Radiology

Note the well demarcated geographic radiolucent lesion in the proximal femur. It has a sharp zone of transition around it with a sclerotic border. These roentgen signs suggest a benign lesion.

Diagnosis: Monostotic Fibrous Dysplasia

The skeletal lesions of fibrous dysplasia are not usually present at birth; they are present, however, several years prior to puberty and often progress throughout the entire life of the patient. Because of the progressive turnover of bone, patients with fibrous dysplasia will have a positive bone scan. All of the bones of the body may be involved; however, there is a particular site predilection for monostotic and polyostotic involvement.¹

Monostotic Fibrous Dysplasia

The most common location for monostotic fibrous dysplasia is in the proximal one third of the femur and the posterior ribs.¹ Most lesions affecting the long bones are placed in the diametaphysis and spare the subarticular surface of the bone. This anatomic predilection is helpful in the differential diagnosis of Paget’s disease. Paget’s disease, on occasion, may mimic fibrous dysplasia; however, involvement of the tubular bones in Paget’s disease invariably extends to include subarticular bone.¹

The lesions of monostotic fibrous dysplasia are usually radiolucent, often having a loculated or trabeculated appearance (as seen in this case). Scattered throughout the fibrous lesions, there is an appearance of radiopacity. This represents the classic ground glass or smoky appearance of bone. This represents a base matrix of fibrous tissue with scattered osteoid, which Jacobson so appropriately calls the "wipe out of the trabecular patterns" appearance. Many students of radiology have struggled with the phrase "ground glass" appearance of bone. After hearing numerous explanations, the most plausible one offered suggests the appearance of glass following a grinder being used on its external surface to disturb its glistening sheen. This renders a homogenous, ill-defined density across the surface of the glass, which is very characteristic of the appearance within the medullary canal of the bones involved in fibrous dysplasia.¹

These geographic cystic lesions are often very well demarcated and, in the monostotic form, usually have a very thick, sclerotic border, referred to by Jacobson as the rind of sclerosis. There is a widening of the medullary canal, and the endosteum is often thinned and scalloped. Expansion of bone is a common finding. Deformity of bone, particularly in weight-bearing bones, is often found and occasionally is associated with pathologic fracture. There is no evidence of periosteal response, except in those cases following pathologic fracture or malignant change. Most of these lesions render a very typical and characteristic appearance, allowing the radiologist to establish the correct diagnosis in a high percentage of cases.¹ Often these lesions in the proximal femur are asymptomatic.

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

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 available for post-graduate seminars. He may be reached at 1-727-433-0153 or by e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

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Whiplash Injury

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, 25 September 2009 16:36
History This patient was in a motor vehicle accident and hyper-extended her neck. A fracture was seen–where is it? Introduction Fractures of the spinal column are found most commonly at C1-C2, C5-C7, and T12-L2. There has been a significant rise in spinal fractures and spinal cord injuries that appears attributable to an increase in automobile accidents and sports activities.¹ Approximately 20% of spinal fractures are associated with fractures elsewhere. Spinal cord injuries occur in 10 to 14% of spinal fractures and dislocations. Fractures of the cervical spine produce neurologic damage in approximately 40% of cases, whereas the incidence in fractures of the thoracolumbar junction is 4%, and in the thoracic spine it is approximately 10%. The incidence of neurologic deficit is much higher when the fractures affect the neural arch as well as the vertebral body. In 10% of the spinal cord injuries there are no associated fractures.¹ Flexion is the most common line of force in spinal injuries, with extension, rotation, shearing, compression, and distraction occurring less frequently. In order to demonstrate the presence of any fracture or dislocation, the radiographic examination must be comprehensive and of good diagnostic quality. Therefore, a complete series in each region of the spine should be performed, and, occasionally, pillar views, bone scans, or CT may be necessary to demonstrate the presence or absence of a fracture.¹ $Posterior-arch-fracture-at-C-$ Posterior Arch Fracture of the Atlas. This is the most common fracture of the atlas, accounting for at least 50% of all atlas fractures. The fracture is usually a bilateral vertical fracture through the neural arch, through or close to the junction of the arch to the posterior surfaces of the lateral masses. This fracture occurs as a result of the posterior arch of the atlas being compressed between the occiput and the large posterior arch of the axis during severe hyperextension. Almost 80% will have another cervical spine fracture. It is best seen on the lateral projection and can easily be overlooked. Serious complications are unusual, though associated cervical fractures may precipitate spinal cord injury. Close anatomic proximity of the vertebral artery to the fracture site may occasionally inflict serious vascular injury.¹ Anterior Arch Fracture of the Atlas. These fractures are usually horizontal segmental avulsions from hyperextension at the attachment of the anterior longitudinal ligament and longus colli muscle. They constitute less than 2% of neck fractures and often coexist with odontoid fractures. The avulsed fragment is best seen on the lateral film displaced inferiorly from the anterior arch, though a special frontal view with the tube angled caphalad beneath the mandible has been advocated. CT is definitive for diagnosis.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, 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

MRI’s, Herniated Discs, Survey Results and “The Chiropractic Team”

Radiology
Written by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP
Friday, 21 August 2009 11:20
Being a principled, subluxation-based or structural-based chiropractor is not mutually exclusive to being responsible for diagnosing your patient accurately. If the patient has a radiculopathic or myelopathic clinical presentation, the question is, "Why?" This has nothing to do with your practice paradigm; it has to do with your patient’s well being and what the cause is for that nerve pressure. There are many etiologies other than subluxation and our job, as chiropractors, is to ensure an accurate diagnosis that allows us to create a successful prognosis and treatment plan. Based on my experience in the chiropractic setting, approximately 3% of chiropractic patients require referrals for advanced imaging. A July 2009 survey of the profession done by The American Chiropractor indicated that 58.8% of chiropractors order one or less MRI’s per month, suggesting underutilization nationally. As for preference of the type of MRI machine ordered, open, closed or upright, almost 50% have no preference. Only 15% of the profession would prefer neuroradiologists, 85.4% think all imaging companies follow regulatory standards or don’t know and 53.5% think that all types of MRI machines equally detect herniated discs or don’t know. These results scream out to the profession that we, as a profession, do not understand MRI, a critical practice tool, as much as we need to. In 2009, an integral part of our diagnostic ability is predicated on MRI’s and they are all not alike, nor are MRI companies compelled to follow quality standards, in either performing the test or reporting the results, thereby often rendering blind results with potentially false negatives at the peril of the chiropractor and his/her patients. These false negatives are not a result of the radiologist missing a finding on a film but, many times, result from improper imaging protocols with slices that are "too thick." Not improper, just clinically non-diagnostic and not regulated. These false negatives can be eradicated if the chiropractor understands MRI protocols and mandates the correct image sequences and slices in his/her orders. This can only be accomplished with education and it is the responsibility of each individual chiropractor to get the training required to ensure an accurate MRI scan and results. Too many imaging companies, due to economic pressure, will cut corners on these blind items and compromise the results, leaving us in the dark, and that is our fault as much as theirs if we are ignorant. Many will opine that it is a fault of our professional education that we do not have a greater understanding of MRI and they couldn’t be more wrong. The purpose of our formal education is to give us a starting point to care for our patients and to be able to attain licensure by meeting the minimum national and state standards of practice. It is the responsibility of each individual to then take it to the next level. DD and BJ had the big idea. However, if you study history, you will find that BJ Palmer did more research in concert with his medical counterparts than most, if not all, in contemporary research. He created his own team and maintained control of all chiropractic decisions, as you should. Twenty years ago when MRI became readily available, there were no courses for chiropractors to learn how to read images and to teach them what protocols to order. I learned how to read the hard way; every time I ordered an MRI, I would go to the radiology office and ask them to show me what they were diagnosing and have them explain the anatomy and the pathology to me. After 100 to 200 patients and lots of trip to the radiologist, I became proficient in interpreting my own MRI films. Although an ineffective way to learn (formal training is much better), it opened my eyes on how to interpret MRI images, understand protocols and gave me an appreciation for the neuroradiologist. The solution is obviously education and creating your own team. The time has long passed that the chiropractor needs to be part of the medical team. That notion is so long over, it should be dead! Each chiropractor needs to create their own team that includes the medical specialist, when needed. As a result, the clinical decision making is not abdicated to the MD, who has no training in chiropractic, and allows us to maintain full control of our patients using our team for input. Without the requisite training in understanding image protocols and the basics of reading images, we are left in the above paradigm that the survey results brought out and then are forced to be part of the medical specialist’s team, because we will not have the necessary knowledge, mandating someone else, usually the MD specialist, to make the tough decisions and dictate to us the care of our patients. Does this mean we need to become radiologists? No, we need the knowledge and the credentials in reading MRI images and then we can utilize the radiologist as part of our team, to confirm what we are seeing. This brings us to the first member of our team, the radiologist, or more specifically, the neuroradiologist, who is a radiologist that spends an additional one to two years in training focused solely on brain and spine. I not only choose to be the best-of-the-best in clinical excellence through hard work; I also choose to only work with the best-of-the-best and the neuroradiologist is it. As a note, once I started to interpret my own MRI’s, I had numerous disagreements with the general radiologist’s conclusions and, after bringing the neuroradiologist onto my team, I rarely had a disagreement. The second member of my team is the neurosurgeon. If there is a space occupying lesion, such as a herniated disc on the cord or root, I confer with the neurosurgeon to ensure an accurate diagnosis, so I can make the clinical decision for my patient. There is no need for "gray areas" in disc-related diagnosis with today’s technology and your ability to assemble your team. This ensures an accurate prognosis and treatment plan. Over time, the medical specialists will see you as their equal, based upon your clinical excellence and the feedback your patients are giving them in consultation. In the end, this will equate to increased referrals and help to eradicate any negative stigmas that some of the "medical fringe" still harbor towards chiropractic. When you are in conference with co-treating doctors, either primary care or specialists, and you know as much or more than they do, it is only a matter of time before they will be reaching out to you for the solution to their patient’s non-surgical spinal-related care. This is how to build a referral network from the medical community. This is another example of how the only way to win for a lifetime is through clinical excellence. All it takes is a commitment to learn and the direction is clear. Once you have that level of knowledge with the understanding that the learning is ongoing, all that remains is how you communicate with your patients and community. The message is simple; get the knowledge, the credentials, create your own team and be in control. Dr. Mark Studin is the President of CMCS Management which offers the Lawyers Marketing Program,Family/MD Marketing Program and Compliance Auditing services. He can be contacted at www.TeachChiros.com or call 1-631-786-4253 Add new comment

Herniated Discs & Advanced Imaging

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, 21 July 2009 15:33
The patient enters your office and has significant pain radiating into an extremity. Being responsible, you adopt the policy of the insurers and treat the patient conservatively for 4-8 weeks and the pain doesn’t diminish; you then refer the patient to the imaging company for an MRI. In the report, there are minimal findings, so you continue to treat with marginal results. After a few weeks, you refer to an orthopedist who, in turn, refers to a neurosurgeon, who eventually orders another MRI prior to surgery. At first, you get angry because you are out of the loop; secondly, you feel, over time, the patient could have responded to your care; and, finally, you lose sleep worrying about a malpractice suit over something you did or didn’t do. This is the litany of emotions that thousands of us have gone through because we were not in control as a result of our ignorance of anything other than clinical evaluations, spinal X-rays, some electrodiagnostics and adjustments. Being the best-of-the-best in chiropractic includes your ability to understand the innate component of the adjustment and/or the joints’ ability to function normally once put in the proper position. These basics make chiropractic unique and are the foundation for patients getting well in a way no other healing discipline can compete. However, this is 2009 and, with advanced technology, we can see more, understand more and do more in triaging the severe, mild and sub-acute patients. The tool is advanced imaging, specifically MRI and, when contraindicated, 3-D CAT scans. Regarding technology, a 1-Tesla MRI machine will soon be released and will be capable of scanning patients with pacemakers Not every condition responds to chiropractic care, and knowing when to refer will affect the outcome of your patients’ care positively, protect your license, and give you many peaceful nights of sleep. In addition, it will grow your practice over time, better than any marketing scheme you can devise. The reason your practice will grow is twofold. First, your patients will recognize that you have found the cause of their problem, especially if surgery is necessary; you will be the reason that they got better and will tell everyone they know. Secondly, the medical community will recognize you as being the best, based upon your referrals, documentation, triaging and your clinical conclusions and will engage professionally with you, resulting in dialogue and cross referrals. You will become part of the health care team instead of someone on the "outside looking in," based upon your clinical abilities or lack thereof. This has been quoted to me by many medical specialists through the years. There is validity to negative medical comments, if the patient has a condition beyond chiropractic care and you treat them at their peril. Although it should be an indictment against the individual doctor for not triaging the patient properly, it becomes an indictment against chiropractic; fair or not. The truth is that not one health care provider can help every patient. Advanced technology and the knowledge of how to utilize it is often the difference in triaging the patient accurately. Whether you practice in a subluxation or musculoskeletal model, the parameters for triaging the patient remain constant. I strongly recommend that, if the patient exhibits radicular or myelopathic clinical findings, an MRI be ordered to determine the nature of the lesion, prior to commencing aggressive care. There are many models and insurance industry parameters that do not agree. However, my paradigm is simple: If you do not know, you do not touch. The flow of care is diagnosis, prognosis and then creating and executing your treatment plan. A radiculopathic or myelopathic finding indicates that there is a space, occupying lesion on the spinal cord or nerve root and will dramatically change your treatment plan based upon the clinical presentation of that lesion. Being in control of your patient has two components. You need to know the full extent of the cord and/or root lesion when they present clinically and need an MRI; and, secondly, you need to be able to interpret the MRI. The only time in my thirty years of practice where I had a significant problem was when the medical specialist misdiagnosed the patient’s MRI findings and I accepted it as gospel. Since then, I have learned to read MRI’s, realizing that the general radiologist error rate on my patients was upwards of 40 percent. Neuroradiologists and neurosurgeons report the error rate over 70 percent. There are courses that can teach you how to read MRI’s and I strongly urge you to gain control of your patients and your practice by doing so. As technology advances, the information gained, becomes central to the chiropractor in creating an accurate diagnosis, prognosis and treatment plan. Next month, I will discuss how to create a chiropractic team that includes those medical specialists, while maintaining the control over your patients, even if surgery is indicated. That subtle shift is also the key to unlimited referrals from the medical community and all it takes is becoming the best-of-the-best at what you do. Add new comment

Erosive Osteoarthritis

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.
Sunday, 27 July 2008 10:47
History: This female patient complains of pain at the base of her thumb. An X-ray reveals what? Diagnosis: Observe the sclerosis and osteophytes at the base of the first metacarpal, which represents erosive osteoarthritis. Of incidental notation is congenital fusion of the capitate and the hamate (carpal coalition). EROSIVE OSTEOARTHRITIS General considerations: This is a distinctive clinical and radiographic variant of degenerative joint disease first delineated by Crain in 1961. The two most common terms applied to this arthropathy are erosive osteoarthritis and inflammatory osteoarthritis.¹ Clinical Features In contrast to primary degenerative joint disease, the onset of erosive osteoarthritis is characterized by episodic and acute inflammation of the distal and proximal interphalangeal joints of both hands in a symmetric manner. Pain, edema, redness, nodules and restricted motion are found at the involved articulations of the hands. This arthropathy is most commonly found in middle-aged females in the fourth or fifth decades of life. Laboratory investigations are inconclusive, with normal to slightly elevated erythrocyte sedimentation rate and negative rheumatoid factor. Chronic progression of the disease is to be expected with nodular, unstable and malaligned finger joints. The intensity of symptoms with each inflammatory episode may continue to be severe for many years. Approximately 15 percent may develop rheumatoid arthritis, with an average onset of twelve years after the initial episode of erosive osteoarthritis.¹ Pathologic Features: Variable tissue changes are found. These range from proliferative rheumatoid-like synovial abnormalities to cartilage degeneration and bony proliferation as seen in primary degenerative joint disease. Radiologic Features: Essentially, the radiographic changes are those of degenerative joint disease with superimposed bone erosions predominately involving the distal and proximal interphalangeal joints. Occasional involvement of the thumb at the metacarpophalangeal and carpometacarpal joints may occur, as well as between the trapezium and scaphoid articulations. Involvement of the ulnar compartment of the carpus is significantly spared, differentiating involvement from rheumatoid arthritis. All other joints of the body are generally uninvolved.¹ Radiographic changes are characterized by osteophytes, loss of joint space and sclerosis. Osteophytes are identical to those seen in degenerative joint disease. They are marginal in origin, taper distally, and are often larger at the distal articular component. Loss of joint space is usually non-uniform, with adjacent subchondral sclerosis. Superimposed changes of erosions, periostitis and ankylosis on these degenerative features are characteristic of erosive osteoarthritis. Bone erosions are distinctively centrally located on the proximal articular surface and more peripherally at the distal articular surface. The resultant altered joint surface contour has been called the "gull wings" sign. Adjacent linear periostitis is occasionally seen. Bony ankylosis is an uncommon but not unexpected sequel of one or more interphalangeal joints.¹ The main differential considerations are rheumatoid arthritis, psoriasis, and non-inflammatory degenerative joint disease. Rheumatoid arthritis rarely involves the distal interphalangeal joints and has a positive RA latex test. Psoriatic arthropathy is characterized by discrete marginal erosions with adjacent fluffy periostitis ("mouse ears" sign). Non-inflammatory degenerative joint disease will show no erosions, but will otherwise appear identical to erosive osteoarthritis.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, 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: Essentials of Skeletal Radiology, 3rd ed., Williams & Wilkins, Baltimore, Maryland, 2005. Add new comment