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Chiropractic care in general is safe when employed skillfully and appropriately. Manipulation is regarded as relatively safe, but as with all therapeutic interventions, complications can arise, and it has known adverse effects, risks and contraindications. Absolute contraindications to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include rheumatoid arthritis and conditions known to result in unstable joints. Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications include osteoporosis.[34] Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to emergency medical services; these include sudden and severe headache or neck pain unlike that previously experienced.[36]

Spinal manipulation is associated with frequent, mild and temporary adverse effects,[35][36] including new or worsening pain or stiffness in the affected region.[170] They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours;[171] adverse reactions appear to be more common following manipulation than mobilization.[172] Chiropractors are more commonly associated with serious manipulation related adverse effects than other professionals.[37] Rarely,[34] spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults[35] and children.[173] Estimates vary widely for the incidence of these complications,[171] and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern.[35] Estimates for serious adverse events vary from 5 strokes in 100,000 manipulations to 1.46 serious adverse events in 10,000,000 manipulations and 2.68 deaths in 10,000,000 manipulations.[171] Several case reports show temporal associations between interventions and potentially serious complications. Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[148][174] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy and vertebrobasilar artery stroke.[175] The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished. Many chiropractors claim that, the association between chiropractic therapy and arterial dissection is not proven. However, the causality between chiropratic neck manipulation beyond the normal range of motion and vascular accidents is probable[37] or definite.[176]

Chiropractors, like other primary care providers, sometimes employ diagnostic imaging techniques such as X-rays and CT scans that rely on ionizing radiation.[177] Although there is no clear evidence for the practice, some chiropractors may still X-ray a patient several times a year.[51] Research suggests that most chiropractors in Canada are taught and follow stringent radiography guidelines,[178] which were developed to reduce unnecessary radiography.[177]

Risk-benefit

A 2010 systematic review stated that there is no good evidence to assume that neck manipulation is an effective treatment for any medical condition and suggested a precautionary principle in healthcare for chiropractic intervention even if a causality with vertebral artery dissection after neck manipulation were merely a remote possibility.[37] The same review concluded that the risk of death from manipulations to the neck outweighs the benefits.[37] Chiropractors have criticized this conclusion, claiming that the author did not evaluate the potential benefits of spinal manipulation.[179] Edzard Ernst stated "This detail was not the subject of my review. I do, however, refer to such evaluations and should add that a report recently commissioned by the General Chiropractic Council did not support many of the outlandish claims made by many chiropractors across the world."[179] A 2009 review evaluating maintenance chiropractic care found that spinal manipulation is routinely associated with considerable harm and no compelling evidence exists to indicate that it adequately prevents symptoms or diseases, thus the risk-benefit is not evidently favorable.[180] A 2008 summary found that the best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.[181] A 2007 systematic review found that with uncertain efficacy and definite risks, the risk-benefit balance of spinal manipulation can't be positive.[35] A 2006 systematic review of systematic reviews found the risk-benefit balance does not favor spinal manipulation over other treatments like physical therapy.[129]

Cost-effectiveness

A 2011 systematic review found evidence supporting the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain; the results for acute low back pain were inconsistent.[182] A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.[183] A 2006 systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation in the United Kingdom compared favorably with other treatments for back pain, but that reports were based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain.[184] A 2005 systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention.[185] The cost-effectiveness of maintenance chiropractic care is unknown