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Examining Clinical Opinion and Experience Regarding
Utilization of Plain Radiography of the Spine:
Evidence from Surveying the Chiropractic Profession
J Clinical Medicine 2023 (Mar 10); 12 (6): 2169
This survey provides the most extensive insight into the clinical opinion of the US chiropractic profession regarding plain radiography of the spine (PROTS) and suggests that the majority of the DCs consider utilization of PROTS to have value beyond the identification of pathology, to be vital to chiropractic practice and essential to biomechanical analysis. The US DCs who utilized PROTS only to rule out pathology in the presence of red flags are, in fact, statistical outliers in this study and may represent a minority of US DCs. A majority of the DCs also consider the doctors’ clinical experience and expertise, coupled with patient preferences, to be appropriate for recommending PROTS. Most DCs in this survey found that sharing spinal radiographic findings with the patient is beneficial for patient outcomes. All participants in the survey believed that patient outcomes would benefit from continued research regarding appropriate utilization of PROTS. The results of this survey clearly indicate the value of PROTS reflected by DCs and demonstrate the need for continued research to help understand how this value can affect the quality of care, conservative correction of spinal alignment and patient health.
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The Vast Majority of Patients With Fibromyalgia Have a
Straight Neck Observed on a Lateral View Radiograph of
the Cervical Spine: An Aid in the Diagnosis of
Fibromyalgia and a Possible Clue to the Etiology
J Clinical Rheumatology 2023 (Mar 1); 29 (2): 91–94
Most patients with fibromyalgia share an abnormality in common that is verifiable by a simple radiograph. In 83.2% of the patients, the cervical spine was essentially straight (Cobb angle ≤10 degrees). In fibromyalgia patients, the loss of cervical curvature was approximately 6.5 times greater than in control subjects (50.3% vs. 7.8%). A straight neck without other radiographic abnormalities may be a major anatomical abnormality in fibromyalgia that has gone unnoticed. It may assist in the diagnosis, as well as suggest increased muscle tension/pressure as a possible etiology.
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Association of Lumbar Spine Radiographic Changes
With Severity of Back Pain-Related Disability
Among Middle-aged, Community-Dwelling Women
JAMA Network Open 2021 (May 3); 4 (5): e2110715~ FULL TEXT
In this cohort of middle-aged, community-dwelling women, there was no evidence to support an association between a higher number of lumbar segments with radiographic changes (K-L grade, osteophytes, and disc space narrowing) and more severe back pain–related disability cross-sectionally or over time. The findings suggest that the changes detected on lumbar radiographs provide limited value for decision-making regarding back pain management in this population.
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Diagnostic Accuracy of Videofluoroscopy for
Symptomatic Cervical Spine Injury
Following Whiplash Trauma
Int J Environ Res Public Health. 2020 (Mar 5); 17 (5): pii: E1693 ~ FULL TEXT
The videofluoroscopic examination of the cervical spine is a highly accurate test for identifying patients with symptomatic ligamentous instability after whiplash trauma. The imaging modality should be utilized more widely in the clinical investigation of chronic post-whiplash pain
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Where Do Patients with MRI-confirmed Single-
level Radiculopathy Experience Pain, and
What is the Clinical Interpretability
of These Pain Patterns? A Cross-sectional
Diagnostic Accuracy Study
Chiropractic & Manual Therapies 2019 (Oct 7); 27: 50 ~ FULL TEXT
Composite pain patterns from patients in this sample, with L5 or S1 nerve root irritation, only approximated those of sensory dermatomes. Providing clinicians with level-specific knowledge of radicular pain patterns did not improve beyond chance their diagnostic accuracy of the involved nerve root level. On its own, pain distribution appears to provide minimal diagnostic information about the individual nerve root affected, even in this highly selected cohort with MRI-confirmed unisegmental radiculopathy and multiple neurological signs.
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Prevalence of MRI Findings in the Cervical Spine
in Patients with Persistent Neck Pain Based
on Quantification of Narrative MRI Reports
Chiropractic & Manual Therapies 2019 (Mar 6); 27: 13 ~ FULL TEXT
The method presented in this study of using inexperienced people to reliably extract data from narrative reports is a relatively simple way to collect large amounts of imaging data that can be used for research and quality assurance purposes. The prevalence estimates that we have reported for different segmental levels and age categories can provide clinicians and researchers with information on the expected prevalence for specific spinal pathoanatomical findings in patients with neck pain. Overdiagnosis may occur when a medical diagnosis is based on age-related MRI findings. It is therefore important for clinicians to know and communicate to the patient exactly how ‘normal’ these findings are in a patient population in order to avoid incorrect interpretation of MRI findings to be the cause of a patient’s symptoms. Further studies are needed to clarify the clinical relevance of these findings. Also, as spinal MRI findings obviously increase with age researchers should be conscious to report on prevalence according to age categories.
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Validity and Reliability of Clinical Prediction
Rules used to Screen for Cervical Spine Injury
in Alert Low-risk Patients with Blunt Trauma
to the Neck: Part 2. A Systematic Review from
the Cervical Assessment and Diagnosis Research
Evaluation (CADRE) Collaboration
European Spine Journal 2018 (Jun); 27 (6): 1219–1233 ~ FULL TEXT
Our review adds new evidence to the Neck Pain Task Force and supports the use of clinical prediction rules in emergency care settings to screen for cervical spine injury in alert low-risk adult patients with blunt trauma to the neck. The Canadian C-spine rule consistently demonstrated excellent sensitivity and negative predictive values. Our review, however, suggests that the reproducibility of the clinical predictions rules varies depending on the examiners level of training and experience.
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Criteria to Screen for Traumatic Cervical Spine
Instability: A Consensus of Chiropractic Radiologists
J Manipulative Physiol Ther. 2018 (Feb); 41 (2): 156–163 ~ FULL TEXT
Twenty-nine chiropractic radiologists participated in round 1. After 3 rounds of survey, 85% of participants approved the final consensus-based list of criteria for traumatic cervical spine instability screening, including 6 clinical signs and symptoms and 5 radiographic criteria. Participants agreed that the presence of 1 or more of these clinical signs and symptoms and/or 1 or more of the 5 radiographic criteria on routine static radiographic studies suggests cervical instability.
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Posterior, Lateral, and Anterior Hip Pain Due to
Musculoskeletal Origin: A Narrative Literature
Review of History, Physical Examination,
and Diagnostic Imaging
J Chiropractic Medicine 2016 (Dec); 15 (4): 281–293 ~ FULL TEXT
Musculoskeletal sources of adult hip pain can be divided into posterior, lateral, and anterior categories. For posterior hip pain, select considerations include lumbar spine and femoroacetabular joint referral, sacroiliac joint pathology, piriformis syndrome, and proximal hamstring tendinopathy. Gluteal tendinopathy and iliotibial band thickening are the most common causes of lateral hip pain. Anterior hip pain is further divided into causes that are intra-articular (ie, labral tear, osteoarthritis, osteonecrosis) and extra-articular (ie, snapping hip and inguinal disruption [athletic pubalgia]). Entrapment neuropathies and myofascial pain should also be considered in each compartment. A limited number of historical features and physical examination tests for evaluation of adult hip pain are supported by the literature and are discussed in this article.
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Identification Of Subgroups Of Inflammatory and
Degenerative MRI Findings In The Spine and
Sacroiliac Joints: A Latent Class Analysis
of 1037 Patients With Persistent
Low Back Pain
Arthritis Res Ther. 2016 (Oct 13); 18 (1): 237 ~ FULL TEXT
In general terms, the profile of each subgroup can be described in the following way.
Patients in Subgroup 1 had no or few MRI findings and therefore were labelled ‘No or few findings’.
Patients in Subgroup 2 had low sum scores on the variables related to spinal degeneration, with no or very few findings at the SIJs, and therefore were labelled ‘Mild spinal degeneration’.
Patients in Subgroup 3 had higher sum scores on the variables related to spinal degeneration than Subgroup 2, with no or very few findings at the SIJs, and therefore were labelled ‘Moderate/severe spinal degeneration’.
Patients in Subgroup 4 had similar sum scores on the variables related to spinal degeneration as Subgroup 3, but also MRI findings at the SIJ, and therefore were labelled ‘Moderate/severe spinal degeneration and mild SIJ findings’.
Patients in Subgroup 5 had lower sum scores of the variables related to spinal degeneration than Subgroup 4, but higher sum scores of findings at the SIJs, and therefore were labelled ‘Mild spinal degeneration and moderate/severe SIJ findings’ (see Figure 2 for details).
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Bladder Metastasis Presenting as Neck,
Arm and Thorax Pain: A Case Report
Chiropractic & Manual Therapies 2016 (May 4); 24: 14 ~ FULL TEXT
This patient presented in November 2014 with progressive neck, thorax and upper extremity pain. Computed tomography revealed a destructive soft tissue mass in the cervical spine and additional lytic lesion of the 1st rib. Prompt referral was made for surgical consultation and medical management. Distant metastasis is rare, but can present as a musculoskeletal complaint. History of carcinoma should alert the treating chiropractic physician to potential for serious disease processes.
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Pathological Burst Fracture in the Cervical Spine
With Negative Red Flags: A Case Report
J Can Chiropr Assoc. 2016 (Mar); 60 (1): 81–87 ~ FULL TEXT
A 61–year-old man presented to a chiropractic clinic with neck pain that began earlier that morning. After a physical exam that was relatively unremarkable, imaging identified a burst fracture in the cervical spine. The patient's initial physical examination was largely unremarkable, with an absence of clinical red flags. The screening tools were non-diagnostic. Pain with traction and the sudden onset of symptoms prompted further investigation with plain film imaging of the cervical spine. This identified a pathological burst fracture in the C4 vertebrae.
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MRI Findings of Disc Degeneration are More Prevalent
in Adults with Low Back Pain than in Asymptomatic
Controls: A Systematic Review and Meta-Analysis
AJNR Am J Neuroradiol 2015 (Dec); 36 (12): 23942–2399
This meta-analysis of epidemiologic studies demonstrates that MR imaging evidence of disc bulge, disc degeneration, disc extrusions and protrusions, Modic 1 changes, and spondylolysis had significant associations with low back pain in adult patients 50 years of age or younger. The association between these degenerative findings and pain should not be interpreted as causation. These imaging findings may be considered as candidate biomarkers for low back pain in younger patients (younger than 50 years of age). The role of these findings in determining treatment strategies or prognosis of low back pain has not been established.
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Radiology Undergraduate and Resident Curricula:
A Narrative Review of the Literature
J Chiropractic Humanities 2015 (Dec); (22) 1: 1–8 ~ FULL TEXT
Formal radiology education is not taught at all medical programs and little radiology training is incorporated into non-radiology residencies. This results in some medical graduates not being taught how to interpret basic radiology images and not learning contraindications and indications for ordering diagnostic imaging tests. There are no definitive studies examining how to incorporate radiology into the curriculum, how to teach radiology to either undergraduates or residents, or how to assess this clinical competency.
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MRI Spine Protocols
The American Chiropractor (September 25, 2013) ~ FULL TEXT
First, as I have discussed previously, general radiologists have a 42.2% error rate as reported by Lurie, Doman, Spratt, Tosteson, and Weinstein (2009), which makes it virtually imperitive that we, as practitioners, must take control of a critical component in diagnosing our pateints. At the very least, we must understand the basics of MRI spine interpretation to verify the findings or lack thereof. We also must be congnizant of the fact that we often rely on the MRI when ordering and delivering high velocity thrusts into our pateints. At this level, accuracy matters in determining a correct prognosis and treatment plan to ensure the safety of our patients when adjusting the spine. It is imperative for chiropractic.
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Multiple Myeloma Presenting as
Sacroiliac Joint Pain:
A Case Report
J Can Chiropr Assoc. 2012 (Jun); 56 (2): 94-101 ~ FULL TEXT
Multiple Myeloma (MM) is the most common primary cancer of bone in adults. The clinical presentation of MM is varied and depends on the sites and extent of involvement. Most importantly for chiropractors, the leading clinical symptoms of MM are related to bone neoplasm and may mimic pain of musculoskeletal origin. The following is the case of a 56 year old male chiropractic patient presenting with a 6 month history of sacroiliac joint pain previously diagnosed and managed unsuccessfully as a hematoma by multiple providers. Physical examination, imaging, and laboratory investigations confirmed a diagnosis of MM. The case report describes relevant pathophysiology, clinical presentation, imaging, and management for MM, while illustrating key issues in patient management as they relate to chiropractic practice and the recognition of pathology in the context of musculoskeletal pain.
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SPECT/CT Imaging of the Lumbar Spine in
Chronic Low Back Pain: A Case Report
Chiropractic & Manual Therapies 2011 (Jan 11); 19: 2 ~ FULL TEXT
Mechanical low back pain is a common indication for Nuclear Medicine imaging. Whole-body bone scan is a very sensitive but poorly specific study for the detection of metabolic bone abnormalities. The accurate localisation of metabolically active bone disease is often difficult in 2D imaging but single photon emission computed tomography/computed tomography (SPECT/CT) allows accurate diagnosis and anatomic localisation of osteoblastic and osteolytic lesions in 3D imaging. We present a clinical case of a patient referred for evaluation of chronic lower back pain with no history of trauma, spinal surgery, or cancer. Planar whole-body scan showed heterogeneous tracer uptake in the lumbar spine with intense localization to the right lateral aspect of L3. Integrated SPECT/CT of the lumbar spine detected active bone metabolism in the right L3/L4 facet joint in the presence of minimal signs of degenerative osteoarthrosis on CT images, while a segment demonstrating more gross degenerative changes was quiescent with only mild tracer uptake. The usefulness of integrated SPECT/CT for anatomical and functional assessment of back pain opens promising opportunities both for multi-disciplinary clinical assessment and treatment for manual therapists and for research into the effectiveness of manual therapies.
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Accurate Prognosis in Personal-Injury
Cases Using George's Line
Dynamic Chiropractic (March 26, 2010) ~ FULL TEXT
The AMA's Guides to the Evaluation of Permanent Impairments uses George's Line to rate neck impairments. A moderate (3.5 mm) break in George's Line on the flexion and extension lateral X-ray films is a permanent impairment, equivalent to a post-surgical fusion of two cervical vertebra. Most chiropractors see small anterolisthesis and/or retrolisthesis on the films and ignore it or fail to appreciate its significance. Since 35 percent to 45 percent of trauma patients have this injury, it is very likely you have failed to diagnose it many, many times. By failing to diagnose this injury, you have failed to accurately, thoroughly and honestly describe your patient's injuries to the claim adjusters and attorneys, who will use the facts in your patient chart as the basis for the personal-injury settlement. These people need you, the doctor, to give them all the facts so a fair settlement can be reached. The jury also needs to understand whether your patient had this injury in order to decide how much to award your patient in a trial verdict.
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The Effect of Backpacks on the Lumbar Spine
in Children: A Standing Magnetic
Resonance Imaging Study
Spine (Phila Pa 1976) 2010 (Jan 1); 35 (1): 83–88 ~ FULL TEXT
This is the first study to use advanced imaging to demonstrate how backpack loads are responsible for a significant amount of back pain in children, which in part, may be due to changes in lumbar disc height or curvature. This is the first upright MRI study to document reduced disc height and greater lumbar asymmetry for common backpack loads in children.
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Injuries in the Pediatric Patient: Review of
Key Acquired and Developmental Issues
J Clinical Chiropractic Pediatrics 2009 (Dec); 10 (2): 665–670 ~ FULL TEXT
A plethora of conditions specifically target children and adolescents which are not prevalent in the adult population. Understanding the age-related differences in this population can help clinicians improve diagnosis and therefore management of these conditions. Though it is beyond the scope of this paper to extensively address diseases targeting the pediatric population, common key injuries will be discussed with emphasis on the role imaging plays in establishing accurate diagnosis.
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Do Chiropractors Adhere to Guidelines for
Back Radiographs? A Study of Chiropractic
Teaching Clinics in Canada
Spine 2007 (Oct 15); 32 (22): 2509–2514
The results suggest a strong adherence to radiography guidelines for patients with a new episode of low back pain who presented to chiropractic teaching clinics. Although a high proportion of patients had red flags, radiography utilization was lower than rates reported in previous studies suggesting that adherence to guidelines may help prevent unnecessary radiography.
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Reliability and Validity of Lumbosacral Spine
Radiograph Reading by Chiropractors,
Chiropractic Radiologists, and
Medical Radiologists
Spine Journal (Phila Pa 1976) 2002 (Sep 1); 27 (17): 1926–1933
Small differences with little clinical relevance were found. All the professional groups could adequately detect contraindications to chiropractic treatment on radiographs. For this indication, there is no reason to restrict interpretation of radiographs to medical radiologists. Good professional relationships between the professions are recommended to facilitate interprofessional consultation in case of doubt by the chiropractors.
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Radiographic Anomalies That May Alter
Chiropractic Intervention Strategies
Found in a New Zealand Population
J Manipulative Physiol Ther 2004 (Nov); 27 (9): 554–559 ~ FULL TEXT
The 5 most frequently occurring anomalies in descending order were degenerative joint disease (23.8%), posterior ponticle (13.6%), soft tissue abnormalities (13.5%), transitional segments (9.8%), and spondylolisthesis (7.8%). Other noteworthy occurrences because of their generalized status as absolute contraindications to adjustment are fracture (6.6%), malignant tumor (0.8%–3.1%), abdominal aortic aneurysm (0.8%) and atlantoaxial instability (0.6%).
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Sacral Stress Fractures: Tracking Down
Nonspecific Pain in Distance Runners
The Physician and SportsMedicine 2003 (Feb); 31 (2) ~ FULL TEXT
Sacral stress fractures are an underrecognized cause of low-back and gluteal pain in distance runners. The combination of low bone density and increased activity blurs the boundary between fatigue and insufficiency fractures in many runners. MRI is the preferred radiologic technique because of its ability to localize the site of injury and rule out tumors, disk disease, or sacroiliitis. By identifying the condition early, clinicians contribute to a favorable outcome and help most athletes return to full activity in 12 to 14 weeks.
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Are Radiologic Changes in the Thoracic and
Lumbar Spine of Adolescents Risk Factors
for Low Back Pain in Adults? A 25–year
Prospective Cohort Study of
640 School Children
Spine (Phila Pa 1976). 1995 (Nov 1); 20 (21): 2298–2302
Eleven percent of the cohort had a history of low back pain in adolescence, and the results showed an 84% lifetime prevalence of low back pain in these subjects as adults and an increased frequency of low back pain the last month and week before they answered the questionnaire, compared with the rest of the cohort. This study suggests that low back pain in the growth period is "a real problem," with a trend toward aggravation as time passes. Thus, implementing preventive measures in schools may be very important.
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MRI of the Temporomandibular Joint
A wide variety of conditions affect the temporomandibular joint (TMJ) including congenital anomalies, ankylosis, arthritis, and internal disk derangement (1). TMJ disease is common, affecting between 4 and 28 percent of the population. Young females in particular commonly present with TMJ complaints (2).
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Diagnostic Imaging of Meniscal Injuries
Radiographic examination of the knee is often unrewarding, despite physical and orthopedic findings that clearly indicate an abnormality. Much of the supporting anatomy of the knee is invisible with conventional radiography, but more sophisticated techniques can be used to demonstrate these important structures. Magnetic resonance imaging is able to delineate the cruciate ligaments and menisci, providing the clinician a more complete and accurate view of the patient’s condition.
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The Azygos Lobe
This normal variant occurs in less than 5% of the population. Despite it's characteristic shadow, it often alarms physicians not familiar with it's apearance. The azygos lobe forms when the azygos vein fails to migrate over the apex of the lung during fetal life.
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Back Pain in Children
Virtual Pediatric Hospital
A commonly held belief in pediatrics is that back pain in children is rare, and its presence almost always heralds a serious underlying disorder. In reality, this belief only holds true in the prepubertal child, in whom back pain is rare, and if present often has a serious underlying cause. In adolescent children, chronic back pain may be found in up to 13% of them, but the underlying cause is often a sports induced injury. The job of the family practitioner or pediatrician seeing a child with back pain is to distinguish the serious from the non serious causes of back pain.
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Paediapaedia: An Imaging Encyclopedia
of Pediatric Disease
Paediapaedia is aimed at the radiology resident learning pediatric radiology for the first time, the pediatric radiology fellow mastering pediatric radiology for the first time, and for the general radiologist who does a small amount of pediatric imaging on a daily basis. Paediapaedia is meant to be a handbook of pediatric radiology. It is designed to let you get at the information you need easily and rapidly. It is meant to put the information you need most often at your fingertips.
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Deborah Pate, DC, DACBR Articles
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Taking a Wrist Series:
It's About the Carpals
Dynamic Chiropractic ~ January 15, 2012 ~ FULL TEXT
Routine radiographic examination of the wrist is not difficult, but does require some attention to positioning. Keep in mind that to evaluate a joint on X-ray, one must be able to visualize the joint in two planes at 90 degrees to one other. The routine series for a wrist includes PA and lateral views. For further evaluation, oblique projection may also be necessary if trauma or arthritis is evident.
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Joint Pain in Children: A Series of 7 Articles
Dynamic Chiropractic ~ FULL TEXT
Joint pain is a common complaint in children but seldom a symptom of serious joint disease. How can you determine if a child with knee pain has just a strain/sprain or a more serious joint disease, such as Lyme disease, rheumatic fever, or juvenile rheumatoid arthritis? This series of articles reviews the more common joint disorders affecting children.
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The Pediatric Elbow: A Review of Fractures
Dynamic Chiropractic (June 3, 2011)
~ FULL TEXT
The elbow fracture is one of the most common fractures in children. Assessing the elbow for fracture can be difficult because of the changing anatomy of the growing skeleton and the subtlety of some of these fractures. It's important to be aware of the radiographic signs of fracture in the elbow, along with knowing the appearance and fusion of the ossification centers in the pediatric patient, to avoid confusing an ossification center with a fracture fragment. Of course, alignment and radiographic positioning are also extremely important in making a diagnostic assessment.
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Scheuermann's Disease: A Poorly Understood
Abnormality of the Adolescent Spine
Dynamic Chiropractic (August 26, 2009) ~ FULL TEXT
Scheuermann's disease (SD) – osteochondritis of vertebral epiphyseal plates or adolescent kyphosis – was first described in 1921 by Holger Werfel Scheuermann, a Danish surgeon, as an osteochondrosis with cause unknown involving the spine and frequently causing lower thoracic kyphosis. The term juvenile kyphosis has sometimes been used to designate this condition. Although many theories have been proposed, the cause of SD is still unknown. Currently under investigation are the roles of juvenile osteoporosis, hereditary factors, biomechanical factors, and a variety of other causes, but to date no specific etiology has been determined, except that there is a disruption in the normal development of the vertebral end plate.
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Treatment of Disk Herniation: New Study
Compares Surgical vs. Nonoperative Treatment
Dynamic Chiropractic (January 15, 2007) ~ FULL TEXT
In this study, there were two broad treatment categories compared; surgical intervention and nonoperative care. Patients in the surgical group received a standard open diskectomy with examination of the involved nerve root. The nonoperative treatment group received "usual care," with the study protocol recommending that minimum nonsurgical treatment include at least active physical therapy, education/counseling with home exercise instruction, and nonsteroidal anti-inflammatory drugs, if tolerated. Other nonoperative treatments included CMT, acupuncture, braces, magnets, TENS and orthotics. The physicians participating in the study were encouraged to individualize treatment to the patient. I think it's interesting that out of 323 patients in the nonoperative treatment group, only 36 received chiropractic care, as opposed to 142 who received physical therapy. (For more information, take a look at table 2 in the original article.)
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Are You Evaluating Your Patients for Osteoporosis?
Dynamic Chiropractic (March 11, 2004) ~ FULL TEXT
The National Osteoporosis Foundation (NOF) recommends drug therapy for osteoporosis in patients with T-scores of –1.5 or lower and other risk factors. The NOF also recommends drug therapy for patients with T-scores of -2.0 or lower and no other risk factors. No, I am not referring to baseball scores; this regards osteoporosis, which affects approximately 28 million people in the United States.2 I know I have addressed this topic before, but I am now much more aware of this disorder. In fact, this evening, I read about 20 studies on osteoporosis, and noted three compression fractures in three different patients – all men, aged 23, 56, and 83 years. In general, I don't expect to see many compression fractures in that small a series of studies, so I guess I was impressed.
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American Chiropractic College of Radiology
