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Radiology


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.   
Saturday, 08 December 2007 17:18

HISTORY

 

This 60-year-old male patient presents with head and spinal pain.


DIAGNOSIS

 

Note the diffuse osteolytic "punched-out" lesions affecting the bony calvarium which has been called the "raindrop skull" of multiple myeloma.

 

DISCUSSION

Osteolytic Defects. The radiologic hallmark of multiple myeloma is the sharply circumscribed osteolytic defect. These radiolucent lesions have been historically referred to as punched-out lesions. They are multiple, round, and purely lytic. The most frequent sites are in bones with hematopoietic potential. This appearance is most common in the skull, pelvis, long bones, clavicles and ribs. The pattern of widespread lytic lesions of the skull has been referred to as the raindrop skull.1 Calvarial involvement may occasionally be differentiated from metastatic carcinoma by the more uniform size of the lytic lesions in myeloma. The coexistence of both large and small lesions is often the mode of presentation in metastatic disease.1,2

  

Spinal involvement. The lower thoracic and lumbar spine are usual sites; however no spinal region is exempt. Early osteoporosis may be the only radiographic sign. As the disease progresses, pathologic vertebral collapse is inevitable. This often takes the configuration of a vertebra plana compromising the posterior one third of the vertebral body, as well as its anterior two thirds. Pathologic fracture in the spine may be singular or multiple and has been called the wrinkled vertebra of myeloma. Demonstration of punched-out lesions in the spine is rare. The vertebral pedicles are involved much less frequently than the body. Jacobson, et al.,3 suggest that the paucity of red marrow in the pedicles may allow their preservation with vertebral involvement. This has been called the pedicle sign of multiple myeloma. Since Jacobson’s original paper in 1958, there have been numerous cases reported refuting this sign and demonstrating isolated pedicular or combined vertebral body and pedicular involvement in multiple myeloma. Therefore, the usefulness of this pedicle sign to differentiate multiple myeloma from osteolytic metastatic carcinoma appears doubtful.1,2

Pelvic and Long Bones. Diffuse osteolytic round or oval lesions predominate without any reactive sclerosis. Medullary bone destruction abuts the endosteal surface of the cortex. The diaphysis is an area frequently involved in the long bones, which is consistent with the anatomic distribution of active red bone marrow. The humerus and femur are favored sites. Widespread disease throughout the pelvis and sacrum creates diffuse lytic lesions, which are fairly symmetric.1,2

 

Roentgen Signs of Multiple Myeloma

Early: Normal radiographsGross osteoporosis

Late: Diffuse, punched-out lesions Uniform vertebral collapse (compromise of the posterior one-third of the body) Diaphyseal osteolytic lesions Rarely, sclerotic lesions (ivory vertebra) Pedicle sign (preservation of pedicles)

 

TREATMENT AND PROGNOSIS

In patients with multiple myeloma, the overall prognosis is poor.1,2 Over 90 percent die within three years. Treatment is usually palliative, with the aim of minimizing the patient’s suffering. The two major forms of treatment are radiotherapy and chemotherapy. Plasma cells are characteristically radiosensitive and radiotherapy is of established value in the control of localized symptomatic lesions, which typically transform to a blastic area. Of the chemotherapeutic agents presently available, Melphalan and Cytoxan are the two drugs most useful in attempted long-term management. The importance of ambulation and adequate hydration cannot be overemphasized. The constant threat of hypercalcemia, hypercalciuria, and hyperuricemia necessitate continual attention to these aspects of general care.1,2,3

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.        Kyle RA: Multiple Myeloma—review of 869, Mayo Clin Proc 50:29, 1975.

3.        Murray RO, Jacobson HG: The Radiology of Skeletal Disorders. Ed 2, New York, Churchill Livingstone, 1977.

 
Adjusting the Holographic Body Part Four: Allergies
Radiology
Written by Tedd Koren, D.C.   
Thursday, 08 November 2007 16:17

If the body is sick, the mind worries and the spirit grieves; if the mind is sick, the body and spirit will suffer from its confusion; if the spirit is sick, there will be no will to care for the body or mind. – J.R. Worsley

Posture of subluxation (POS)

In Parts One and Two, we discussed how some subluxations can only be accessed (and adjusted) when the patient is in a certain physical or emotional posture (the Posture of Subluxation—POS). In Part Three, we discussed locating and correcting the emotional POS.

 

There are many POS’s; a common one is allergies

The POS is not limited to physical or emotional states. Many diverse health conditions will exhibit a POS. For example, Koren Specific Technique (KST) doctors have discovered that allergies correlate to subluxation postures.

 

KST and allergies

After developing KST, I was often asked if it could help allergy sufferers. I’m happy to report that KST doctors have discovered a simple yet powerful way to help allergy sufferers break the allergy/symptom connection.

 

The analysis

First the patient is analyzed and adjusted so they are free of subluxations in neutral posture (i.e. lying on a table). Now put the patient in the allergy posture of subluxation.

How do you do that? It is rather simple to do. First, have the patient think of the allergy. While they are thinking of the allergy, the body will subluxate. Now they are in the allergy POS.

KST is a quick and accurate method of analysis utilizing a bio-indicator. Bio-indicators, used in Applied Kinesiology, DNFT/Activator/Truscott, Body Talk, Toftness and other healthcare modalities, are physiological responses to stressors. In KST, the bio-indicator we prefer is the occipital/mastoid drop (OD) because there is no patient muscle fatigue and there are no posture restrictions—you can test a patient in nearly any posture.

While the patient is thinking of the allergy, the practitioner will find that their subluxation-free patient is suddenly subluxated again! They will have a positive OD (biofeedback) and will be "locked up" or subluxated. In most cases, the subluxations are best accessed in the cranials.

Let’s say you have the patient think of their cat allergy. While they are in their "cat allergy" state of mind, their body will subluxate.

 

Now the correction

As the patient is thinking of the cat (allergen), the subluxations are adjusted. I like to use an adjusting instrument, as this permits the patient to stay in one position so the force/energy/information (adjustment) can be directed specifically.

Next, ask the patient to think of the allergen again. There should be no OD. If there is an OD, go through the analysis and adjustment again. You may have missed something.

Are you finished?

Not quite.

Now ask the patient to think about the allergy from a different angle. Tell the patient, "Imagine holding a cat." Then test for an OD. If you get a positive response, analyze and adjust.

Please realize that we are not using the actual physical allergen to elicit this reaction (although we could do that as well); we are using the mental/emotional POS of the allergy.

Try other statements to defuse the allergy. Tell the patient to imagine how their symptoms feel when they have an allergic reaction. Have them think of petting a cat; have them think of the age they first experienced the allergy; have them think of the emotional stress that occurs when they have the allergy. Tell them to imagine breathing the allergen. Tell them to imagine clear sinuses.

Go through a number of these exercises until you simply can’t elicit an OD from the patient.

 

That’s it

It’s that simple. KST doctors are reporting very good results using this procedure.

 

What exactly are we doing?

As with other allergy elimination protocols, we appear to be breaking a psycho-neuro-immunological reflex that caused the patient to overreact to an allergen.

DD Palmer said that the causes of subluxations are emotions (auto-suggestion), toxins and trauma. With KST we are adjusting a patient when they are in the toxin (allergy) "posture of subluxation" or POS.

Using KST procedures, chiropractors can easily and quickly locate and correct subluxations as they reveal themselves in any posture—physical, emotional or chemical.

In Part Five, we’ll discuss the POS as it relates to weight loss, smoking, dyslexia and bad habits.

or call 1-800-537-3001. Write to Dr. Koren at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Degenerative Spondylolisthesis
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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.   
Saturday, 08 September 2007 10:59

HISTORY

 

This 50-year-old female patient presents with a six-month history of lower back pain without peripheral radiation.

DISCUSSION

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.

 
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 .

 

 

 
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, 3rd 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.

 
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