Radiology

Degenerative spondylolisthesis (Type III) has been referred to as a “pseudospondylolisthesis” by Junghans, to differentiate spondylolisthesis with an intact neural arch from those with a true defect of the neural arch.1 Macnab2 prefers the phrase “spondylolisthesis with an intact neural arch,” which is a more accurate description. Thus, degenerative spondylolisthesis is another type of nonspondylolytic spondylolisthesis.

Degenerative spondylolisthesis is approximately ten times more common at L4 than at the L3 or L5 vertebrae and is six times more common in females sixty years of age or older, compared with males of the same age.3 Type III is rare in persons younger than fi fty years of age. Degenerative spondylolisthesis is three times more common in blacks than in whites, with no adequate explanations for these sexual and racial disparities. Finally, degenerative spondylolisthesis is four times more likely to be found in association with a sacralized fi fth lumbar vertebra.1,2

Figure 1. Observe the 20 percent anterior
displacement of L4 upon L5 without pars defects.
There is underlying discogenic spondylosis and
posterior facet arthrosis. This represents a
degenerative spondylolisthesis (pseudospondylolisthesis).

The mechanisms of displacement are thought to involve a combination of zygapophyseal joint arthrosis, disc degeneration, and remodeling of the articular processes and pars.2 An increase of the “pedicle-facet angle” has been noted in the degenerative type of spondylolisthesis.1 This angle, formed by the long axis of the pedicle (or vertebral root) at its intersection with the long axis of the articular pillar, indicates the more horizontal alignment of the degenerative zygapophyseal joints as seen on the lateral radiograph and demonstrates the overriding of the articular surfaces.1

The Three F's of Degenerative Spondylolisthesis

Female

Four (L4)

Above Forty years

Several explanations have been proposed for degenerative spondylolisthesis occurring with such great frequency at the L4 level. Allbrook has stated that the greater mobility of L4 due to the sagittal orientation of the facets at the L4/L5 level may explain the unusual frequency of degenerative spondylolisthesis at the L4 level. Additionally, the fi rmly attached, normal lumbosacral joint may place increased stress on the L4/L5 intervertebral joints, ultimately leading to hypermobility and degeneration of the articular triad.3 No greater than 25 percent anterior displacement of the L4 vertebral body occurs, and the majority involves 10 to 15 percent displacement.1,3

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. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 1-303-690-8503 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References:

1. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3rd ed., Lippincott, Williams & Wilkins, Baltimore, Maryland, 2005.

2. Macnab I: Spondylolisthesis With an Intact Neural Arch – So Called Pseudospondylolisthesis, J. Bone Joint Surg (BR) 32:325, 1950.

3. Rosenberg, MJ: Degenerative Spondylolisthesis, Clin Orthop 1976.117:112, 1976.

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Prostate Osteoblastic Metastasis

Radiology
Written by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.
Thursday, 05 July 2007 10:38
HISTORY This 60-year-old male patient presents with a history of prostate cancer with surgical removal. Note the metallic clips in the pelvic basin consistent with prostatectomy. There are multiple "snowball" areas of blastic metastasis scattered throughout the pelvis and proximal femora. This radiographic appearance is consistent with osteoblastic metastatic carcinoma from the prostate gland. DISCUSSION The sacrum and bones of the pelvis are involved in about 12% of skeletal metastases and may show either lytic or blastic lesions. Seeding from the viscera via Batson’s venous plexus explains this high incidence in the pelvis, as well as in the lumbar spine. Blowout lesions of renal and thyroid origin often affect the bony pelvis. Lesions located in the sacral ala or the posterior ilium are often difficult to perceive on standard radiographs. With the advent of CT scans, a wide variety of lesions involving the osseous pelvis can be more readily seen. The ability of CT to provide accurate measurements of tissue attenuation coefficients and to provide a cross-sectional scan for three dimensional viewing has made it a powerful tool in musculoskeletal diagnosis, with a profound influence on patient management. It provides information about the extent of the bony lesion, localization (for biopsy and radiation therapy), and relationships with other structures. As equipment improves, it seems probable that CT will assume a more primary role in diagnostic evaluation, particularly of the pelvis, where the complexity of bones and the overlying bowel content prevent ideal evaluation with conventional radiographs. Occasionally, blastic lesions affecting the pelvic rim, especially from carcinoma of the prostate, exhibit an expansion of bone. This occurs as a result of cortical thickening from endosteal or periosteal apposition of bone. The bony enlargement may mimic the appearance of Paget’s disease. Usually, other skeletal lesions are present to assist in radiologic differentiation. Biopsy of the lesion may be necessary as a final step in diagnosis. 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. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 1-303-690-8503 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it . Add new comment

Multiple Myeloma

Radiology
Written by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.
Friday, 04 May 2007 13:04
HISTORY This 65-year-old female patient presents with acute symptoms of right-sided radiculopathy, paresthesia and pain in the right upper extremity. There has been no trauma. DIAGNOSIS Observe the gross osteoporosis about the entire cervical spine. There has been pathological collapse of the C5 vertebral body, which is uniform in configuration. This is very characteristic of a malignant pathological fracture. This patient’s radiculopathy occurred as a result of posterior compression on the spinal cord resulting from the pathological collapse. The compression created an extradural defect on the spinal cord. General Considerations Multiple myeloma occurs as a result of a malignant proliferation of plasma cells, which infiltrate the bone marrow. The first patient known to have multiple myeloma was seen in 1845, after severe recurrences of pain during a 17-month period. His urine contained unusual "animal matter" that became soluble when boiled and formed again when cooled. Although William MacIntyre recognized the effect of heat on the urine and outlined the clinical findings, it was the young physician and chemist Henry Bence Jones who described the protein in detail. In 1873, von Rustizky named and outlined in detail the clinicopathologic features of the this disease. Multiple myeloma is occasionally referred to as Kahler’s disease, after the clinician from Prague who lectured extensively on myeloma in the late nineteenth century. In more recent times, the diagnosis of myeloma was facilitated by Longsworth, et al., in 1939, with the development of electrophoretic techniques and with immunoelectrophoresis as described by Grabar and Williams. Incidence Multiple myeloma is the most common primary malignant tumor of bone and accounts for 27 percent of biopsied bone tumors. Together, myeloma and osteosarcoma account for almost half (46 percent) of the primary malignant tumors of bone. Multiple myeloma represents about one percent of all types of malignant disease and slightly less than ten percent of hematologic malignancies. In the last two decades, the death rate from multiple myeloma has increased; however, it is likely that these increases are related to earlier and more improved diagnosis rather than representing an actual rise in incidence. Clinical Features Age and Sex Distribution: Typically 75 percent of myeloma patients are between fifty and seventy years of age, with an average age of sixty. It is rarely seen before the age of forty, but a few cases have been reported before the age of thirty. There is a male to female ratio of 2:1. Signs and Symptoms: The clinical picture of the disease comprises four types of abnormalities: anemia owing to replacement or alteration of the hematopoietic tissues by proliferating plasma cells, deossification of bones that house red marrow production of abnormal serum and urinary proteins, and renal disease. Pain is the cardinal initial symptom, often suggesting arthritis or neuralgia. Initially, the bone pain is intermittent; in later stages, it becomes continuous. It is worse during the day and aggravated by exercise and weight bearing. The pain is often better at night with bed rest. Low back pain in myeloma patients is frequently misdiagnosed as disc or sciatic problems initially. A rapid onset of severe pain after slight strain or mild trauma usually indicates the development of a pathologic fracture. In the late stages of the disease, pathologic fractures occur in 20 percent of patients. Paraplegia may occur with vertebral collapse and is more common with a solitary presentation (plasmacytoma). As the disease progresses, the pain becomes more severe and prolonged, often requiring narcotics for relief. SOLITARY PLASMACYTOMA General Considerations Solitary plasmacytoma represents a localized form of plasma cell proliferation. It is much less common than multiple myeloma. Approximately 50 percent of patients present before age fifty. Most commonly, patients complain of localized pain. Laboratory findings are occasionally normal, or the abnormal serum electrophoresis may disappear after tumor excision. The mandible, ilium, vertebrae, ribs and proximal femur and scapula are the favored sites. Pathologic fracture is common. Isolated cases have been reported in extramedullary sites affecting the soft tissues of the upper respiratory tract. Rarely, solitary plasmacytoma can present as an ivory vertebra. The typical roentgen appearance is a geographic radiolucent lesion, often highly expansile, with a soap bubble internal architecture. The radiographic differential diagnosis includes pseudo-tumor of hemophilia, hydatid disease of bone, fibrous dysplasia, giant cell tumor, brown tumor of hyperparathyroidism, and blow-out metastases from renal or thyroid origin. Often, these lesions initially appear benign; however, 70 percent of patients who have what seems to be a solitary focus develop diffuse multiple myeloma and die within five years. Progression to multiple myeloma has been documented in cases up to twenty-three years after the initial presentation of solitary plasmacytoma, emphasizing the importance of long-term follow-up with these patients. The balance of the lesions remain localized and are treated quite successfully with local irradiation and/or surgical excision. Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of NationalCollege 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 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. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 303-690-8503 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it . *References* 1. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3^rd ed., Lippincott, Williams & Wilkins, Baltimore, Maryland, 2005. 2. Deutsch A, Resnick D: Eccentric cortical metastases to the skeleton from bronchogenic carcinoma, Radiology 137:49, 1980. 3. Yuh WTC, Zachar CK, Barloon TJ, et al.: Vertebral compression fractures: Distinction between benign and malignant causes with MRI Imaging. Radiology 172:215, 1989. 4. Shih TT, Huang KM, Li YW: Solitary vertebral collapse: Distinction between benign and malignant causes using MR patterns. J Magnetic Reson Imaging 9(5):635, 1999. Add new comment

A Case of RA/DISH

Radiology
Written by Paul Sherman, D.C.
Sunday, 04 March 2007 10:38
Discussion: RA/DISH is a disorder involving two conditions: rheumatoid arthritis (RA) and diffuse idiopathic skeletal hyperostosis (DISH), which is also known as Forestiers disease or ankylosing hyperostosis.^1,3,5 RA is considered the most common inflammatory arthritide.¹It is a systemic connective tissue disorder that primarily affects the synovial lined joints.¹ It is characterized by an inflammatory, hyperplastic synovitis (pannus formation), which causes cartilage and bone destruction ultimately leading to loss of joint function.¹ It typically affects the small joints of the body, i.e., hands, wrists, elbows, shoulders, feet, knees and hips.^1,5 It is usually seen bilaterally and affects the joints symmetrically.^1,5The onset of RA is generally between the ages of twenty and fifty and affects women more often than men.^1,5When RA is seen in older individuals above sixty years of age, the ratio of occurrence between men and women becomes almost equal.¹ Generally speaking, rheumatoid arthritis rarely affects the axial skeleton, but when it does, the cervical spine is the most common region of involvement, resulting in anterior translation (movement) of the atlantoaxial complex 9.5 percent to 36 percent of the time.¹ This forward translation is most often caused from erosion of the odontoid process or transverse ligament laxity from pannus formation.¹ Laboratory tests such as the rheumatoid factor (RF) assist in confirming a diagnosis. A positive rheumatoid factor is usually seen in 70 to 80 percent of the patients with rheumatoid arthritis.¹ Other laboratory tests such as a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and anti-nuclearantibodies (ANA) assay may help to confirm and evaluate patients with rheumatoid arthritis.¹ DISH is classified as a rheumatological abnormality characterized by marked proliferation of bone where the ligamentous and tendinous attachments to bony sites are found.¹ DISH can affect the spine or extraspinal areas, but tends to develop most commonly in the anterior longitudinal ligament (ALL) of the spine.¹ It tends to affect males more than females and is usually seen in patients over the age of fifty.⁵ The typical radiographic findings are characterized by large flowing ossifications, sometimes referred to as candle wax drippings, located along the anterolateral aspect of the vertebral bodies of at least four contiguous vertebrae, with relative preservation of the disc heights and absence of facet ankylosing and sacroiliac erosion/fusion.^1,5 It should be noted, as a result of the large flowing ossification about the anterolateral aspect of the vertebral bodies, secondary complications of dysphagia can arise in approximately 20 percent of the patients, causing displacement of the pharyngeal air shadow.⁵ In addition, there is a higher incident of patients diagnosed with DISH having associated diabetes mellitus, approximately 13-49 percent of the time.¹ Laboratory tests are generally unremarkable; however, patients with DISH tend to show hyperinsulinemia following glucose challenge tests.^1,5 Evaluation of the HLA B8 antigen may be positive in approximately 40 percent of the patients with DISH.⁵ Differential Diagnosis: Differential diagnoses should include other more common inflammatory arthritides like anyklosing spondylitis (AS) also known as Marie-Strumpell’s disease, as well as other inflammatory arthritides like psoriatic and Reiter’s arthritis.⁵In addition, a common non-inflammatory arthritide like degenerative joint disease (DJD), also known as osteoarthritis or wear and tear disease, should not be overlooked as a possible differential diagnosis.⁵ Radiographic Findings: The radiographs being depicted are those of an eighty-nine-year-old male patient who consulted me because of pain, stiffness, spasm and restricted range of motion in his cervical and cervicothoracic spine. The patient’s X-rays revealed an increase in the atlantodental interspace (ADI), which normally should measure no greater than 3mm in an adult and 5mm in a child.^1,5Also noted is the presence of forward displacement of the posterior cervical line, prominent flowing bone spurs (candle wax drippings) and fusion of several vertebral segments along the anterior longitudinal ligament. The articular facets and many of the disc spaces of this patient’s cervical spine are still preserved. Reference X-rays for these abnormal findings. Treatment: Treatment for RA/DISH should be directed toward obtaining meaningful symptomatic improvement, because there is no known cure for these two disorders.² Patients afflicted with RA and/or DISH require that treatment goals be directed toward relieving pain, spasm, inflammation and trying to slow down or stop joint damage, as well as improve the patient’s sense of well-being and his ability to function.^2,4 Medical physicians usually prescribe medication to help control these symptoms.^2,4Physical therapy, along with mild non-strenuous movements and exercises, may also help stabilize and strengthen joints and muscles to help to increase articular range of motion.^2,4 Goals should also include emphasizing that patients obtain adequate rest and exercise.^2,4 The X-rays depicted in this case revealed significant osseous changes resulting from DISH, along with anterior displacement of C1 from RA, which precluded any osseous manipulation or adjustments from being administered to this patient’s cervical spine. However, in carefully selected patients without significant upper cervical pathology, where there is no concern for injury to the spinal cord or other neurological elements, gentle and measured manipulation may be an option the chiropractic physician would want to consider. Physiotherapy modalities, such as electro-muscle stimulation, ultrasound, hydrocollator therapy, soft tissue manipulation, trigger point therapy and light stretching, may be of help in reducing the patient’s symptomatology. It is prudent to remember, treatment should always be designed to fit the patient’s needs rather than the patient being required to fit the therapy. All or some of the above procedures, depending upon the stage of the patient’s RA/DISH, may be of clinical benefit in ameliorating the patient’s active symptoms, which is a result of these two disorders. Stress reduction techniques can be helpful in assisting the patient in dealing with the emotional and physical challenges patients experience with these disorders.⁴ In some cases, where severe joint damage has occurred, surgery may be required to reduce pain and improve joint function, which may also help improve the patient’s ability to perform his normal activities of daily living. The procedures to accomplish this may include joint replacement, tendon reconstruction and synovectomy.⁴ In rare cases involving DISH, where ossification of the anterior longitudinal ligament (ALL) becomes so significantly calcified wherein it causes the patient difficulty with swallowing, the patient may need to undergo surgery in order to remove the bony spurs.² In any event, the patient’s age, health status and stage of his disease would determine the most appropriate course of treatment. Dr. Paul Sherman practiced in New Jersey for sixteen years. Presently, he is an assistant professor of clinical sciences and a post-graduate faculty instructor at the University of Bridgeport College of Chiropractic, Bridgeport, Connecticut. He is also an instructor and writer for Chirocredit.com, a chiropractic continuing education website. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it . References 1. Marchiori, Clinical Imaging with Skeletal, Chest and Abdomen Pattern Differentials, Mosby, 1999 2. MayoClinic.com article on diffuse idiopathic skeletal hyperostosis, May 2006 3. Resnick and Niwayama, Diagnosis of Bone and Joint Disorders, 2nd Edition, WB Saunders, 1988 4. U.S. Department of Health and Human Services, National Institutes of Health (NIH) Publication No. 04-4719, May 2004 5. Yochum and Rowe, Essential of Skeletal Radiology, 2nd Edition, Williams and Wilkins, 1996 Add new comment

The Cervical Acceleration / Deceleration Practitioner

Radiology

Written by Dwight C. Whynot, D.C.

Friday, 01 December 2006 10:52

So, you want to treat patients that have suffered a cervical acceleration/deceleration (CAD) trauma. Then you must learn to examine and treat a CAD injured person properly and with the proper tools. First of all, if you have never treated these types of injuries before, then you should arm yourself with the knowledge of the etiology of CAD trauma. Courses like those given by Dr. Arthur Croft (CRASH) and Dr. Dan Murphy (CCST) can help you understand the mechanics behind the injury. But this, alone, won’t help you. Imagine that you have a real-life patient that is hurting in front of you and you need to evaluate that patient in such a way that you take that patient’s subjective symptoms and turn them into objective evidence—FACTS, the type of facts that a jury can understand and use in order to make an informed verdict.

Let’s take a look at a typical CAD injury evaluation. It looks like this in its simplest form:

HISTORY  EVALUATION  DIAGNOSTIC TESTING

According to the above examination flow chart, the doctor takes the history of the injury and records the appropriate responses that lead to the mechanism of injury. The history should focus on the patient’s past and current history so that the doctor can apply the latest evidence in the form of research studies to formulate the answer to questions on whether or not this injury could have happened—questions that relate to prior accidents, size of vehicles, seatbelts on/off, loss of consciousness, etc.

The doctor then performs the standard cervical evaluation by performing the needed orthopedic examination, neurological examination, ROM and muscle tests. This paints a picture as to how the patient was doing physically when the patient was initially examined. However, the examination process is very subjective and should not stop there. The doctor should take the subjective examination results and examine them in an objective manner by utilizing diagnostic tests.

All of the subjective complaints and tests that were found during the evaluation process need to be evaluated by utilizing diagnostic tests. The diagnostic tests that are chosen should be reliable and reproducible for what they are examining. For instance, the Guides to the Evaluation of Permanent Impairment, 5th edition, (AMA Guides), states that ROM testing should be evaluated utilizing dual inclinometry. Dual inclinometry is the most accurate and reliable means to perform ROM tests. The research literature also states that computerized duel inclinometry is the gold standard along with computerized muscle testing.1,2,3 Diagnostic tests then serve two purposes. Firstly, diagnostic tests are able to document the injury of the patient and, secondly, they are able to provide information that can be readily retested so that the doctor can prove whether or not the patient is improving, staying the same or getting worse. The subjective complaints and the diagnostic tests that should accompany them are listed in Table 1.

TABLE 1

Subjective Complaint	Diagnostic Tests That Should Accompany Them
Pain	OA Questionaires (Oswetry, Neck Pain, Roland Morris, VAS, Headaches Disability Index), Pain Presure Treshold Testing (Algometry)
Numb/Tingling/Burning Pain	NCV testing, EMG testing, DSEP Testing
Disc Lesions	MRI
Fractures	CT, Radiographs
Loss of Range of Motion
Loss of strength	cMT Testing
LMS	Radiographs

Questionnaires provide a reliable means of documenting the patient’s level of pain and its impact on their activities of daily living (ADL’s).4,5 Questionnaires such as the Neck Pain Disability Index and the Rand-36 should be utilized. Even though they are considered to be subjective, they are a high form of subjective data. So high, in fact, that insurance companies such as United Healthcare with ACN require that the patient complete a health-oriented questionnaire to pre-authorize care and every time there is a request for more visits.

Nerve conduction velocity (NCV), electromyography (EMG), and dermatomal somatosensory evoked potential (DSEP) testing provide a valid and reliable means of documenting the patients neurological pain.6 The AMA Guides place objective neurological findings in a DRE Category III 15-18 percent Impairment of the Whole Person (AMA Guides Table 15-5). Foreman and Croft place the patient in a Grade III Major Injury Category (MIC) when there are neurological findings present. This is significant, because the treatment recommendations for a patient in a Grade III MIC are seventy-six visits or more. Therefore, the significance of performing neurological tests and other diagnostic tests on your patients goes beyond your simply evaluating the patient. You are able to create an objective treatment plan, a treatment plan that is not based on your opinion but based on the objective data and placed in a set of guidelines (Whiplash Injuries, 3rd edition, by Foreman and Croft).

MRI studies are very useful in evaluating the patient for disc lesions. Computed tomography (CT) is very useful in evaluating the skeletal structures for fractures, especially those that are missed by radiographic analysis. MRI studies that demonstrate a herniated disc at the level and on the side that would be expected for a subjective radiculopathy equates to a DRE Category II 5-8 percent Impairment of the Whole Person, according to Table 15-5 of the AMA Guides.

Computerized range of motion testing (cROM) is very useful in determining the degree of the loss of cervical function. ROM testing is able to reliably indicate a physical impairment in people suffering from chronic whiplash.2

Computerized muscle testing (cMT) is an excellent way of determining a loss of muscle function, because it is not based on a subjective standard. In order to reliably determine that a patient has a decrease in muscle strength, the patient must have at least a 35 percent loss in strength. This means that a doctor would not be able to reliably determine a loss in strength if it is only a 25 percent loss. Muscle strength should be compared from left and right measurements and they should not exceed more than 10 percent.

Radiographs should be taken and then digitized to examine for motion segment integrity loss (MISL) as defined by the AMA Guides. The AMA Guides state that the only way to evaluate a patient for MSIL is by utilizing the flexion/extension films and measuring for an increase in translational or rotational movement. Translation and rotation are biomechanical terms. Translation is movement of a body in straight line and should not exceed 3.5mm in the cervical spine. Rotation is defined as movement of body about a fixed point and should not exceed 11 degrees in the cervical spine (AMA Guides Table 15-5). These are significant findings according to the AMA Guides because, if the patient has MSIL, as defined by the flexion/extension radiographs, then the patient is placed in a Category IV 25-28 percent Impairment of the Whole Person. This equates to the same thing as a greater than 50 percent compression fracture of a vertebral body. What does this mean clinically? It means that you would not adjust someone at C5 if they had a 50 percent fracture of the C5 vertebrae and, therefore, you should not adjust someone that has an increased motion segment at C5 either. The only objective way to determine the MSIL is by having the radiographs digitized. This allows an outside source to determine the injury and how bad that injury is. If the defense attorney tries to refute the findings, he looks very incompetent in front of the jury because he is arguing against the facts.

As you can imagine, the jury likes to have concrete facts of the case to make an informed decision. This is why shows like CSI are very popular right now. For those of you that get frustrated at the thought of treating personal injury cases, it’s probably due to the fact that you are not collecting all of the objective evidence and providing only subjective data to the attorneys. Give the plaintiff’s attorney facts to argue with, not opinion. Believe me, there will be enough opinions flying out of the defense attorney. Get the equipment that will objectively gather the data, like computerized ROM testing and computerized muscle testing and algometry. The proper treatment protocols for treating CAD injuries can be found in Foreman and Croft’s, Whiplash Injuries, 3rd Edition, and the AMA Guides, 5th Edition. If you are not following the protocols set forth in these two texts, you are going to become increasingly frustrated. A very good friend of mine once stated, “Learn the rules, play by the rules, and win by the rules.”

Dr. Dwight C. Whynot is in fulltime practice in Johnson City, Tennessee. Dr. Whynot gives license-renewal lectures on Evidence-Based Chiropractic Practices which are promoted by the International Chiropractors Association and sponsored by Myologic and Spinal-logic Diagnostics. For questions regarding evidence-based practice procedures, email questions to This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

For 12-hours CCE license renewal lecture dates and places call the ICA at 1-800-423-4690. For more information on Myologic or Spinal-logic, go to www.myologic.com or www.spinallogic.com.

References
1. Bohannon RW, Andrews AW. Standards for Judgments of Unilateral Impairments in Muscle Strength. Perceptual and Motor Skills 1999, 89, 878-883.
2. Dall’Alba P., Sterling M., Treleaven J., Edwards S., Jull G.. Cervical Range of Motion Discriminates Between Asymptomatic Persons and Those With Whiplash. Spine 2001; 26; 2090-2094 (October 1, 2001)
3. Jasiewicz J., Treleaven J., Condie P., Jull G.. Wireless Orientation Sensors: Their Suitability to Measure Head Movement for Neck Pain Assessment. Manual Therapy. September 2006.
4. Ware JJ, Sherbourne CD. The MOS 36-Item short form survey (SF-36). I. Conceptual framework and item selection. Medicare 1992; 30:473-83.
5. Hsieh JCY, Phillips RB, Adams AH, Pope MH. Functional outcomes of low back pain: comparison of four treatment groups in a randPhysical Medicine Rehabilitation 80:1273-1281, 1999omized controlled trial. Journal of Manipulative & Physiological Therapeutics 1992; 15(1):4-9
6. Haig AJ, Tzeng H-M, LeBreck DB. The value of the Electrodiagnostic Consultation for patients with upper extremity nerve complaints: A Prospective Comparison with the History and Physical Examination. Archives of Physical Medicine Rehabilitation 80:1273-1281, 1999.

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