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Radiology
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Radiology
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Written by Terry R. Yochum, D.C., D.A.C.B.R., Fellow, A.C.C.R., and Chad J. Maola, D.C.
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Saturday, 25 June 2011 03:47 |
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CASE HISTORY
This young adult patient presents with neck pain following an MVA. You note an abnormality in the upper cervical spine at C1 & C2. Is this a fracture?
DISCUSSION
Anomalies of the odontoid process are considered uncommon (1) and are usually discovered by the principle “traumatic determinism.” This means that the underlying condition predated the injury and is not caused by this current trauma. These anomalies may be associated with Down’s syndrome, Klippel-Feil syndrome, Morquio’s syndrome, and spondyloepiphyseal dysplasia.
 Clinical Features:
Any symptoms the patient may manifest are usually the result of atlantoaxial instability with resultant cord compression; however, if there is compression of the vertebral artery resulting from stretching of the artery during C1 subluxation on C2, then the symptoms may be considerably greater. Increased deep-tendon reflexes, proprioceptive loss, or sphincter incompetence may be encountered. Additionally, compression of the vertebral arteries may result in local thrombosis and vascular occlusion. The thrombus may also serve as a source for emboli to the brain.
Clearly, the combination of os odontoideum with high-velocity injury can produce central cord syndrome or even fatal injury.
Radiologic Features:
The X-ray diagnosis of os odontoideum in a child below the age of 5 years can be made, if there is demonstration of hypermobility of the odontoid process on the body of C2 during flexion and/or extension. In the adult, an X-ray diagnosis is certain, if a smooth, wide, lucent defect is seen to separate the odontoid process from the C2 body at the level of the superior articular processes, and there is an associated stress hypertrophy (enlargement) of the anterior tubercle of the atlas. This finding will not be present in the child, as the biomechanical stresses on the anterior arch of the atlas will not have been present for a long enough period to allow the hypertrophy to develop. Os odontoideum must be differentiated from an acute fracture of the odontoid process. A helpful radiographic sign that may be present and that confirms a developmental defect of the odontoid process is a “molding: of the anterior arch of C1 into the ventral aspect of the odontoid process.
Magnetic resonance imaging is useful in evaluating the spinal cord for angulation, compression, and intramedullary injury (contusion).
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, CO, 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 Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is available for post-graduate seminars. He may be reached at 1-727-433-0153 or by email at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
Reference
1.Yochum, T. R., Rowe, L.J.: Essentials of Skeletal Radiology, 3rd ed., Williams & Wilkins, Baltimore, Maryland, 2005.
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Radiology
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Written by Andrew Cheeseman
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Monday, 25 April 2011 18:13 |
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T he technology used in conventional X-ray film is 100 years old. There are not many technologies that do not evolve and improve in 100 years, and the X-ray field is no different, although many doctors have not yet made the technology jump in this area. In the last 10 years alone, we have seen the development of affordable technology in the field.
The world of digital technology has ushered in incredible savings in cost and time across the board in our daily lives. We have seen vivid changes in the way that we take our family snap shots and the trickledown effect has been the acceptance of digital technology—in all aspects of life. The societal push for less waste and more efficiency should make most doctors at least explore the options afforded to their practices by going digital when it comes to X-rays.
 What are the dollars and cents of going with digital X-ray opposed to conventional film? There is a front-loaded cost to digital radiography but, as an investment, digital radiography not only offers cost savings (no film, no chemicals, no processors), it can actually become a profit center. Going digital, X-ray moves from a cost per film, to a fixed cost—meaning that, dependent upon the number of X-rays that you take, it will make the practice a profit. As the doctor sees more patients, the cost of taking X-rays, per patient, actually decreases.
When upgrading from film to a digital system, the DC should consider that there may need to be additional equipment that they must upgrade as well, depending on which system they choose. In most instances this is the case but, with some systems, you can use the existing generators and bucky stand, so the doctor only has to purchase the digital plate, making the transition more affordable but easier to install. The doctor needs to determine which system requires new equipment and which ones can use existing modules, as this element does factor into over all cost and complexity—or lack thereof—of the switch to digital.
Radiation Level Comparison
I often get asked about the comparison of radiation levels between the conventional X-ray to digital. The newest text books in radiology now indicate that you can increase the kVp to higher levels with digital imaging because the software now controls contrast. So, you can limit the patient dosage by increasing the penetration of the beam—thereby reducing the absorbed dose. An increase in kVp does have to be within reason but, by increasing kVp, you can decrease mAs. Of course, with heavier patients you must increase the kVp in order to penetrate the excess mass and fluids.
There are also other safety benefits by going digital. There is no doubt that—as the office no longer uses processing chemicals—the air becomes much more clean and fresh; no one is exposed to toxic chemicals in film development or in having to dispose of the chemicals.
There is no doubt that—as the office no longer uses processing chemicals—the air becomes much more clean and fresh
What about maintenance?
Every company and system has different requirements for continuing maintenance. Most companies charge a monthly fee for technical support and also charge for all computer software upgrades. But not every company charges for technical support or computer software upgrades. It would be prudent to ask each vendor about their policies in these areas, as there could be hidden costs a doctor doesn’t realize unless he looks into maintenance and upgrade charges with each system.
Required Office Space and Training
Once a practice goes true digital X-ray, it eliminates the need for a processor, dark room and all of the required space to store film. CR still requires the use of a processor.
As far as training required to go digital, a doctor does need to traverse and understand the difference between digital images compared to film. The doctor needs to consistently evaluate diagnostic images and will require some training to do so. Some vendors have radiographers on staff who work with their clients to develop a technique chart that enables the doctor to obtain the desired images, leading to accurate diagnoses.
Image Quality Comparisons
Digital allows for further manipulation of the X-ray. In your general terms, it is the ability to window and level, or in layman’s terms, the ability to manipulate contrast and density, that enables the doctor to see different qualities in the image. Using digital X-ray allows the DC to get a consistent, quality image, because of the software manipulation ability, as compared to using film.
Using digital X-ray allows the DC to get a consistent, quality image, because of the software manipulation ability, as compared to using film.
HIPPA Compliant Issues
As with many things these days in a chiropractor’s office, you must consider HIPPA compliancy when making decisions on new technologies. With digital systems, the software allows password protection of the data via internal processes and procedures set for onsite security, thereby complying with HIPAA. (For doctors that want off-site HIPAA compliant storage, we have partnered with Central Data Storage, which stores and manages electronic patient imagining and documents.)
Summary
The standard for images must remain constant throughout the health care field. In order for chiropractors’ roles to become more vital today, they must take advantage of improved—and evolved—technology. That isn’t to say all facets of chiropractic care have to evolve, as many key elements of spinal adjustments may remain constant. But using conventional film X-ray is a technology that is 100 years old. As is the case with your family photos—now taking advantage of digital technology—it makes sense for the doctor of chiropractic to afford some of those same, related advantages by no longer using film in the process.
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Radiology
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Written by Terry R. Yochum, D.C., D.A.C.B.R., Fellow, A.C.C.R., and Chad J. Maola, D.C.
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Sunday, 13 March 2011 16:47 |
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 CASE HISTORY:
This 8-year-old fell and hyperextended his wrist.
Diagnosis: Torus fracture–distal radius.
FRACTURES OF THE WRIST
Distal Radius Fractures.
The distal radius is one of the most common sites of fracture in the wrist. Care must be taken to search all projections for these fractures, many of which are often subtle and obscure. In the absence of an obvious fracture, close observation on the lateral projection for displacement of the pronator quadratus fat line is a useful indicator for the presence or absence of fracture. Normally, this fat line appears as a well-defined linear lucency, oriented parallel with the plane of the radius, 2 to 5 mm from its anterior surface. In almost all cases of distal radius fractures, the pronator quadratus fat line will be altered.1 These alterations include anterior displacement, blurring, irregularity and obliteration of the line. The most common fracture of the wrist in the elderly is Colles’ fracture and in a child is a torus fracture of the distal radius.
Colles’ Fractures.
In 1814, Abraham Colles wrote the definitive description of this fracture which, consequently, bears his name. The injury is defined as a fracture of the distal radius, approximately 20 to 35 mm proximal to the articular surface, with posterior angulation of the distal fragment. More than 60% will have an accompanying fracture of the ulnar styloid process. The usual mechanism is a fall on an outstretched, extended hand. The physical appearance of the fractured distal forearm and wrist has led to its being called the dinner fork deformity. The incidence of the fracture increases with age, and this increase is so rapid in women that, by age 65, the lesion is six times more common in women than in men. Osteoporosis appears to be the underlying influencing factor. Complications are common and may be severe.
Torus Fracture.
This is the most common fracture of the wrist between 6 and 10 years of age. Typically, the fracture is located 2 to 4 cm from the distal growth plate. A torus fracture can occur in any long bone and is the term applied to a buckled cortex following trauma. As such, the key radiologic sign is a localized cortical bulge, bump or offset.1
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, CO, 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 Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is available for post-graduate seminars. He may be reached at 1-727-433-0153 or by email at
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 and Wilkins, Baltimore, 2005.
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Radiology
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Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.
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Tuesday, 08 March 2011 10:46 |
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I t is critical for every chiropractor to have a support team of health care specialists in order to render the highest level of care for our patients. The radiologist is the first specialist that you should add to your team. In the triaging of our patients, the progression is to create an accurate diagnosis, prognosis and treatment plan and then to treat. Imaging, both basic X-rays and advanced imaging such as MRI's, CAT scans and bone scans are often a critical step in getting to "first base," with the diagnosis. Without any diagnosis, we cannot treat our patients and, without an accurate diagnosis, we can go from spinal experts rendering quality care to well meaning practitioners who hurt their patients.
It was reported by Lurie, Doman, Spratt, Tosteson, and Weinstein (2009) that 42.2% of the cases reported by radiologists were not clear in their description of the morphology of the lesion seen in MRI. While this does not conclusively represent that the radiologist made an error (although, in many cases, gross errors are seen nationally), it does create a huge issue for the clinician who relies on the radiologist to paint a "verbal picture" of the tissue and lesion structure, in order to create an accurate diagnosis, prognosis and treatment plan.
The research study was done with general radiologists and not neuroradiologists. As a note, neuroradiology is not a level of licensed practitioner, but a level of academic degree. A neuroradiologist goes into a fellow program and studies only brain and spine for an additional 18-24 months. A general radiologist does rotations in brain and spine in residency, called a "neuro" rotation, and the spine rotation is usually five weeks. The rest of the education for a radiologist is general radiology, studying joints and other organs. Many MRI companies hire general radiologists and not neuroradiologists for economic reasons, and some of these general radiologists have not seen spine MRI for five, ten or twenty years since their residency. It is always suggested that, if you have a choice, request that a neuroradiologist review your MRI's.
It was reported by Lurie, Doman, Spratt, Tosteson, and Weinstein (2009) that 42.2% of the cases reported by radiologists were not clear in their description of the morphology of the lesion seen in MRI.
According to Magdy Shady, M.D., a neurosurgeon and fellow in neuro-trauma, he disagrees with the general radiologist over 80% of the time in the description of the morphology of the lesion, and will not make a surgical decision unless he has personally reviewed the films. This begs the question for the chiropractic profession, "At what level should we accept the radiologist's interpretation of the film, and at what level of reading expertise should the individual chiropractic practitioners involve themselves in the process of interpreting the images rendering an accurate diagnosis?"
From a clinical perspective, some of the more common errors seen by radiologists are referencing the wrong side and calling cauda equina compressions "cord compressions." Just recently, a radiologist in Washington state reported an enlarged artery on the intervertebral foramen erroneously. Each of these miscues alters the diagnosis, prognosis and treatment plan and creates havoc for both the patient and the practitioner.
In each of the above scenarios, the errors were realized by a chiropractor who was trained in MRI spine interpretation. Although chiropractors can return to school and get a diplomate in radiology (D.A.C.B.R.) which is highly recommended for those who want to focus primarily on interpreting film, the vast majority of us want to stay in our offices. For those practitioners, it is highly suggested that, as a profession, every D.C. take post-doctoral training in MRI spine interpretation, so that we all understand and can interpret the films to create an agreement with the radiologists’ reports.
Call it an ability to do an over read on the radiologist and it must be done. The 2009 Spine article mandates that we, as a profession, take responsibility for an accurate diagnosis of our patients. With a 42.2% unclear (error rate) reporting of the morphology of the lesion, circumstances require that we, at least, know the basics to say, "Something isn't right and we need another opinion." When there is a discrepancy in the interpretation, the team approach comes into play and we confer with the radiologist and ask what they see vs. what you see. If there is not an agreement, then a third party, hopefully a neuroradiologist, will be the final arbiter, so that an accurate diagnosis can be rendered. In some instances, another MRI sequence might be necessary. Either way, from a posture of clinical excellence, unless an accurate diagnosis is rendered, the clinician cannot create a treatment plan and render care. How can you treat what you do not know?
Reference
1. Lurie, J. D., Doman, D. M., Spratt, K. F., Tosteson, A. N., & Weinstein, J. N. (2009). Magnetic resonance imaging interpretation in patients with symptomatic lumbar spine disc herniations: Comparison of clinician and radiologist readings. Spine, 34(7), 701–705
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Radiology
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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.
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Friday, 24 September 2010 14:10 |
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Intertrochanteric Fracture Of The Proximal Femur
by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.
CASE HISTORY
This elderly female patient slipped getting out of the bath tub. She heard a crack and felt immediate pain.
DIAGNOSIS
Fractures around the proximal femur are relatively uncommon in young to middle-aged patients with a sharp increase in the geriatric patient.1 Severe forces are necessary to fracture the proximal femur in the young and middle years, while only moderate to minimal trauma may induce a fracture in the osteoporotic bone of the elderly. Certain predisposing factors may allow fractures to occur, such as the presence of Paget’s disease, fibrous dysplasia, benign or malignant bone tumors, osteoporosis, osteomalacia and radiation-induced osteonecrosis.1
The overall incidence of all types of fractures of the proximal femur shows a two to one female-to-male ratio. A five to one female predominance exists with intracapsular fractures. The average age is approximately seventy years. It has been estimated that 10 percent of white females and 5 percent of white males will sustain fracture of the proximal femur by the age of eighty years. The incidence by the age of ninety years increases to 20 percent for women and 10 percent for men. Many elderly patients with fractures of the proximal femur die within six months of the original injury. This occurs secondary to pulmonary or cardiac complications. Therefore, fracture of the proximal femur and their attendant sinister1 complications are of such proportions that they represent a major health hazard to the elderly and constitute a significant public health issue because of their frequency, morbidity, and cost.
The standard radiographic examination of the hip joint includes an anteroposterior (AP) full pelvis, AP hip spot (involved side) and an oblique or frog-leg projection.1
Types of Hip Fractures
The types of hip fractures are divided into intracapsular and extracapsular, as determined by the relationship of the fracture line to the joint capsule. In general, intracapsular fractures have a high incidence of nonunion and avascular necrosis due to probable disruption of the tenuous blood supply. 1
Intracapsular Fracture. Any fracture involving the femoral head or neck proximal to the trochanters is classified as being intracapsular. These are then named according to the fracture location:
a) subcapital (involving the junction of the femoral head and neck;
b) midcervical (through the midportion of the fermoral neck);
c) basicervical (traversing ) the base of the femoral neck and its junction with the trochanters.
Most femoral neck fractures are subcapital; midcervical and basicervical fractures are uncommon.
Extracapsular Fracture. This type of fracture occurs outside of the joint capsule and includes intertrochanteric, subtrochanteric and avulsion fractures of the greater or lesser trochanters. Avascular necrosis and nonunion are uncommon complications in extracapsular fractures.
The intertrochanteric fractures are usually comminuted, with the greater or lesser trochanter, or both, forming separate fragments. The oblique fracture line usually splits the trochanters, separating the femur into two components. The proximal component consists of the head and neck, and the distal component includes the shaft and the remainder of the trochanter.
The subtrochanteric fracture is found in the area two inches below the lesser trochanter. This is an uncommon type of fracture of the proximal femur. Middiaphyseal fractures follow severe trauma and are prone to malalignment unless treated appropriately. Pathologic fractures of the proximal femur often occur in the subtrochanteric region. Paget’s disease and metastatic lesions in the proximal femur may be predisposing factors to the development of a subrochanteric fracture; thus the presence of a subtrochanteric fracture should be a signal to the observer to look closely for roentgen signs of adjacent bone disease.
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., Williams & Wilkins, Baltimore, Maryland., 2005
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