Manipulation under Anesthesia (MUA) has been shown to be a viable approach in the treatment of chronic recalcitrant spinal pain. The results have been remarkable in many patients who have exhausted efforts using conventional models of conservative management.
“Because of the advancement of new medications and the use of conscious sedation, the anesthesia element of the MUA makes the procedure one of the most easily adaptable neuromusculo skeletal treatment modalities that manual practitioners have at their disposal for chronic and certain acute neuromuscular skeletal problems.”1
This procedure has been widely used for centuries and recently has had major improvements in its efficiency by combining it with another mode of pain management, fluoroscopically guided intra- articular injection known as MUJA.
Since the combination of these two procedures, our team of physicians, which include anesthesiologists, osteopathic physicians, and chiropractors, has successfully performed over five thousand manipulations under joint anesthesia.
Manipulation under joint anesthesia (MUJA) was presented in 1999, at the Conference of the World Federation of Chiropractic, as an alternative to office manipulation. There is literature that dates back to 1938, in which manipulation was performed following an anesthesia injection of the sacroiliac joints.2
In 1997, Nelson, Aspegren, and Bova studied the benefits of the use of epidural steroid injection and manipulation on patients with chronic low back pain.3
As described by the CPT 2003 Code 22505, spinal manipulation under anesthesia is defined as an outpatient manipulation of the posterior motor units of the spine, requiring anesthesia and designed to reduce fibroblastic proliferation and restore range of motion and visco-elasticity to the per capsular connective tissue and para vertebral musculature in areas of the spinal segmental dysfunction not amenable in office manipulation.4
Upon careful selection of the patient by the persons performing the injection and delivering the manipulation, the patient is then assessed as to what type of injection will be performed at precisely what level.
The procedure is then executed in a properly equipped surgical suite to allow for optimal setting of both injections and the manipulation being performed. Upon completion of the injection, whether it is an epidural, facet block, trans-foraminal, or sacroiliac, the manipulation under joint anesthesia is then performed. A series of facial lengthening, tendon stretching and ligamentous mobilization along with the realignment of the joint are carried through while the patient continues under conscious sedation. These results are attained by using passive stretches, myofascial release, and specific articular and adjustment procedures.
“The basic concepts behind the mobilization, manipulation, and adjusting procedures, while the patient is under a sedative/hypnotic, is to increase ligamentous, tendinous, and muscular flexibility that has not been achieved in the office therapeutic routine. Standard manipulative techniques are used, but the physiologic state of the patient is changed and the procedure is done in a controlled environment. When used on properly selected patients, it is more cost effective and more productive to the patient’s return to normal lifestyle than prolonged conservative care or possible surgical intervention.”5
The rational for using sedation is to allow those patients who cannot tolerate any use of manual techniques due to muscle guarding, spasm, severe pain, and muscle contractors to regain their activities of daily living and begin a structured regimen of home exercise.
The medication of choice used for conscious sedation is Propofol. “This medication allows the patient to not respond to the initial pain stimuli with an immediate muscle contraction. The maneuvers could then be performed without losing their end range. The natural protective mechanism are present, but slowed down temporarily, and pain is perceived at a lowered threshold and not remembered.”6
As discussed throughout this paper, MUJA is an excellent choice for patients who continue to suffer from recalcitrant pain. There is an over abundance of chronic cases which have shown no improvement with conventional approaches to neuromusculoskeletal injuries along with spinal axial pain. For this patient population, a course of manipulation under anesthesia should be considered as the next phase in their treatment prior to surgical intervention. Standardization of this protocol would allow more potential patients, who continue to suffer, a chance to get their lives back and return to the activities they enjoyed prior to their injury.
1. Gordon R. Commentary: Manipulation Under Anesthesia, Journal of Manipulative and Physiological Therapeutics. 2001 Vol. 24 Number 9.
2. Haldeman KO, Soto Hall R., The diagnosis and treatment of sacroiliac conditions by injection of procaine (Novocain). J Bone Joint Surgery 1938; 20-A :675-86.
3. Nelson L. Aspegren D, Bova C. The use of epidural injection and manipulation on patients with chronic low back pain. J. Manipulative Physiology Ther. 1197; 20: 263-6.
4. CPT 2003 American Medical Association 47-C Procedure Musculoskeletal/Surgery
5. Gordon R. Conservative. Chiropractic adjustive therapy versus MUA adjustive therapy. Florida Chiropractic J 1993;1:22-3.
6. Gordon R. Commentary: Manipulation Under Anesthesia. Journal of Manipulative and Physiological Therapeutics 2001 Vol. 24 Number 9.
Dr. Peter M. Ferraro is a 1996 graduate of New York Chiropractic College. He began early in his career specializing in the treatment of herniated disc injuries by becoming certified in the Cox Distraction techniques at National Chiropractic College. In the past four years, Dr. Ferraro has become certified in Manipulation Under Anesthesia and has performed over 5,000 MUA/MUJA treatments.
For more information, Dr. Ferraro can be reached at 973-478-2212 or at