Radiology


Chiropractic Clinician and the Radiologist: A Partnership with a Caveat
Radiology
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Tuesday, 08 March 2011 10:46

radiologist

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

 
Intertrochanteric Fracture Of The Proximal Femur
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, 24 September 2010 14:10

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

 
Osteolytic Metastatic Carcinoma
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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.   
Thursday, 23 September 2010 14:57

Osteolytic Metastatic Carcinoma

by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.

 

Osteolytic Metastatic Carci

 

 

CASE HISTORY

 This adult male patient complains of back pain, especially at night, and it awakens him from sleeping.

Diagnosis: Osteolytic metastatic carcinoma of the left L-3 pedicle and vertebral body. This is the "one-eyed pedicle" sign or the "winking owl sign" of lytic metastatic disease.
(Figure 1)

 

 

 

 

Table 1.  Radiologic Features
of Spinal Metastasis

LOCATION:v   Lumbar/thoracic spine v   Vertebral body, pedicles 

SIGNS: Altered bone densityv   Decreased: moth-eaten, permeative diffusev   Increased: localized, ivory vertebra   Cortical destruction   Disc space unaffected     Pathologic collapse      v   Decreased posterior vertebral body heightv   Endplate disruption (malignant Schmorl’s node)   Pedicle destructionv   One-eyed pedicle sign (winking owl sign)

v   Blind vertebra (both pedicles destroyed

 

 

 

 

 

 

 

 

 

 

 

 

 

DISCUSSION: Pedicle. The pedicle is an important radiologically detectable site for osteolytic metastatic carcinoma. Any component of the neural arch can be involved, although the pedicle is by far the most common location. Destruction of the posterior vertebral body with contiguous involvement of the pedicle attachment results in loss of the cortical outline of the pedicle.1 This has been referred to as the one-eyed pedicle sign or the winking owl sign and is most commonly found in the lower thoracic and lumbar spine. It is most easily visualized on the AP radiograph. Most cases of pedicle destruction involve a single vertebra; however, multiple levels can be affected. Occasionally, bilateral pedicular destruction may occur and is referred to as the blind vertebra. (Table 1)

The most common cause for a missing pedicle is osteolytic metastatic carcinoma; however, agenesis of a pedicle may also occur. The key to radiologic differentiation is to search for a stress-related reactive sclerosis and enlargement of the contralateral pedicle. If this sign is present, it represents a firm assurance that osteolytic metastatic carcinoma is not present. Those cases of agenesis of the pedicle that create no stress hypertrophy of the opposite pedicle must be considered metastatic tumors until proven otherwise. Previous radiographs in this circumstance will be very helpful. Destruction of a pedicle in a patient under the age of thirty years is most commonly due to aneurysmal bone cyst (ABC), osteoblastoma, neurofibroma, or other cord tumors.

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

 

Reference

1. Yochum TR, Rowe LJ: The Essentials of Skeletal Radiology, 3rd ed.,

Baltimore, Williams & Wilkins, 2005.

 
Tourette Syndrome and Chiropractic Care
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Radiology
Written by Lisa Brittain, D.C., B.S.   
Thursday, 23 September 2010 13:25

Tourette Syndrome and Chiropractic Care

by Lisa Brittain, D.C., B.S.

 

History and Presenting Symptoms The patient is an 11-year-old male who was diagnosed at the age of four with Tourette syndrome. He has complex vocal and motor tics, which are made worse by stress. The tics affect his daily life; school, sports and his self esteem. The patient also notices he has fatigue and irritability. The patient has been on many different medications—clonidine, inversine, depakote, orap, clarinex, and singular—several causing side effects but never alleviating his tics. Exam Findings The patient is a very active young man; he plays golf, basketball, football, and baseball, as well as excelling at school. He has a good diet. Postural examination revealed anterior head carriage. Motion Palpation found a decrease in range of motion of the cervical spine along with tender spots at C1 and C2. An increase in muscle spasm throughout the right side of the thoracic spine, due to a side bend tic was noted. Surface EMG along with a Rolling Thermal Scan were performed. The sEMG revealed large amounts of nervous system disturbances at C1, C3, C5, C7, T1, T2, T4, T6, T8, T10, T12, L1 and L3. The Rolling Thermal Scan only showed one area of disturbance at T1. Imaging AP and Lateral cervical spine X-rays were performed and revealed a slight decrease in the cervical lordotic curve. Severe rotation and lateral fl exion of C2, along with lateral fl exion of the atlas, were also noted. Clinical Impression Cervical and thoracic segmental joint dysfunctions with associated myospasm in thoracic spine were present. Treatment Plan Diversifi ed adjustments were used to correct the subluxations. Bilateral pisiform adjustments were used to address the thoracic spine; side posture with specifi c contact was used to correct the lumbar spine. For the cervical spine, master cervical was used and a seated occiput adjustment was used to correct the occipital subluxation. The patient was adjusted three times a week for four weeks then re-evaluated. Response to Care The patient tolerated the adjustments very well. During the course of treatment, the patient stopped all of his medications. At the beginning of care, the patient rated his tics, both motor and vocal, an eight out of ten in severity; after twelve treatments, the patient rated his vocal tics a two out of ten and a three out of ten for motor tics. Also the patient noticed he had less fatigue and less irritability, since starting his chiropractic treatments Discussion The chiropractic adjustment relieved pressure that was being put on the nerves in the cervical spine which has direct relation to the brain and nervous system. In this case, the chiropractic treatments were the only thing that relieved the patient from his symptoms, allowing him to be medication free and back to his normal self.

 

Dr. Lisa Brittain graduated from Cleveland Chiropractic College in August 2006. That is where she met her husband, Jacob, who is also a Chiropractor. They opened their own practice in Overland Park. Dr. Brittain can be contacted at offi ce # 913-825-3900, cell # 913-269-1625. Offi ce address 10841 W. 87th Suite 200, Overland Park, KS 66214. Home 950 E. 126th Terr Olathe, KS 66061

 
Rasterstereography: Radiation - Free Technology for the Analysis of the Spine and Pelvis
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Radiology
Written by Jean Pierre Gibeault, P: eng.   
Thursday, 23 September 2010 13:23

Rasterstereography: Radiation - Free Technology for the Analysis of the Spine and Pelvis

by Jean Pierre Gibeault, P: eng.

 

RECENTLY IN THE LITERATURE: In a recent study, researchers demonstrated an excellent correlation between X-ray measurements and measurements made with rasterstereography (Schulte 2008). Schulte, et al., produced rasterstereographs and compared them to digitized A-P radiographs of the same 16 patients with idiopathic scoliosis. In this longitudinal study design, with a mean follow-up period of 8 years (range 3 to 10 yrs.), lateral vertebral deviation and vertebral rotation were measured between C7 and L4. This study design mimics actual clinical environments and, therefore, provides invaluable data to the clinician. During the 10 year time frame, Cobb angle measurements increased on average by 13 degrees. The study showed an excellent correlation between rasterstereographic and radiographic progression. The mean difference between rasterstereographs and radiographs was 3.21 mm for lateral vertebral deviation and 2.45 degrees for vertebral rotation. In conclusion, using the parameters of lateral vertebral deviation and vertebral rotation, rasterstereography accurately refl ects the radiograph measured progression of idiopathic scoliosis during the long-term follow-up. The authors do comment that the parameters used are not directly comparable with the Cobb angle. However, they recommend a rasterstereographic examination every 3 to 6 months and a radiographic examination every 12 to 18 months, provided that rasterstereography does not show rapid deterioration of the scoliosis. If this result is reproducible, patients and practitioners alike will want to change the way conditions, such as scoliosis and other global postural distortions are managed. Further studies confi rming the high accuracy of this technology can be found on both normal populations (Hackenberg 2003), as well as those with rotational scoliosis (Drerup 1997). With respect to these studies, it is reasonable to say, rasterstereographs can signifi - cantly reduce the amount of X-rays needed, without sacrifi cing clinical data. In fact, the sophistication of rasterstereography today affords the practitioner a cornucopia of postural information, well beyond what is possible with plain fi lm projections alone. Of course, X-rays do provide unique information about bone and soft-tissue that cannot be gleaned from any other source and, because of this, I believe that both will be a necessary part of chiropractic practice in the future. The Diers Formetric produces the rasterstereographs using an optical light scanner and computer software which automatically fi nds anatomical landmarks without markers or user placement. Thousands of images are taken over an adjustable time frame, which provides information for the quantifi cation of sway patterns, breathing tendencies, weight distribution, and a 3-D computer generated representation of the spine and pelvis. Although not as breakthrough, rasterstereography equipment available in the United States also offers range of motion analysis, cervical spine imaging, and a dynamic forceplate which can invert, dorsifl ex, plantarfl ex and elevate one foot at a time. This is particularly useful when assessing the effects of an orthotic or shoe lift on pelvic and spinal alignment. Rasterstereography is not new; Stokes and Moreland utilized the same technology twenty years ago (Stokes, et al., 1987) when they evaluated for changes in rib hump in seated, standing and forward bending postures.

 
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