Search

Prior research has identified an association between cauda equina syndrome, a severe form of lumbosacral nerve root injury, and constipation. However, it is not well known if this association also applies to those with the more commonplace lumbosacral radiculopathy (LSR), which most often results from lumbar degenerative conditions. This study will investigate the association between LSR and constipation. We hypothesize that those with LSR have a greater odds of developing constipation than those with nonradicular low back pain (LBP). In this study we will utilize a multisite national electronic health records-based network (TriNetX) to query two cohorts of LBP patients: radicular (LSR) and nonradicular LBP, then compare these cohorts using propensity score matching (PSM) to control for covariates and determine the odds of developing constipation over a 1-year follow-up. Exclusions from both cohorts will include severe pathological causes of LSR such as infection and cancer, and inflammatory bowel disease that may trigger constipation. Results will be calculated in terms of odds ratios and risk ratios with 95% confidence intervals.

Low back pain (LBP) is the most common cause of non-urgent emergency department (ED) visits, and represents a condition commonly treated by chiropractors. Limited research has examined the association between receiving chiropractic spinal manipulative therapy (SMT) and ED utilization. This study will investigate the association between receiving SMT and ED utilization in adults with non-urgent low back pain (LBP). We hypothesize that recipients of chiropractic SMT will have a reduced odds of visiting the ED in a 1-year window after the index date of LBP diagnosis, which will be maintained after controlling for confounders. This study will utilize a large national multicenter electronic health records (EHR) based network (TriNetX) to identify patients age 18-89 with incident non-urgent LBP receiving or not receiving chiropractic SMT, and record the presence of a low-back-related ED visit within 1-year follow-up. Exclusions from both groups will include urgent and emergent low-back-related diagnoses. Propensity score matching (PSM) will be used to control for differences between cohorts. Measures of association will include odds ratios and risk ratios with 95% confidence intervals.

Background: Lumbar magnetic resonance imaging (MRI) is often overutilized in those with low back pain (LBP), associated with overtreatment, and does not improve health outcomes. This study will be the first to investigate the association between utilization of chiropractic spinal manipulative therapy (SMT) for radicular low back pain (LBP) and MRI utilization. We hypothesize that adults with incident radicular LBP receiving chiropractic SMT will have reduced odds of undergoing a lumbar MRI over a 6-week follow-up window as the primary outcome as well as at 6-months and 1-year, and findings will be maintained after controlling for key confounding variables. Methods: A national database of aggregated electronic health records (TriNetX) will be queried for adults age 20-70 with incident radicular LBP with a search window January 1, 2011 to one year preceding the search date. Patients with lumbar radiograph, computed tomography, MRI or a diagnosis warranting early appropriate MRI in the preceding 90 days will be excluded. Propensity score matching will be used to control for variables associated with lumbar MRI utilization. The odds of lumbar MRI at 6-week, 6-month, and 1-year follow-up windows following the index date of LBP diagnosis will be calculated. Results: Measures of association will include the number and percentage of patients undergoing lumbar MRI in each cohort and odds ratios with 95% confidence intervals and p-values for each follow-up window before and after propensity matching. Conclusions: This study will utilize a large propensity-matched sample to evaluate lumbar MRI utilization in recipients of chiropractic SMT relative to other forms of care. The results of this study will serve as a marker of MRI guideline concordance in the management of patients with radicular LBP.

While prior studies have found that recipients of chiropractic spinal manipulative therapy (SMT) have reduced odds of opioid prescription, no research has examined the association between SMT and benzodiazepine (BZD) prescription. As a primary outcome, we hypothesize that utilization of chiropractic SMT for radicular low back pain (LBP) will be associated with reduced odds of a BZD prescription over a 12-month follow-up window after controlling for confounding variables. We will also explore BZD prescription over 3- and 6-month follow-up windows. Adults age 18-49 with incident radicular LBP will be identified from a national 67-million patient electronic health records-based network (TriNetX). Using propensity score matching (PSM) to adjust for confounding variables, we will determine the odds of BZD prescription over a 3-, 6-, and 12-month follow-up window. Variables associated with increased BZD utilization such as mental health conditions will be controlled for using PSM. Serious pathology, complex etiologies of LBP, alternative sites of neurological lesions, and absolute contraindications for BZDs will be excluded. For each cohort, the number and percentage of patients with a BZD prescription will be reported, along with odds ratios with 95% confidence intervals and p-values for each time point. Sensitivity analysis using the E-value will be used to explore the impact of patient preference to avoid prescription drugs. A significant reduction in odds of BZD prescription in adults with radicular LBP receiving chiropractic SMT could suggest that this care pathway influences downstream use of BZDs.

While serious adverse events (AEs) occurring after spinal manipulative therapy (SMT) such as fracture, cauda equina syndrome, or vascular adverse events are estimated to be rare, there is a lack of large, real-world studies reporting the incidence of AEs. This retrospective study aims to examine the incidence and severity of AEs of patients receiving spinal manipulation, with the primary hypothesis that AEs of at least a severe grade will occur at an incidence of less than 1 per 100,000 SMT sessions. As a secondary outcome, independent predictors of AEs of at least a severe grade will be explored.

There is a limited understanding of the frequency at which chiropractors encounter patients with severe pathology such as fracture, infection, and malignancy. This study will be undertaken to primarily investigate the prevalence and types of serious pathology, and secondarily the clinical features of adults presenting with a new complaint of low back pain to chiropractors integrated within a multidisciplinary healthcare organization.

Introduction: Although chiropractors often treat patients with lumbar disc herniation (LDH) and lumbosacral radiculopathy (LSR) with chiropractic spinal manipulative therapy (CSMT), limited research has examined the association between this treatment pathway and the odds of undergoing lumbar discectomy. Objective: This study will examine the association between CSMT and lumbar discectomy in patients with LDH and/or LSR. We hypothesize that adults receiving CSMT for a new diagnosis of LDH or LSR will have reduced odds of lumbar discectomy over a 1-year and 2-year follow-up window compared to those receiving other care. Methods: This study will query a national electronic health records network (TriNetX) including large, academic healthcare organizations, to identify patients age 18-49 with a new diagnosis of LDH or LSR. Patients will be divided into cohorts according to receipt of CSMT. Those with prior lumbar surgery, absolute indications for surgery, lumbar spine trauma, spondylolisthesis, and scoliosis will be excluded. Propensity score matching will be used to control for variables associated with the likelihood of lumbar discectomy (e.g., demographics, body mass index). Odds of lumbar discectomy will be calculated by dividing odds in the CSMT by the other care cohort. Sensitivity analysis will examine the effect of the unmeasured variable of income. Results: The number and percentage of patients undergoing lumbar discectomy in each cohort and an odds ratio with 95% confidence intervals and p-value will be reported for 1-year and 2-year follow-up windows.

Additional file 1: Table 1. Radicular low back pain inclusion codes with Boolean “OR”. Table 2. Exclusions for both cohorts, and corresponding assessment window relative to index diagnosis of radicular low back pain. Table 3. Additional inclusion/exclusion codes based on receipt of spinal manipulative therapy. Table 4. Magnetic resonance imaging codes. Table 5. Variables to be controlled for in propensity score matching. Figure 1. Cohort propensity score before matching (left) and after matching (right). Purple is the chiropractic cohort; green is the other care cohort. The propensity scores are similar before matching and overlap even more closely after matching, with no observable difference between cohorts.

Supplementary Material 1