|
Radiology
|
|
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
 Historically, 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
- 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.
|
|
|
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 |
 Case 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
.
|
|
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? 
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. |
|
|
Radiology
|
|
Written by Ryan Everhart
|
|
Sunday, 22 July 2012 21:05 |
|
X -rays play an important role in determining the exact cause for many health complications in patients. The advancements in radiography are allowing physicians to pinpoint the exact cause of complications through high quality output in a matter of seconds. As a chiropractor, it is important to determine what part of the body is causing the trouble, and you can do that easily with digital radiography. You can choose one of three digital X-ray options to set up in your chiropractic clinic.
Computed Radiography
 Computed radiography (CR) is the closest process to traditional radiography because it still includes the use of X-ray cassettes and films, albeit in a different form. Instead of the traditional X-ray film, computed radiography makes use of a reusable phosphor plate. After taking each image, the plate will be processed through a scanner that then erases the image so that the plate can be used again. As the process of obtaining imaging is very similar to traditional radiography, computed radiography also takes the same time to finish one cycle.
As the images are now digitized, the need for chemicals, X-ray films and a darkroom does not exist. Computed radiography equipment requires regular maintenance and replacement as the moving parts tend to wear out after prolonged use.
Charge-Coupled Device
The charge-coupled device is the closest arrangement to flat panel digital X-rays. They produce fairly high quality imaging using an extensive setup of cameras and mirrors. Some elaborate arrangements are known to contain almost 192 cameras. Charge-coupled device (CCD) systems were extremely popular a while back because they produced results closest to those from flat panel detectors for a fraction of the cost. CCDs are still highly preferred among physicians and clinics because they are cost effective. By choosing the right model, you will get high quality imagery with lower maintenance costs than computed radiography.
Although they are much cheaper, charge-coupled devices are bulky and occupy a lot of space. They also require high frequency generators to produce high quality images. The hundreds of cameras attached to the device need to be recalibrated every few weeks to ensure that there are no blank spaces in the output. A huge advantage CCD has over computed radiography is the response time. Each image can be captured and digitized in just about five seconds.
Flat Panel Digital X-ray
Although flat panel digital X-ray detectors were considered to be too pricy a few years ago, they are now more affordable and popular than ever. Most hospitals are switching to flat panel detectors because they produce the best results in the shortest amount of time. These detectors are also the safest for patients as they emit the least amount of radiation. Flat panel detectors (FPDs) are known to produce the most detailed images, which help chiropractors detect even the smallest inconsistencies in the body. As they contain no moving parts, FPDs are long-lasting with an average lifespan of at least one million exposures. Unlike CCDs, flat panel detectors do not require high frequency generators to achieve excellent image quality. Taking only two to five seconds for each image, an FPD’s only drawback is its slightly higher price than CR or CCD. However, a flat panel upgrade is the most economical long-term digital X-ray solution in my opinion.
Ryan has been involved in the X-Ray business for 15 years. He started doing X-Ray service and is now a top sales producer at Viztek based in Garner NC. The evolution of Digital X-Ray imaging has created numerous opportunities for streamlining medical practices throughout the country. Ryan specializes in converting Analog customers to a completely Digital Imaging solutions.www.Viztek.net
|
|
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
|
|
Saturday, 02 June 2012 02:31 |
 [Case History]
This male patient has a history of multiple traumas to his humerus. Are these radiopacities exuberant callous formation from hematoma?
Diagnosis: The answer is no!! This is a rare sclerotic skeletal dysplasia referred to as “MELORHEOSTOSIS”.
General Considerations
Melorheostosis is a rare, sclerosing bone dysplasia that was first described in 1922 by Leri and Joanny. Synonyms include Leri type of osteopetrosis, osteosis eberneizzante monomelica, and flowing hyperostosis. The name melorheostosis is of Greek derivation, meaning limb, flow, and bone, and aptly describes the hyperostotic appearance that has been likened to wax flowing down a lighted candle.
Radiologic Findings
Cortical thickening in a streaked or wavy pattern is the most marked roentgen feature. In children the hyperostosis is primarily endosteal; in adulthood, periosteal bone deposition is more dramatic. (1) The radiographic findings appear to reflect developmental errors at the sites of intramembranous and enchondral bone formation. (1) The hyperostotic bone protrudes under the periosteum and usually follows along one side of a long bone. Endosteal involvement may encroach upon the medullary space. Bony masses resembling osteochondromas extend into adjacent articulations.
Bone scintigraphy shows increased tracer uptake in the involved area.
Involvement of the carpal and tarsal bones resembles the multiple bone islands that are seen in osteopoikilosis. In the pelvis and scapulae (flat bones) the sclerotic bone may be in the form of dense radiations from the joint. Heterotopic bone formation and soft tissue calcification are encountered and may lead to joint ankylosis. Bone scintigraphy shows increased tracer uptake in the involved area. A number of other disorders have been found in association with melorheostosis. These include linear scleroderma, osteopoikilosis, osteopathia striata, neurofibromatosis, tuberous sclerosis, and hemangiomas. (1)
Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chi-ropractic, 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
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
Reference: 1.Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3rd ed., Williams & Wilkins, Baltimore, Maryland, 2005.
|
|
|
|
|
|
|
Page 1 of 13 |
|
|
|
