Spinal cord compression seen on MRI is not, in and of itself, a contraindication to cervical manipulation. The severity of myelopathy decides it. Compression without myelopathy, or with mild myelopathy, is not a contraindication; moderate or severe myelopathy is. An upfront diagnostic workup of history, examination and MRI is how severity is determined.

Degenerative cervical myelopathy (DCM)
Dysfunction of the cervical spinal cord caused by degenerative narrowing of the canal. Cervical spondylotic myelopathy (CSM) is by far the most common form; ossification of the posterior longitudinal ligament (OPLL) is another.
Cord compression (encroachment)
An MRI finding in which disc material, osteophyte, ligamentum flavum hypertrophy or a combination of these narrow the canal enough to obliterate the cerebrospinal fluid signal on T2-weighted images on one or more sides of the cord, or distort its shape.[1] Compression can be present with or without myelopathy. Myelopathy is a clinical diagnosis.

Cord Compression on MRI Is Common, and Often Silent

Compression of the cervical cord is a frequent incidental finding. A 2021 systematic review and meta-analysis estimated the prevalence of asymptomatic cord compression at 24.2% in healthy people undergoing MRI, higher in older groups, against 2.3% for DCM itself.[2]

Most do not develop myelopathy in the short term. In the systematic review behind the AO Spine guideline, about 8% of patients with spondylotic cord compression and no myelopathy developed it within a year, and 23% at a median follow-up of 44 months.[3] That risk is why these patients are followed, and why the image alone cannot settle the treatment question.

Is Cord Compression a Contraindication to Manipulation?

No. Compression on its own is not a contraindication; the severity of the myelopathy is what matters. The 2017 AO Spine clinical practice guideline (Fehlings and colleagues), still the current AO Spine guideline as of October 2026, treats compression without myelopathy as a condition to counsel, educate and follow, and suggests against prophylactic surgery for those patients when there is no radiculopathy.[4] Many patients with compression and no myelopathy, or with mild myelopathy, do well with chiropractic care that includes manipulation.

The Upfront Diagnostic Workup: History, Examination and MRI

Diagnosis takes all three: the MRI shows the compression, and the history and examination show whether myelopathy is present.

History

  • Age, typically over 50, with men affected more often than women.
  • Fleeting pains in the legs.
  • Sensory symptoms that are radicular in the arms but non-radicular in the legs.
  • Unsteadiness (ataxia).
  • Loss of hand dexterity: trouble with buttons, zippers and other fine tasks.
  • Bladder difficulty, a late feature.

Examination

Signs can be subtle. Look at gait (spastic, stiff-legged or scissored, with reduced arm swing), heel walking, Romberg’s sign, joint position and vibration sense, and Lhermitte’s sign; in the hands, intrinsic wasting (the “myelopathy hand”), the finger escape sign and slowed rapid alternating movements.

Reflex findings include hyperreflexia below the lesion, an inverted radial reflex, an upgoing plantar response (Babinski sign), and Hoffmann’s and Trömner’s signs, which place the lesion at C5-C6 or higher, though false positives do exist. When upper motor neuron signs appear, localize the lesion with the superficial abdominal reflexes, the scapulohumeral reflex, the jaw jerk and a sensory level, so that a brain or thoracic lesion is not mistaken for a cervical one.[1]

MRI

T2-weighted sagittal and axial images confirm where the cord is compressed, whether it is deformed, and whether there is signal change within it.

Which Patients Are at Risk of Progression?

People with asymptomatic cord compression or mild myelopathy who carry these risk factors are at increased risk of worsening. These are the clinical, imaging and functional indicators Dr. Murphy teaches:

  • Large global range of motion
  • Spondylolisthesis at the level of maximum compression
  • Kyphotic angle at the segment of maximal compression
  • Decreased signal in the spinal cord on T1 images
  • Increased signal in the spinal cord on T2 images
  • Circumferential versus transverse narrowing of the central canal
  • Diabetes
  • mJOA score below 12
  • Abnormal EMG, including sensory and/or motor evoked potentials
  • Older age
  • Cardiovascular events
  • Severe gait disturbance

The presence of several of these factors raises the likelihood of clinical progression.

Cervical manipulation is not on the list, because there is no evidence that it is a consistent cause of worsening myelopathy in these patients. In Dr. Murphy’s 2006 case series, none of the 27 patients developed new or increased neurologic symptoms or signs.[1]

Severity also predicts the course. A 2024 meta-analysis of patients managed without surgery found 91% of those with mild DCM neurologically stable at one year and 75% at five years, against 83% and 55% for moderate or severe DCM (as each study defined severity).[5]

What the 2006 Case Series Shows, and What It Does Not

Dr. Murphy’s 2006 case series, with Eric Hurwitz and Amy Gregory in the Journal of Manipulative and Physiological Therapeutics, found no new or increased neurologic symptoms or signs in any of 27 patients with cord encroachment on MRI treated with an approach that included cervical manipulation. Its primary purpose was to assess complications, for which a case series design is considered valuable.[1]

  • Patients: 27 people (18 women, 9 men, aged 23 to 65, mean 44.3) with neck and/or arm pain, seen at the Rhode Island Spine Center between March 1998 and February 2004. Encroachment was confirmed on both the MRI report and the films.
  • Severity: three had upper motor neuron signs. None had severe or acute myelopathy, and none had advanced cord signal change indicating myelomalacia.
  • Treatment: a mean of 12 treatments that included manipulation (range 2 to 32), using high-velocity, low-amplitude thrust or low-velocity muscle energy technique, as part of a broader plan of care.
  • Outcomes: in the 21 patients with follow-up data, mean patient-rated improvement at the last follow-up was 70%. Among those scored on the Bournemouth Neck Disability Questionnaire, scores improved by a mean of 23.7 points (31%), and among those scored on the single-level Numerical Pain Rating Scale, pain fell by a mean of 3.9 points.
  • Adverse events: three patients (11.1%) had increased pain lasting 1 to 4 days. There were no major complications.

The paper concludes that cord encroachment on MRI or CT “should not be considered an absolute contraindication to chiropractic cervical spine manipulation, provided the manipulation is applied by an appropriately trained and experienced practitioner, and is performed with the utmost care and skill.”

Reports of myelopathy after manipulation do exist, and the paper reviews them. Many involve other pathology, such as a fracture through an ankylosing spondylitis fusion or a metastatic mass, and some describe manipulation by a barber or a bonesetter. Because progression of myelopathy is not uncommon on its own, these reports cannot show whether the progression resulted from the manipulation or was incidental to it, though the paper accepts that injury after manipulation is possible.

Managing the Patient Once Severity Is Graded

Dr. Murphy teaches five pathways, chosen on severity, risk of progression, patient-specific factors and the practitioner’s own comfort:

  1. Monitor: periodic follow-up with neurologic examinations.
  2. Manage: treat the cervical pain as usual.
  3. Monitor and manage: treat the cervical pain as usual, with repeat neurologic examinations.
  4. Refer: to physical medicine and rehabilitation (PM&R) or to a surgeon.
  5. Manage and refer: treat the cervical pain as usual alongside a PM&R or surgical referral.

There are no hard and fast rules. Manipulation is not likely to improve myelopathy, but it can help neck pain where there is joint dysfunction. A practitioner who is not comfortable or confident with a particular patient should not proceed, and that is a sound decision in itself.

In the case series every patient was first taken slowly into the premanipulative position and asked whether it caused pain or other symptoms; if it peripheralized symptoms into the arm, a different direction was chosen.

Slight flexion of the cervical spine as a whole may let the practitioner avoid extension at the targeted level, which can add to cord compression, while keeping the flexion slight avoids increased axial stress on the cord.[1] This is the kind of reasoning taught in the Clinical Reasoning in Spine Pain framework and expected of the Primary Spine Practitioner.

Signs That Call for Prompt Referral

Progressive hand clumsiness, a significant change in gait or balance, new bladder symptoms, or new or worsening upper motor neuron signs on re-examination call for prompt referral for surgical or PM&R evaluation. Moderate to severe myelopathy calls for referral. The AO Spine guideline recommends surgery for moderate and severe myelopathy (mJOA 14 or less) and suggests surgery or a supervised trial of structured rehabilitation for mild (15 to 17), with surgery if the patient deteriorates neurologically.[4]

How Should a Medicolegal Reviewer Read These Cases?

A reviewer should read past the MRI report to the clinical record, because compression on imaging does not show that manipulation was contraindicated. The questions that matter are these:

  • Was there an appropriate history and examination?
  • Was the myelopathy absent or mild when manipulation was given, or was it moderate to severe?
  • Were signs and symptoms of moderate to severe myelopathy present and was the patient referred accordingly?

Worsening after a course of care is not, by itself, evidence that the care caused it. In patients with symptomatic DCM treated without surgery, 20% to 62% deteriorate neurologically within 3 to 6 years.[6] As with vertebral artery dissection, sequence is not necessarily causation.

Dr. Murphy’s medicolegal services apply this evidence to case review and expert testimony, and he teaches the same workup to clinicians through consulting and speaking. To discuss a case, a consultation or a talk, contact Dr. Murphy.

Frequently Asked Questions

Does manipulation treat the myelopathy itself?

No. Manipulation is not likely to improve myelopathy. In these patients its aim is neck pain where there is joint dysfunction, while the myelopathy is monitored or referred for PM&R or surgical care according to its severity.

Is low-velocity manipulation, such as muscle energy technique, safer than high-velocity manipulation when the cord is compressed?

The 2006 case series cannot say. Transient increases in pain followed high-velocity, low-amplitude manipulation, muscle energy technique and the two combined, and the sample was too small for firm conclusions. Muscle energy technique remains a reasonable choice for a patient who is uncomfortable with high-velocity manipulation, or where the risk of increased pain seems highest.

Does increased T2 signal in the cord rule out manipulation?

There are no hard and fast rules. No patients with increased T2 signal were identified in the 2006 case series. However there is no indication that increased T2 signal in and of itself contraindicates manipulation.

References

  1. Murphy DR, Hurwitz EL, Gregory AA. Manipulation in the presence of cervical spinal cord compression: a case series. J Manipulative Physiol Ther. 2006;29(3):236-244. PubMed DOI ↩

  2. Smith SS, Stewart ME, Davies BM, Kotter MRN. The prevalence of asymptomatic and symptomatic spinal cord compression on magnetic resonance imaging: a systematic review and meta-analysis. Global Spine J. 2021;11(4):597-607. PMC ↩

  3. Wilson JR, Barry S, Fischer DJ, Skelly AC, Arnold PM, Riew KD, Shaffrey CI, Traynelis VC, Fehlings MG. Frequency, timing, and predictors of neurological dysfunction in the nonmyelopathic patient with cervical spinal cord compression, canal stenosis, and/or ossification of the posterior longitudinal ligament. Spine (Phila Pa 1976). 2013;38(22 Suppl 1):S37-S54. PubMed ↩

  4. Fehlings MG, Tetreault LA, Riew KD, et al. A clinical practice guideline for the management of patients with degenerative cervical myelopathy: recommendations for patients with mild, moderate, and severe disease and nonmyelopathic patients with evidence of cord compression. Global Spine J. 2017;7(3 Suppl):70S-83S. PMC ↩

  5. Sarraj M, Hache P, Foroutan F, Oitment C, Marion TE, Guha D, Pahuta M. Natural history of degenerative cervical myelopathy: a meta-analysis and neurologic deterioration survival curve synthesis. Spine J. 2024;24(1):46-56. PubMed ↩

  6. Nouri A, Tessitore E, Molliqaj G, et al. Degenerative cervical myelopathy: development and natural history [AO Spine RECODE-DCM Research Priority Number 2]. Global Spine J. 2022;12(1 Suppl):39S-54S. PMC ↩