|
Radiology
|
|
Radiology
|
|
Written by Jeff Cronk, DC
|
|
Friday, 22 April 2005 13:21 |
|
The theory behind evidenced based practice is scientific knowledge gathered through good research. Clinical examination procedures can lead to clinical consensus and standardization with regard to diagnosis, decision making and treatment guidelines.
X-ray digitation fits into this model, since it is a clinically accurate way to objectively assess spinal stability and spinal motion segment integrity loss. Two or more doctors can now look at the same patient, review the same findings and arrive at the same conclusions.
The application of evidenced based procedures can provide unparalleled confidence to the practitioner and can provide patients with a higher quality of care and, in addition, objective measurements can help inform our patients about their clinical picture and their future outcomes.
It’s important to know the rules and recommendations (Health Care Financing Administration [HCFA] Examination Guidelines, American Medical Association [AMA] Guides to the Evaluation of Permanent Impairment, Croft Treatment Guidelines) and apply them better than any other professional. To do this, though, we must stay up to date in our diligence and application of any guidelines that improve our ability to perform.
Let’s look at one clinical aspect of our practices, spinal injuries, to illustrate how this new paradigm works.
When a patient suffers a spinal injury, HCFA Examination Guidelines dictate that we perform our Ortho/Neuro exams with special emphasis on Range of Motion (ROM) and Muscle Strength Assessments. It also indicates that there should be, “assessment of stability with notation of any dislocation (luxation), subluxation or laxity.” In order to test stability of subluxation, we need to test the stability of the ligamentous structures that stabilize the vertebral motion segments. Which guide tells us what to do here?
The AMA Guides to the Evaluation of Permanent Impairment tells all practitioners what to do. “Motion of the individual spine segments cannot be determined by a physical examination, but is evaluated with flexion extension roentgenograms,” page 379, Fifth Edition. The guides go on to explain the parameters for Loss of Motion Segment Integrity (LMSI). LMSI is the degree of instability due to ligament compromise that the described spinal motion unit is experiencing. For purposes of conservation of article space, I will describe only the cervical parameters, which are 3.5 mm translation variation and greater than 11 degrees angular variations.
Now, let’s put it together, clinically, and then you will see how we can tie in all of the guide’s procedures into sound diagnostic and treatment protocols.
The injured patient comes in. A history, consultation and examination are performed. Part of your examination is to X-ray the cervical spine. The guides tell you, with injury or history of injury, you are to take flexion/extension views. To assess spinal stability in terms of degrees and millimeters, you send your films out to have them accurately assessed for LMSI by X-ray digitization. This ensures the most accurate and unbiased second opinion of your patient’s spinal stability. Your films come back from digitization with a report that shows that the patient has LMSI at C5, which is a ratable impairment.
What does this mean? Well, it means that the vertebral motion unit of C5 moves too much in angular or translational motion, as described by the guides. If we look further to the guides, they will tell all practitioners (not just chiropractors) that this means that this patient has a ratable impairment of 25-28 percent, which is permanent. Twenty-five percent with no residual symptoms and twenty-eight percent, if the patient has residual pain with this condition. Impairment means that this condition (LMSI) will, both now and in the future, on average, restrict this patient from fully being able to perform activities of daily living by 25-28 percent. It will interfere in the areas of self-care, communication, physical activity, sensory function, non-specialized hand activities, travel, sexual function and sleep. The assessment and treatment of these injuries are not to be taken lightly.
The guides give all practitioners further clarifications of this finding by categorizing it in a hierarchy according to level and seriousness of injury. LMSI is a category IV injury. To summate the cervical categories and give you a feel for the hierarchy, it goes as follows in the chart.
If you do not understand the seriousness of this Category IV, which is LMSI (severe ligament compromise) please visualize, having the clinical findings necessary to put you into a Category II or III, and then realize a Category IV is worse, according to the entire scientific and clinical consensuses which are available to all disciplines of providers. This ligament injury, according to the guides, is comparable to a 50 percent or greater vertebral compression fracture that has no residual neural compromise. An educated dentist would understand this; but do we, the spinal experts, understand this? Many of us do, but, unfortunately, many of us proceed to adjust this segment 10-50 times and wonder why the patient is not getting better.
In clinical practice, this is the procedure to follow on injured patients: History -> Examination -> X-rays (Flexion Extension Included) -> X-rays Digitized for Ligament Assessment, an LMSI Diagnosed -> Report Received, LMSI Confirmed, Treatment plan areas of adjustment revised, if need be, and patient is educated on the findings.
Croft Guidelines for the treatment of cervical acceleration/deceleration (CAD) injuries indicate that this finding (LMSI) puts your patient in a Grade III-IV. This means that, regardless of your technique, your guidelines allow for up to 76 clinical interventions in order to restore as much function as is possible, and monthly pro re nata (PRN) or “as needed” care can be indicated permanently. This is provided that there are no other complicating factors other than LMSI.
If your technique does not provide you with a good clear picture of how to restore optimal function in this scenario, then you must upgrade your technique knowledge, both from within and without of that specific technique, so that you are proficient in handling this condition.
Correct clinical management of your patients is the largest practice builder you will ever engage in, and it is the easiest and most profitable way to succeed.
An educator of mine said, “We must learn the rules, play by the rules and win with the rules.” If we engage in this, then and only then will we, as a profession, be making our environment, rather than adapting to one that was never meant for our inclusion.
Dr. Cronk was in private practice from 1988-2004. In 2004 he sold his clinic to move closer to his family in Wisconsin. He has since become a consultant with Myologic Diagnostics, Inc., and Spinologic Diagnostics, Inc. He can be reached for comment at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
|
|
|
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.
|
|
Tuesday, 15 March 2005 02:29 |
|
History
This young adult patient has had a motor vehicle accident with a “whiplash” type injury. Painful hyperextension of the cervical region is experienced by the patient.
 |
|
Figure 1. Note the unilateral fracture of the posterior arch of the atlas.
|
Discussion
The radiolucent unilateral defect in the posterior arch of this patient’s atlas represents a complete acute vertical fracture.
Fractures of the posterior arch of the atlas are the most common of all C1 fractures.1,2,3 They account for at least 50% of all atlas fractures.1,2 The fracture is usually a bilateral vertical fracture through the neural arch, through or close to the junction of the arch to the posterior surface 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.3 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 impact serious vascular injury.1,2
References
1. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, 3rd ed., Lippincott, Williams & Wilkins, Baltimore, Maryland, 2005.
2. Levine, AM, Edwards CC: Fractures of the Atlas: J Bone Joint Surg (Am) 73:680, 1991.
3. Landells CD, Van Peteghem PK: Fractures of the Atlas: Classification, Treatment and Morbidity. Spine 13:45, 1988.
Dr. Terry R. Yochum is a second generation Chiropractor and a Cum Laude Graduate of the 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’s 3rd edition textbook, Essentials of Skeletal Radiology, was released in the fall of 2004 and is now available for purchase. 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 the National College of Chiropractic. Dr. Maola has co-authored five chapters in Dr. Yochum’s 3rd edition textbook and is rendering post-graduate lectures with Dr. Yochum and separately throughout the United States. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. Dr. Maola 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
.
|
|
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, 15 January 2005 00:03 |
|
History
The young patient fell on an outstretched arm while playing football.
Discussion
The “S” shape and normal overlap with the upper ribcage renders the clavicle a difficult structure to evaluate on straight anteroposterior projections. The optimum view is anteroposterior projections with 15 degrees cephalad tube angulation. Weights (10-15 pounds) may be held to aid in detecting undisplaced fractures. The exposure factors should be approximately half of that utilized in standard shoulder projections, to prevent overexposure.
Radiological Features
Generally, a clavicle fracture follows direct trauma and is the most common bone fractured during birth and in childhood.
Medial Clavicle Fractures
This is the least common site, representing only approximately 5% of all clavicle fractures.1 These are difficult to observe and usually require CT scans.
Middle Clavicle Fractures
This is the most common site, representing approximately 80% of all clavicle fractures.1 A force applied to the distal end of the “S” shaped clavicle creates a shearing effect at the middle third, producing the fracture. The fracture is usually complete, with the medial fragment elevated by the action of the sternocleidomastoid muscle, and the lateral fragment depressed by the weight of the shoulder and upper extremity. In addition to misalignment, an overlap at the fracture site is common, with the distal fragment usually lying below the medial fragment. Healing is often associated with extensive callus formation.
Lateral Clavicle Fractures
These account for approximately 15% of all clavicle fractures.1 There are three varieties:
1) undisplaced;
2) displaced, where the distal fragment moves anterior and inferior; and
3) articular surface extension.
Whenever a fracture of the lateral third is identified, weight bearing stress views should be obtained to clarify the status of the coracoclavicular ligaments.2 Notably, fractures that extend into the joint frequently precipitate the onset of degenerative arthritis.
Complications of Clavicle Injuries
Childhood clavicular fractures usually heal without sequelae; however, in adults, the incidence of complications increases.
Neurovascular Damage
Associated injury to the underlying neurovascular structures most frequently involves the subclavian artery, less commonly the vein and, occasionally, the brachial plexus and sympathetic chain.3 Compressive effects from the hypertrophic callus can also precipitate pressure-related neurovascular disturbances.1,4
Nonunion
A failure to unite the fracture requires surgical fixation. The key signs of nonunion are located at the fracture margins, where sclerosis, rounding, and a smooth contour will be visible.
Malunion
In the presence of fragment overlap and massive callus formation, a cosmetic deformity may result. Correction requires osteotomy, realignment and fixation.
Degenerative Arthritis
Painful degenerative arthritis frequently follows intra-articular fractures of the clavicle. This is evidenced by loss of joint space, sclerosis and osteophyte formation.
Post-Traumatic Osteolysis
A peculiar bone response to clavicular injury is resorption of the distal segment, usually 1-3 mm, but never more than 2-3 cm. The initiating injury may be relatively minor, often lacking the severity of that required to cause a fracture or dislocation. It first becomes radiologically visible 2-3 months after injury. The precise mechanism is uncertain, although synovial hypertrophy suggests inflammatory osteoclastic activity.5 Pain is mild to moderate, while the disorder takes a self-limiting course over a number of months.
The earliest radiographic sign in the development of osteolysis is a cystic rarefaction of the clavicular subarticular cortex, followed by cortical dissolution.5,6 The joint appears wide and the clavicular surface is frayed and irregular or cup-shaped. With healing, there are varying degrees of bony reconstitution to complete restoration of structure to a permanently tapered distal clavicle and increased joint space.
Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty. He is currently Director of the Rocky Mountain Chiropractic Radiological Center, in Denver, CO, an Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as an instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum is, also, a consultant to Health Care Manufacturing Company that offers a Stored Energy system. For more information, 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 Maola is a 1999 Magna Cum Laude graduate of National College of Chiropractic.
References
1. Pavlov H, Freiberger RH: Roentgenology of Fractures and Dislocations, Shoulder. Edited by B. Felson, New York, Grune & Stratton, 1978.
2. Heppenstall RB: Fractures and dislocations of the distal clavicle. Orthop Clin North Am 6:477, 1975.
3. Yates OW: Complications of fractures of the clavicle. Injury 7:189, 1975.
4. Rockwood CA, Green DP: Fractures, Philadelphia, JB Lippincott, 1975.
5. Levine, HL, Pais MJ, Schwartz EE: Post-traumatic osteolysis of the distal clavicle, with emphasis on early radiologic changes. AJR 127:781, 1976.
6. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, ed 3. Baltimore, Lippincott Williams & Wilkins, Baltimore, 2005.
|
|
|
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, 14 November 2004 22:15 |
|
Embryology—Ossification of the first cervical vertebra begins about the seventh fetal week at the lateral masses and proceeds perichondrally in a dorsal direction, creating the posterior arch of the atlas. In the second year of life, a secondary growth center for the posterior tubercle develops between these neural arches. Complete fusion of the posterior arch should be noted between the third and fifth years.1
 |
Figure 1 - Note the congenitally malformed posterior tubercle of C-1 with posterior arch missing. Osteolytic metastatic carcinoma would not leave such a clear posterior tubercle and is very rare to affect the atlas.
(Case courtesy of Kelly Jarvis, DC, DABCO; Heber City, Utah) |
Description—The basic defect in agenesis of the posterior arch of the atlas is the lack of a cartilage template on which the ossification process builds. Complete or partial agenesis of the posterior arch is rare, and posterior arch defects, by themselves, should not be the cause of neurologic or biomechanical findings, unless found in association with other anomalies such as Klippel-Feil syndrome.
Radiologic Features—An absent posterior arch can be easily visualized on standard lateral cervical radiographs by the lack of a bony posterior neural arch. A commonly associated finding is enlargement of the superior aspect of the second cervical spinous process, which has been referred to as a mega-spinous process, representing fusion of a rudimentary posterior arch and posterior tubercle of the atlas (not present in this case).2 One may also observe increased size of the anterior arch of C1, which is thought to be stress related and present in this case. This is a helpful radiographic sign and suggests a long-standing congenital origin to the defect.
Medicolegal Implications of Agenesis of the C1 Posterior Arch
The integrity of the transverse ligament may also be compromised in the maldevelopment process; therefore, a cervical flexion radiograph should be performed to evaluate the atlantodental interspace.
References:
1. Gehweiler JA, Daffner RH, Roberts L: Malformations of the atlas simulating the Jefferson fracture. AJR 140: 1083, 1983.
2. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3rd Edition, Lippincott Williams & Wilkins, 2004.
Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty. He is currently Director of the Rocky Mountain Chiropractic Radiological Center, in Denver, CO, an Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as an instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum is, also, a consultant to Health Care Manufacturing Company that offers a Stored Energy system. For more information, 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 Maola is a 1999 Magna Cum Laude graduate of National College of Chiropractic.
|
|
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.
|
|
Tuesday, 14 September 2004 21:37 |
|
History
This patient fell off a horse while competing in a high level equestrian event. The patient fell directly over the sacrum and experienced immediate severe localized pain in the sacral area.
Discussion
Sacral fractures usually occur as the result of a fall upon the buttocks or following a direct traumatic blow. There are two types: Horizontal and Vertical.
Horizontal (transverse) Fractures
These are the most common type 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 lateral radiograph is usually required to demonstrate the fracture. Often, the lower segment of the sacrum may be displaced or angled forward.
A horizontal fracture of the upper sacrum, affecting the first or second sacral segments, may occur as a result of falls from a height. It is usually associated with suicidal attempts by jumping ("suicidal jumpers" fracture).
Vertical Fractures
These usually occur as a result of indirect trauma to the pelvis. They are visible on the frontal radiograph, but not the lateral view. The cephalic tilt-up view may be necessary to demonstrate the vertical fracture line, which usually runs nearly the entire length of the sacrum. 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 of the frontal radiograph for associated fracture of the pelvic rim or symphysis pubis is often beneficial.
Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty. He is currently Director of the Rocky Mountain Chiropractic Radiological Center, in Denver, CO, an Adjunct Professor of Radiology at the Los Angeles College of Chiropractic, as well as and instructor of Skeletal Radiology at the University of Colorado School of Medicine, Denver, Co. Dr. Yochum is, also, a consultant to Health Care Manufacturing Company that offers a Stored Energy system. For more information, 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 Maola is a 1999 Magna Cum Laude graduate of National College of Chiropractic.
References:
1. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, ed 3. Baltimore, Williams & Wilkins, 2004.
2. Rogers LF. Radiology of Skeletal Trauma, Volume 1 & 2, New York, Churchill Livingston, 1982.
|
|
|
|
|
|
|
Page 11 of 13 |
|
|
|
