Radiology


MRI Spine Protocols
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Radiology
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Wednesday, 25 September 2013 23:32
Y
our pateint has radicular pain in the lumbosacral distribution that is status post-motor vehicle accident and you order a lumbar MRI. The report rendered by a board certified general radiologist concludes mild disc bulging at L5-S1. However, upon further review by both a neuroradiologist and yourself (once you have been certified and trained to interpret MRI), you realize the general radiologist erred and the scan reveals a protrusion-type herniation compressing the left L5 nerve root correlating to your pateint’s clinical presentation.
 
mrispineprotocalsfig1Herein lies multiple potential culprits for an inaccurate diagnosis. First, as I have discussed previously, general radiologists have a 42.2% error rate as reported by Lurie, Doman, Spratt, Tosteson, and Weinstein (2009), which makes it virtually imperitive that we, as practitioners, must take control of a critical component in diagnosing our pateints. At the very least, we must understand the basics of MRI spine interpretation to verify the findings or lack thereof. We also must be congnizant of the fact that we often rely on the MRI when ordering and delivering high velocity thrusts into our pateints. At this level, accuracy matters in determining a correct prognosis and treatment plan to ensure the safety of our patients when adjusting the spine. It is imperative for chiropractic.
 
A second factor in accurate MRI reporting is the precise acquisition of slices. Too many MRI technicians are not meticulous in positioning where the slices are taken and often catch too much of the end plates or the vertebrae, and sometimes do not catch the disc at all. After reviewing thousands of MRIs in the last few months, I can report that almost 75% of images are not done to the required standard, and in many cases radiologists must guess with incomplete image acquisitions. A case in point is image 1, which has both good and bad slice acquisitions. 
 
Referencing Figure 1, the slices should be through the disc and not catching the end plates or the vertebrae when diagnosing the disc. If we look at L5-S1 and slices 734, 735, and 736, you will notice that all of the slices catch the end plates and not one clean slice of the disc was acquired. If we go to the level above at L4-L5 and slices 727, 728, and 729, the top two slices are 100% through the disc (good), while 729 misses the disc entirely. Although acquisition of bone is necessary, that was not the intented purpose of that slice.
 
If we compare L5-S1 to L4-L5, it illustrates this problem in one patient. Every disc ideally should have a minimum of three clean slices through the disc without catching the end plates. There should then be slices through the bone as well to diagnose any osseous issues. The lack of clean slices is nothing more than the MRI technician “missing the target” and the radiologists accepting inferior images to interpret. In teaching hospitals, as with my patients, I demand clean slices or I mandate the center redo the scan if I feel that I am missing pathology. Should your imaging company offer 3-D technology, as mine does (a topic for another article), you can get 24 slices through one disc. However, most MRI centers do not yet have this technology available. 
 
Many will argue that, based on either the scout image or the sagittal view, it does not warrant thin slices or that thin slices will create too much signal-to-noise ratio and cause poor quality images. That is a great argument to take thick slices and result in fewer images increasing the profit margin of the imaging center. Otherwise, the argument is moot and centered on the bottom line versus quality patient care.
 
Slice thickness is another critical component of a quality MRI. The American College of Radiology (ACR) has set forth the following guidelines for maximum thicknesses:

mrispineprotocalsfig2The key to this graph is the concept “maximum” and it does not illustrate a complete sequence to ensure that most pathologies are not missed. In addition, most MRI centers tout that they are ACR accredited and that is factual. However, being ACR accredited does not mean that they use ACR guidelines in their scans. In addition, there are no regulatory standards in any state enforcing those guidelines for imaging centers. That “ruse” is quite profitable for those centers at both you and your patients’ expense because this often leads to many missed pathologies. So it also leaves you exposed to hurting your patients—caveat emptor!

According to Robert Peyster, MD, neuroradiologist and section chief of neuroradiology of State University of New York at Stony Brook Medicine who acquired his neuroradiology education at Mass General (Harvard) and has been published more than sixty times on MRI, the following sequences should be considered:

mrispineprotocalsfig3Please note that all of the scenarios involve “no gap.” They are no longer necessary with today’s technology. These recommendations exceed the ACR guidelines and are meant to do so. As I have already articulated, those guidelines are minimum standards with maximum slice thicknesses. The thinner the slice, the more you see with “volume averaging” in image acquisition.

Understanding that this article is intended to serve as a guide, I urge every DC worldwide to learn the significance of each sequence and be able to interpret MRIs (or at least the basics) to protect patients from any of the above scenarios. Dr. Peyster and other world-class specialists teach MRI to DCs at www.teachdoctors.com. This course carries a certification from the University of Bridgeport, College of Chiropractic and State University of New York at Buffalo, School of Medicine and Biomedical Sciences. This is the only program that offers a “cross certification” through both chiropractic and medical academia. Although this has had significant positive ramifications for chiropractic in the courts nationally by allowing DCs to testify as experts when challenged, the real winners are the patients.

Do not be taken advantage of by unscrupulous imaging centers when ordering MRIs. Winning through clinical excellence is the only solution and DCs now have the opportunity to learn how to interpret MRIs from the same educators who have taught thousands of medical neuroradiologists to interpret spinal MRIs. This level of clinical excellence has nothing to do with your philosophy of practice or method of delivery of care. It is purely about accurately triaging your patients with an accurate diagnosis, prognosis, and treatment plan.

References:
  1. Lurie, J. D., Doman, D. M., Spratt, K. F., Tosteson, A. N. A., & Weinstein, J. N. (2009). Magnetic resonance imaging interpretation in patients with symptomatic lumbar spine disc herniations. Spine, 34(7), 701-705.
  2. American College of Radiology (2011). MRI practice guideline for the performance of magnetic resonance imaging (MRI) of the adult spine. Last retrieved July 11, 2013 from http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/MRI_Adult_Spine.pdf
 
Degenerative Spondylolisthesis and Leg Pain: What’s the Connection?
Radiology
Written by Terry R. Yochum, DC, D.A.C.B.R., Fellow, A.C.C.R., & Alicia M. Yochum, DC, R.N., BSN   
Tuesday, 25 June 2013 19:15
figure1dsandlegpainHistory
This 60-year-old female patient presents with lower back and sciatica pain through the buttock into the posterior thigh. 
 
Diagnosis:  
Observe the extensive sclerosis and osteophyte formation occurring bilaterally at the L5/S1 facet structures. There is a degenerative anterolisthesis of L5 upon the sacrum of approximately 4 mm. No evidence of pars defects is seen at the L5 segment.
 
Degenerative Spondylolisthesis:
figure2dsandlegpainDegenerative spondylolisthesis is a type of non-spondylolytic spondylolisthesis (no pars defect). Schmorl and Junghans refer to this condition as “pseudo-spondylolisthesis” to differentiate it from cases with a neural arch defect (spondylolytic spondylolisthesis). Macnab prefers the phrase “spondylolisthesis with an intact neural arch,” which is a more accurate description.¹
 
Degenerative spondylolisthesis can affect any degenerated vertebral segment positioned within a lordotic curve. In the lumbar spine, it most commonly affects L4, with approximately 10 times more prevalence than at the L3 or L5 vertebrae. Generally, anterior displacement of the L4 vertebral body is not > 25%, and the majority of cases involve only 10-15% displacement. ¹
 
Degenerative spondylolisthesis is a forward displacement of a vertebral body secondary to extensive superior and inferior facet arthrosis. This is frequently associated with degenerative disc disease and is most commonly found at the L4 segment in females > 40 years of age (the three Fs of degenerative spondylolisthesis).¹
 
The Three F’s Of Degenerative Spondylolisthesis
  • Female
  • Fourth lumbar vertebra
  • Forty years old or older 1
The absence of a pars defect (which would increase the sagittal dimensions of the central canal) results in narrowing of the antero-posterior (AP) diameter of the spinal canal, which causes central spinal stenosis, in addition to lateral recess and neuroforaminal stenosis. The contours of the thecal sac have an hourglass or cosntrictred outline. Because the vertebral body projects anterior and inferior in relation to the disc below, a pseudo-disc appearance can be created on the CT or MRI studies.¹
 
Synovial Cyst Formation
Synovial cysts are degenerative in nature and can occur in or adjacent to degenerative facet joints. They may reach considerable size and cause localized back and leg pain. On T1-weighted images, synovial cysts may be seen as low signal intensity masses in the posterior spinal canal. They may be better delineated on T2-weighted scans because their fluid contents become hyperintense. The key to the diagnosis is their location and the proximity of the cyst to the synovial joint. Although an unusual finding, gas-filled synovial cysts have been reported. This degenerative vacuum phenomenon may be present in the apophyseal joint, and the continuity of cysts within the synovial joint can allow gas to become trapped within the cyst.¹
 
Clinical Comment And Summary:
Patients with degenerative spondylolisthesis who present with not only back pain but also ongoing leg pain that does not resolve with conservative treatment should be evaluated by an MRI scan to rule out a degenerative synovial cyst. These cysts can compress the exiting nerve root and produce unremitting leg pain. Cox has described reduction of these cysts with flexion distraction treatment as was documented by the work of Wilby on blockage of the 12 mm drainage opening from the facet joint to the ligamentum flavum as the cause of the cyst. ² Cox has reported a number of cases where there has been successful decompression of these cysts with flexion distraction treatment.3,4,5 Surgical intervention has also been recommended to remove the cysts rather than just decompress the cysts by means of puncture. Without surgical removal, the cysts often recur similar to a Baker’s cyst recurring in the knee.
 
References
  1. Yochum TR, Rowe LJ: The Essentials of Skeletal Radiology, 3rd ed., Baltimore, Williams & Wilkins, 2005.
  2. Martin J. Wilby, Robert D. Fraser, Barrie Vernon-Roberts and Robert J. Moore: SPINE, Volume 34, Number 23, pp. 2518-2524.
  3. James Cox, Chiropractic Treatment of Lumbar Spine Synovial Cysts: A Report of Two Cases, J. Manipulative and Physiological Therapeutics.28(2), Feb. 2005, p. 143-147.
  4. James Cox, Chiropractic Treatment of Lumbar Spine Synovial Cysts: A Report of Two Cases, J. Manipulative and Physiological Therapeutics.28(2), Feb. 2005, p. 143-147.
  5. L. Hazen, James Cox: Lumbar Intraspinal Extradural Synovial Cyst: A Case Study, J. Neuromusculoskeletal System, 1(4): 1993. 
Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chi­ropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 1-303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Dr. Alicia M. Yochum is a third generation chiropractor and 2011 Suma Cum  Laude Graduate of Logan College of Chiropractic, as well as a Registered Nurse. She is in a Radiology residency at Logan College in St. Louis, MO. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .  
 
Pending Spondylolysis and/or Spondylolisthesis: What’s It All Mean?
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Radiology
Written by Terry R. Yochum, D.C., D.A.C.B.R., Fellow, A.C.C.R., and Alicia M. Yochum, D.C., R.N., BSN   
Sunday, 24 February 2013 22:13
Case History
This 18-year-old female gymnast is complaining of unilateral left-sided lumbar spine pain at the L5 level.  Standard plain film radiographs show no evidence of pathology, pars defects or spondylolisthesis.  Because this patient’s pain did not respond to conservative treatment, an MRI scan was performed for further evaluation.
 
Imaging Findings of this Patient
Observe the area of bright (white) signal intensity seen in the pedicle pars region on the left side at the L5 segment (arrows).  This is nicely demonstrated on both the axial study and the left-sided parasagittal imaging.  No true pars defects are identified at this time.  The areas of increased signal intensity in the left pedicle pars region of L5 represent bone marrow edema and a “PENDING SPONDYLOLYSIS.”  No pars defects were identified on the axial or parasagittal images.  The author (Terry R. Yochum) has coined the term “PENDING SPONDYLOLYSIS” for those patients who are developing a stress fracture prior to any actual frank separation in the bone.  If these patients continue to perform their repetitive hyperextension activities, the area where the bone marrow edema is present will cause the pars to actually fracture and separate.
 
Discussion
spondylolysisorlisthesisHistorically, two modes of diagnostic imaging have been used to assess whether physiological activity is present and associated with the existing pars defects or “PENDING” defects.  Radionuclide bone scan imaging, particularly SPECT (Single Photon Emission Computed Tomography), has often been the examination of choice; however, it suffers from two drawbacks:  it exposes the patient to ionizing radiation and it provides very little anatomical information. Fortunately, these concerns have been addressed with the advent of MR imaging. Understanding that pars defects represent a stress fracture of the fatigue variety rather than an inherited congenital anomaly or predisposition has been a life-long quest for me (Terry R. Yochum). Having reviewed many athletes’ images, I have had the opportunity to see the proven value of MR imaging for the assessment of physiological activity that occurs adjacent to a pars defect, or that which is hidden in the region of the pars interarticularis when the defect is in fact “PENDING.”  I feel, at this point in time, that SPECT imaging is no longer the exam of choice, since there is so much more information obtained with the physiological imaging of magnetic resonance.
 
I have seen many cases where bone marrow edema adjacent to the pars or hidden within an intact pars on its way to becoming a pars defect (PENDING SPONDYLOLYSIS) has been missed on standard T2-weighted images.  A STIR imaging sequence clearly provides this information.  The STIR imaging sequences are the equivalent of fat suppression techniques or fluid-sensitive pulse sequences and significantly enhance the ability to see bone marrow edema within the region of the pars.  If a STIR imaging sequence reveals bone marrow edema adjacent to an existing pars defect or within the pars interarticularis in a “PENDING SPONDYLOLYSIS,” patients must cease participating in any sports-related activities and be placed in a Boston Overlap brace for a minimum of three to four months.  Once appropriately braced and physical activity is reduced, patients with “PENDING SPONDYLOLYSIS” usually do not develop a true bony pars defect.
 
The patient presented in this case study never developed actual pars defects and back pain was 90% reduced after being placed in a Boston Overlap brace for approximately three months.  The patient’s lower back pain was 90% better once placed at a position of anti-lordosis, which is the purpose of the Boston Overlap brace.
 
For a more detailed discussion of this condition, its imaging evaluation, treatment and prognosis, please see Chapter 5 of the new edition of Yochum and Rowe’s Essentials of Skeletal Radiology published by Lippincott, Williams & Wilkins, 2005.
 
References 
  1. Yochum TR, Rowe LJ:  Essentials of Skeletal Radiology. 3rd ed. Baltimore  MD): Lippincott, Williams & Wilkins; 2005.
Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chi­ropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 1-303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Dr. Alicia M. Yochum is a third generation chiropractor and 2011 Suma Cum  Laude Graduate of Logan College of Chiropractic, as well as a Registered Nurse. She is in a Radiology residency at Logan College in St. Louis, MO. She can be reached at alicia.yochum@ gmail.com.
 
Sacral Fractures
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Radiology
Written by Terry R. Yochum, D.C., D.A.C.B.R., Fellow, A.C.C.R., and Alicia M. Yochum, D.C., R.N., BSN   
Tuesday, 23 October 2012 17:50
sacralfractures2jpgCase History:  This male patient was working on the roof of his garage when he slipped and fell 12 feet to the concrete pavement of his driveway.  He has sharp pain over his proximal sacrum. Does he have a fracture?

Diagnosis:  Note the fracture through the anterior surface of the second sacral segment creating an acute offset of its anterior cortical surface.  
 
Sacral Fractures. 
Sacral fractures usually occur as a result of a fall upon the buttocks or following a direct trauma. There are two types – horizontal and vertical.
 
Horizontal (Transverse) Fractures. These are the most common type of sacral fractures. The most common location is at the level of the third and fourth sacral tubercle, which is near the lower end of the sacroiliac joint. The fracture line is frequently difficult to identify due to overlying gas and feces. Often, a cleansing enema of the lower bowel and rectum before the radiological examination facilitates its demonstration.The lateral radiograph is usually required to demonstrate the fracture. Often, the lower segment of the sacrum may be displaced or angled forward.  (1)
 
A horizontal fracture of the upper sacrum, affecting the first or second sacral segments, may occur from falls from a height.  It is usually associated with suicidal attempts by jumping (“suicidal jumper’s” fracture).  (1)
 
Vertical Fractures. These usually occur as a result of indirect trauma to the pelvis. They are visible in the frontal radiograph but not the lateral view. The cephalic tilt-up view or a coronal C.T. scan may be necessary in order to demonstrate the vertical fracture line, which usually runs nearly the entire length of the sacrum.  (1)  The normally symmetrical transverse sacral foraminal lines should be carefully scrutinized for detection of the fracture line.
 
Isolated fractures of the sacrum are uncommon, and a diligent search for an associated fracture of the pelvic ring or symphysis pubis is often beneficial.
 
Coccygeal Fractures. Most fractures of the coccyx are transversely oriented, similar to those of the sacrum.  Seldom are they seen on the frontal radiograph; the lateral film best demonstrates this type of fracture.The fracture line is usually oblique in presentation, and slight anterior displacement of the distal coccyx is quite common. Developmental variation in the position of the distal coccygeal segment may provide some concern to the inexperienced observer.
 
Reference
1. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 
3rd ed.,Lippincott, Williams & Wilkins, Philadelphia, PA, 2005.
 
Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chi­ropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 1-303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Dr. Alicia M. Yochum is a third generation chiropractor and 2011 Suma Cum  Laude Graduate of Logan College of Chiropractic, as well as a Registered  Nurse. She  started her Radiology Residency at Logan College in  April 2012. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .  
 
Unilateral Spondylolysis
Radiology
Written by Terry R. Yochum, D.C., D.A.C.B.R., Fellow, A.C.C.R., and Alicia M. Yochum, R.N., D.C.   
Wednesday, 29 August 2012 23:27
Case History: This is a young college student who plays competitive basketball and is complaining of chronic mid lumbar spine pain. She hurts on hyperextension and has some relief on flexion. The specific diagnosis is?

unilateralspondylolysis
Figure 1.   
Diagnosis: 
Unilateral Spondylolysis (pars defect) with contralateral sclerotic hypertrophy of the opposite pedicle.

Unilateral Spondylolysis 
Spondylolysis may involve only one pars interarticularis of a single vertebra and may allow a 5 - 10% anterolisthesis.  Unilateral spondylolysis may result in a compensatory stress hypertrophy of the contralateral pedicle in the region of the pars.  (1)  This compensatory hypertrophy is manifested radiographically by a contralateral, dense, sclerotic, enlarged pedicle and pars region.  This appearance may mimic osteoid osteoma, osteoblastoma, or osteoblastic metastatic disease, which are common at this site.  Agenesis of the pedicle may also show the same stress hypertrophy of the contralateral pedicle and pars region.  The key differential sign is the presence of a unilateral pars defect.  Regression of the compensatory bone changes may occur, should a stress fracture develop on the same side as the dense pedicle, resulting in bilateral spondylolysis and thereby equalizing the weight bearing and reducing the stress within the involved spinal motion segment. (1)
 
A MRI scan with STIR (fat suppression or fluid sensitive imaging) imaging will be positive at the active lesion demonstrating bone marrow edema (BME).  That may be the unilateral pars defect or the contralateral sclerotic enlarged pedicle or both.  If active, these areas would also be “hot” on a SPECT bone scan. These physiological studies drive the patient management.  (See chapter 5 of Yochum & Rowe).
 
Reference:
 
1. Yochum TR, Rowe LJ:  Essentials of Skeletal Radiology, 3rd ed., Lippincott, Williams & Wilkins, Philadelphia, PA, 2005.

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chi­ropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 1-303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Dr. Alicia M. Yochum is a third generation chiropractor and 2011 Suma Cum  Laude Graduate of Logan College of Chiropractic, as well as a Registered  Nurse. She is starting her Radiology Residency at Logan College in  April 2012. She can be reached at alicia.yochum@ gmail.com.  
 
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