Response letter concerning: correctly identify practitioners and put adverse events of spinal manipulation into perspective

Dear Editor Thanks for your interest concerning our case report: Massive hematothorax after thoracic spinal manipulation for acute thoracolumbar pain, published in Orthopedic Reviews.1 Firstly we agree that chiropractics represent in general a very safe procedure. With regard to the comment of Cramer and Smith,2 we agree that the use of the correct terminology for the description of chiropractic/osteopathic procedures is problematic. In our opinion this is based on different and often synonymous use of the termini in different countries. In our case report we tried to accommodate this major concern by detailed description (please refer to lines 5 to 15 within the Case Report section: The osteopathic physician used the so called Bauerngriffmaneuver which consists of a high velocity thrust to the middle portion of the thoracic spine and the adjacent costo-vertebral joints….). As we stated in our manuscript the procedure was performed by a medical physician with additional chiropractic and osteopathic education (osteopathic physician). The spinal manipulation leading to the hematothorax was not performed by another healthcare practitioner. We are sorry that the terminus osteopathic physicain lead to your misunderstanding. Furthermore chiropractics including manipulative care is not an unlicensed profession. It represents an additional education for approbated medical doctors. Concerning the second issue of Cramer and Smith with regard to the reported frequency of adverse events we definitely agree that the majority of adverse events reported are benign and transitory. But the occurrence of serious or even life-threatening events cannot be excluded. As we stated within the discussion section the risk of adverse reactions has been reported 1 in 40,000 manipulations for mild complications and 1 in 400,000 to over millions manipulations for serious complications ranging from stroke to spinal injuries. Nevertheless we believe that it is our duty to report even of very rare side events also with emphasis on medical jurisprudence to provide quality control for future patient treatment and to minimize even these very rare risks. We still believe that chiropractics represent a safe procedure in professionalized well educated hands.