OBJECTIVE: To provide a qualitative systematic review of the risk of spinal manipulation in the treatment of lumbar disk herniations (LDH) and to estimate the risk of spinal manipulation causing a severe adverse reaction in a patient presenting with LDH. DATA SOURCES: Relevant case reports, review articles, surveys, and investigations regarding treatment of lumbar disk herniations with spinal manipulation and adverse effects and associated risks were found with a search of the literature. DATA SYNTHESIS: Prospective/retrospective studies and review papers were graded according to quality, and results and conclusions were tabulated. From the data published, an estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or cauda equina syndrome (CES) in patients presenting with LDH was calculated. This was compared with estimates of the safety of nonsteroidal anti-inflammatory drugs (NSAIDs) and surgery in the treatment of LDH. RESULTS: An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million. CONCLUSION: The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.
Reprinted from the Journal of Manipulative and Physiological Therapeutics with copyright permission from the National University of Health Sciences.

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