other clinician types, warranting further research. Given the overlapping symptoms of CSF leak and musculoskeletal neck pain or headache, clinicians who manage spinal disorders should be aware of this condition.