CHAPTER 6: RADIOLOGIC MANIFESTATIONS OF SPINAL SUBLUXATIONS
CHAPTER 6:
RADIOLOGIC MANIFESTATIONS OF SPINAL SUBLUXATIONS



This is Chapter 1 from R. C. Schafer, DC, PhD, FICC's best-selling book:
“Basic Chiropractic Procedural Manual”


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Spinal Subluxations
  Definition and Significance
  Radiologic Manifestations

  Terminology of Radiologic Manifestations of Subluxations  
    Static Intersegmental Subluxations
    Kinetic Intersegmental Subluxations
    Sectional Subluxations
    Paravertebral Subluxations

  Classification of Radiologic Manifestations  
    Static Intersegmental Subluxations
    Kinetic Intersegmental Subluxations
    Sectional Subluxations
    Extraspinal Subluxations

  Case Presentations  
  Case Illustrating Classifications A-I and C-3 
  Case Illustrating Classifications A-I and R-2 
  Case Illustrating Classifications A-2, A-3, A-8, C-1, and C-2
  Case Illustrating Classifications A-2, A-6, A-9, and C-1 
  Case Illustrating Classification A-3 
  Case Illustrating Classifications A-3, C-3, C-4, and D-1 
  Case Illustrating Classification A-3 
  Case Illustrating Classification A-4 
  Case Illustrating Classifications A-4 and C-2 
  Case Illustrating Classification A-5 (Spondylolisthesis) 
  Case Illustrating Classifications A-5, A-6, A-8 and A-9 
  Case Illustrating Classification A-7 
  Case Illustrating Classifications A-1, A-3, A-4, A-7, and A-8
  Case Illustrating Classification A-8 
  Case Illustrating Classifications A-1, A-3, A-4, A-8, and A-9
  Case Illustrating Classifications B-1, C-2, C-4, A-8, and A-9
  Case Illustrating Classifications C-1, A-1, A-3, and A-8 
  Case Illustrating Classification C-1 and A-1 
  Case Illustrating Classifications C-2 and A-3 
  Case Illustrating Classifications C-4 and B-1


Chapter 6: Radiologic Manifestations of Spinal Subluxations

This chapter describes the radiologic signs that may be expected when spinal subluxations are demonstrable by radiography.


     SPINAL SUBLUXATIONS

Through the years, there have been several concepts within the chiropractic profession about what actually constitutes a subluxation. Each has had its rationale (anatomical, neurologic, or kinematic), and each has had certain validity contributing to our understanding of this complex phenomenon.

Articular disorders of the spine are not always demonstrable by roentgenography, and to depict them radiographically often requires techniques other than those routinely used in spinal radiography (spinography). The radiologic manifestations of spinal subluxation described in this chapter are an attempt to provide a uniform classification of manifestations that may be found when there is radiologic evidence of the presence of subluxation. Admittedly, there are other classifications and concepts. Those chosen were selected because they were believed to be defensible, widely acceptable, and relatively easy to understand.

Note:   In years past, what is referred to above as a motion unit was called a motor unit. The term motion unit was incorporated into chiropractic terminology in the late 1970s to avoid confusion with the neurologic term motor unit, meaning a single motor neuron and the muscle fibers its branches innervate.

The method used for classifying roentgenographic manifestations of subluxation is based on the concept of the intervertebral motion unit. An intervertebral motion unit consists of two vertebrae and their contiguous structures (disc interface and two posterior apophyses) forming a set of three articulations at one intervertebral level. It is best illustrated by using a lateral view (Figs. 6.1 and 6.2).

A motion unit has an anterior and posterior portion, and each has peculiar and special characteristics. The articulations are the mobile portions of the unit. This is mentioned because of the tendency to speak of a "subluxated vertebra" when in fact it is the articulations that subluxate.

The anterior portion of the motion unit includes the vertebral bodies, the interposed disc, the anterior and posterior longitudinal ligaments (which are not truly visible on a radiograph), and, of course, the muscles and other soft tissues not radiographically visible. The function of the anterior portion of the motion unit is essentially weight bearing and supportive. It has little sensory innervation. Changes or pathology affecting these structures, while they may be quite spectacular in appearance on a radiograph and alter spinal biomechanics significantly, are seldom accompanied by severe subjective discomfort in the local area.

The posterior aspect of a motion unit consists of the pedicles, neural foramina, articular processes and apophyseal articulations, the ligamenta flava, apophyseal capsules, the laminae, spinous processes, the inter- and supra-spinous ligaments, and all the muscles and other attached soft-tissue structures. Many of the posterior elements of a motion unit are richly endowed with sensory and proprioceptive innervation. Therefore, problems, pathologies, stresses, and distortions affecting these structures are typically painful.

The following sections explain and illustrate the consensus statement regarding subluxation from the historic Houston Conference of Chiropractic that was held in November of 1972.


Definition and Significance

A subluxation is the alteration of the normal dynamics and anatomical or physiologic relationships of contiguous articular structures. In evaluating this complex phenomenon, we find that it has or may have biomechanical, pathophysiologic, clinical, radiologic, and other manifestations. Subluxations are of clinical significance as they are affected by or evoke abnormal physiologic responses in neuromusculoskeletal structures and/or other body systems.


Radiologic Manifestations



In considering the possible radiologic manifestations of subluxations, it should be emphasized that clinical judgment is necessary to determine the advisability of exposing a patient to the potential hazards of ionizing radiation. An important purpose of exposure, in addition to the evaluation of subluxations, is the determination of other pathologies.

Radiographic procedures necessary to determine possible fractures, malignancies, etc, may not be the specific views needed to evaluate the possible radiologic manifestations of subluxation. When subluxation can be evaluated by other clinical means, it may be prudent to avoid radiation exposure.


Terminology of Radiologic Manifestations of Subluxations

      Static Intersegmental Subluxations

A-1.   Flexion malposition.
A-2.   Extension malposition.
A-3.   Lateral flexion malposition (right or left).
A-4.   Rotational malposition (right or left).
A-5.   Anterolisthesis (spondylolisthesis).
A-6.   Retrolisthesis.
A-7.   Laterolisthesis.
A-8.   Altered interosseous spacing (decreased or increased).
A-9.   Osseous foraminal encroachments.


      Kinetic Intersegmental Subluxations

B-1.   Hypomobility (fixation subluxation).
B-2.   Hypermobility (loosened vertebral motion unit.
B-3.   Aberrant motion.


      Sectional Subluxations

C-1.   Scoliosis and/or alteration of curves secondary to musculature imbalance.
C-2.   Scoliosis and/or alteration of curves secondary to structural asymmetries.
C-3.   Decompensation of adaptational curvatures.
C-4.   Abnormalities of motion.


      Paravertebral Subluxations

D-1.   Costovertebral and costotransverse disrelationships.
D-2.   Sacroiliac subluxations.

Note:   The code names (eg, A-1, B-2, C-3, or D-2) listed above are rarely used in professional communications. A descriptive title is used such as "flexion malposition of C5," rather than "A-1 C5."


        


Classification of Radiologic Manifestations

      Static Intersegmental Subluxations


Flexion Malposition.   In flexion subluxation, there is wedging of the disc space anteriorly as the vertebral bodies somewhat approximate one another anteriorly (Fig. 6.3).

Because of this, the spinous processes separate (open) and the inferior articular processes of the vertebra above glide upward upon the superior articular processes of the vertebra below. This elongates the intervertebral foramen (IVFs) so they appear larger in their vertical dimension.





Extension Malposition.   In this type of subluxation, which is one of the most commonly encountered (especially in the low back), the vertebral bodies approximate posteriorly and thus the disc narrows posteriorly (Fig. 6.4).

The posterior articulations show radiographic imbrication as the inferior articular processes of the vertebra above glide downward relative to the superior articular processes of the vertebra below. As the motion unit extends, the IVFs of the unit appear to become smaller in their vertical dimension.





Lateral Flexion Malposition.   This subluxation is characterized by lateral wedging of the disc interspace produced by approximation of the vertebral bodies on the side toward which the vertebra above laterally flexes (Figs. 6.5 and 6.6).

This also causes the facet articulation on the side of disc narrowing to imbricate while the contralateral articulation shows separation (opening) of the articular processes as the inferior articular process of the upper vertebra glides upward on the apposing process of the lower segment. dimension.





Rotational Malposition.   Intervertebral rotation, even in subluxation, is extremely limited at any single intervertebral level except in the upper cervical spine. Thus, there are usually several segments involved in a rotational disrelationship (Fig. 6.7).

The preponderance of the body of a rotated vertebra relative to its spinous process on the side toward which the vertebra has rotated posteriorly is well known to all doctors of chiropractic. A line drawing taken from an actual radiograph will show reverse rotation between the vertebrae that can be portrayed by a dotted line with the top three and the lower two vertebrae rotated in corresponding relationship to one another.




        

The next three types of subluxation are those in which the suffix "listhesis" is used. This suffix means "slippage," and the displacement is usually a gross distortion.

Anterolisthesis or Spondylolisthesis.   This malposition is typically produced by interruption of the isthmus (usually congenital) of a displaced vertebra at its pars interarticularis.

This allows separation of the anterior portion of the motion unit to separate from the posterior portion, resulting in anterior slippage of the vertebral body above upon the lower one (Fig. 6.8). In some cases, anterior slipping can occur without pars separation if considerable disc degeneration or facet arthrosis has developed to make the motor unit markedly unstable.





Retrolisthesis.   Posterior malpositioning of the upper segment of two vertebrae set (motion unit) is known as retrolisthesis.

The displacement is usually obvious in a radiograph (Fig. 6.9) and often accompanied by some extension of the motor unit and/or approximation of the vertebral bodies due to intervertebral disc (IVD) narrowing.





Laterolisthesis.   The lateral slipping characteristic of this type subluxation is typically accompanied by considerable segmental rotation.

The result is a demonstrable overhang of the lateral margin of the vertebral body of the upper segment relative to the one below (Fig. 6.10).





Altered Interosseous Spacing.   This form is probably the most common of all subluxations in elderly people. It mainly occurs when IVD degeneration has caused narrowing of disc space, which approximates the vertebral bodies and jams the posterior facets (Fig. 6.11).

Rarely, there may be some swelling or other abnormality of the disc causing increased interosseous spacing (Fig. 6.12).





The last type of static subluxation, foraminal occlusion, may be a consequence of one or more of those malpositions previously described (Fig. 6.13).

On the other hand, on rare occasion, there may be no other evidence of disrelationship per se.




        

      Kinetic Intersegmental Subluxations

Segmental hypomobility, also called a "fixation subluxation" by many clinicians, may affect one or several motor units.

It is characterized by reduced motion of the “Spinal Motion Unit”
(Please refer to Spinal Anatomy 101), which has been forced to the extreme of a range of motion (eg, flexion, extension, etc). See Figure 6.14. Stress views or videofluoroscopy are necessary to depict this and other kinetic subluxations radiographically, but motion palpation and some orthopedic tests may reveal their presence clinically.

Editor's Note:   In the following picture, the inferior facet of C5 fails to slide forwards and upwards upon the superior facet of C6. Because of that, the IVF cannot open more fully, and the spinous process of C5 fails to move away from the C6 spinous. All together, these are the classic signs of HYPO-mobility.





Hypermobility, called loosening of the vertebral motor unit by Earl Rich and Junghanns, may also be found at one or several levels. It is often found as a compensatory mechanism accompanying hypomobility (fixation) at one or more other levels in the kinematic chain.

Hypermobility (ie, an excessive range of motion) allows excessive range(s) of motion during flexion (Fig. 6.15). Again, this entity can be demonstrated by clinical means as well, but it takes stress radiography to document its presence objectively.

Editor's Note:   If there is excessive translation on flexion/extension films (more than 3 mm), this is a classic sign of instability. (Read Steven Eggleston, DC's article as it reviews the methodology for measuring spinal instability.)





Aberrant motion exists when one or several vertebrae move in a way that is not in coordination with neighboring segments during some movement of the spine.

One vertebra, at least, is not in phase with the general movement of neighboring segments (Fig. 6.16). In this view, one segment is extending while the others are in flexion.

Editor's Note: White & Panjabi, in their textbook “Clinical Biomechanics of the Spine” refer to this as “paradoxic motion”.




        

      Sectional Subluxations

Sectional subluxations are another group to be considered. They comprise disrelationships of a group of vertebrae.

Scoliosis and/or Alteration of Curves Secondary to Muscular Imbalance.   Such disrelationships are quite common.

They are demonstrated by abnormal curvature in which the usual compensatory mechanisms are not evident (Fig. 6.17).





Scoliosis and/or Alteration of Curves Secondary to Structural Asymmetries.   This is a frequently found scoliosis usually due to a short leg with pelvic unleveling (Fig. 6.18).

Any other asymmetrical defect may cause a similar distortion.





Decompensation of Adaptational Curvatures.   This is usually a relatively acute situation superimposed over a chronic deformity or distortion (Fig. 6.19).





Abnormalities of Motion.   These disorders can be found in spinal regions or at individual motor units (Fig. 6.20).

There is lack of ability of one or more to perform a movement normally (smoothly). The motion exhibited is an aberration, a departure from normal, such as a "jerky" or "jumpy" movement.




        

      Extraspinal Subluxations

The final classification of subluxations consists of articulations in which extraspinal structures articulate with the spine. The common disrelationships occurring at these articulations (costotransverse or costovertebral) are poorly shown radiographically, but the dysfunction incidental to the disrelationship may well cause spinal distortions suggestive of the subluxation. Marginal sclerosis of the articular surfaces is presumptive evidence of the existence of a subluxation.


     CASE PRESENTATIONS

Following are some case presentations depicting the various classifications of subluxations described above. Also included are some facts of historical significance, pertinent physical findings, diagnostic conclusions, and a short description of the patient's response to chiropractic management. The reader should keep in mind that these are not comprehensive reports. They will, however, underscore some relevant points.


Classification of Radiologic Manifestations

Case Illustrating Classifications
A-I (Flexion malposition) and C-3 (Decompensation of adaptational curvatures).

Note that there is a mild right-inferior pelvic tilt due to deficiency of the right lower extremity in the film shown in Figure 6.21. Yet, there is no distinct evidence of a lumbar scoliosis to the right as would normally be expected. This interesting finding was observed as one of the roentgenographic findings in the following case presentation.

This 50-year-old female presented herself to chiropractic service with the complaint of severe right sciatic pain and pain in the lower back. The patient had this complaint 3 years previously, when on consultation with an orthopedic surgeon, she was advised to have spinal surgery. To this she agreed; and the procedure was performed, apparently with removal of a portion of the L4 or L5 disc. After the surgery, however, she was never pain free. At various intervals she had received cortisone injections in the back in an attempt to alleviate the pain. With repeated urging by a friend, she finally decided to consult a chiropractic physician. Upon physical examination, the following information was learned:

1. A general physical examination was performed, and nothing of clinical significance was observed.

2. On orthopedic evaluation, however, the following signs were elicited: (a) positive Lasegue's test on the right at 20°; (b) positive Bragard's test on the right; (c) positive Kemp's test on the right; (d) well-leg-raise test produced lumbar pain on the right; (e) positive lumbar hyperextension on the right; (f) coughing and sneezing produced pain in the right buttock and down the right (posterior aspect); (g) right patellar reflex had a diminished response; (h) positive Neri's bowing test on the right; and (i) lumbar flexion was restricted to 20°.

The A-P film, as previously described, did not show the expected lumbar scoliosis to the right. Instead, the lumbar spine was quite straight. This abnormality is classed as a decompensation of an adaptational curvature (C-3).



The lateral lumbar view (Fig. 6.22) shows a marked flexion subluxation of L4 over L5 (A-1). In addition, we see loss of interosseous spacing at L5 and S1. No other evidence of osseous or soft-tissue abnormality is noted on this film.

The patient was placed on a schedule of conservative chiropractic management. After a period of 4 months of chiropractic treatment, the patient was released completely asymptomatic, with a full range of lumbar motion and normal and equal deep tendon reflexes. The patient returned for two treatments the following year. Since then, she has reported no experience of any of the previous symptoms.





Case Illustrating Classifications

A-I (Flexion malposition) and B-2 (Scoliosis and/or alteration of curves secondary to structural asymmetries)

In this case, films of a 48-year-old female show a patient who has sustained a torsion-flexion injury to the cervical spine when the automobile she was driving was struck at the left front. She was taken in a conscious state to the emergency room of the nearest hospital where she was given only a brief examination and released without roentgen study or other evaluations. She was told she lacked injuries and had no need for therapy. On presenting herself to chiropractic service, she complained of marked stiffness of the neck, blurred vision, vertigo, neck pain, and severe pain at both temples. She reported no previous neck injury.

The neutral lateral cervical film (Fig. 6.23) defines a definite hypolordosis, with abnormal flexion of C4 over C5 (A-1). Mild degenerative change is present at C5 and C6.




In the forward-flexed position film (Fig. 6.24), hypermobility (B-2) of C4 is seen as a definite segmental subluxation of the hypermobile type.




In the cervical extension position, restriction of the total range of mobility is seen (Fig. 6.25).




The right posterior oblique film in flexion (Fig. 6.26) discloses unilateral hyperflexion of C4 over C5 and C5 over C6, with widening of the IVFs.




The general alignment on the A-P film is good (Fig. 6.27).

In this instance, following physical and orthopedic evaluation, a diagnosis of cervical hyperflexion-torsion strain was made. The cervical spine was initially immobilized. This period of rest was followed by cervical adjustments. Recovery was slow, but no residual disability remained after the course of treatments.





Case Illustrating Classifications A-2,   A-3,   A-8,   C-1, and C-2

One of the most common subluxations found in the lower back is that of hyperextension of the vertebral motion unit. This usually accompanies, or is caused by, a posterior shift of weight bearing and is frequently found associated with an increased lumbosacral angle. It is characterized on film by an approximation of the spinous processes, extension or imbrication of the facet articulations, and posterior wedging of the interbody disc space.

This type of subluxation is demonstrated in the lateral radiograph (Fig. 6.28) at L4-L5 (A-2).





The oblique projection (Fig. 6.29) shows the downward displacement of the L4 articular process relative to the opposing superior articular process of L5. he contralateral oblique film demonstrates facet disrelationship on this side that even more marked than that seen on the other side (Fig. 6.30).

The left anterior oblique film (Fig. 6.29) revealed the facet compromise, which is apparent at the lumbosacral junction where the superior articular process of S1 is jammed against the undersurface of the L5 pedicle.

The inferior articular process of L5 had glided downward. Note the reactive sclerosis that this facet disrelationship has produced.




The right anterior oblique film (Fig. 6.30) shows similar but less marked jamming of the facet on the left. Reactive scoliosis is also obvious.

The lateral film (not shown) also revealed a marked narrowing of the disc space at L5-S1. This is classed as decreased interosseous spacing (A-8), and such a disrelationship is usually caused by IVD degeneration.

In the elderly, it's a common subluxation. Much of its importance is in the jamming of the facets, caused by approximation of the vertebrae under loading.




In the A-P projection (Fig. 6.31), we see a rather severe right inclination of the vertebrae above L5, which produces a right rotoscoliosis extending into the thoracic spine and including the vertebrae above those visualized in this film.

This inclination exists despite the fact that the pelvis and hips are relatively level. A rather severe right lateral flexion malalignment (A-3) of L4 upon L5 has occurred, and this lateral tilt of L4 gives an inclined surface on which the vertebrae above rest.

This is the basis for the scoliosis. Asymmetrical development of the posterior arch and articular structures (the right articular processes is smaller than the left) is the structural cause for the disrelationship. The oblique films (not shown) also show this asymmetry.

Such a lateral inclination is frequently seen where posterolateral disc protrusion exists. In most like circumstances, the disc herniation causes flexion of the motion unit as well as lateral flexion. In this case, the motion unit is extended (A-2) and laterally flexed (A-3).




The x-ray findings in this case include evidence of four classifications of subluxation A-2, A-3, C-2, C-1, and A-8:

  1. Extension subluxation (A-2) at L4-L5 (not shown).

  2. Severe right lateroflexion subluxation at L4-L5 (A-3) in this case, at least partially due to asymmetrical structural development.

  3. Scoliosis cephalic to L4 from the L4-L5 facet asymmetry. Muscular imbalance is also a factor in this scoliosis (C-1).

  4. Narrow interosseous spacing at L5-S1 (A-8). Discopathy is the cause of the narrowed spacing at L5-S1, and there is resultant facet arthrosis.

As explained previously, the presenting complaint in this case was low-back pain with sciatic neuralgia radiating down the left leg to the ankle. The patient came to the doctor of chiropractic after having spent 2 weeks in the hospital where hot packs, bed rest, and traction provided little relief. He was taking Robaxin (methocarbanol), which gave little comfort, and said that his MD had told him he was suffering from a "disintegrated disc."

Examination showed him to be in severe pain, with an obvious antalgic posture. He was guarding his movements very cautiously. The pain was so severe that a full physical examination could not be made. All low-back motions were severely restricted, and sitting aggravated the pain. The patient was wearing a back support provided by the orthopedic surgeon. Orthopedic tests brought out the following signs:

  • Lasegue SLR: positive on right at 80°, left at 10°.

  • Goldthwait: positive on the left.

  • Well-leg raising: positive on the right.

  • Lewin supine: pain on left.

  • Gaenslen: positive on the left.

  • Kernig: positive on the left.

  • Leg rocking: positive on the left.

  • Ely's test: positive bilaterally.

The diagnosis was Grade 4 disc syndrome, and especially careful chiropractic manipulation was started. A sitting disc adjustment afforded marked relief almost immediately. He was then sent home to bed. The following day the patient called and was in too much pain to come for treatment.

Two weeks from the date of first visit, he presented himself in worse pain than at the time of the initial visit. He had been in the hospital for a week, having been released the day before this visit. The orthopedic surgeon had recommended disc surgery, and he was scheduled for a myelogram the next day. A chiropractic adjustment again gave marked temporary relief. He was advised to return home to bed and to have another treatment the next day. The DC's reasoning concluded, since each adjustment helped temporarily, further treatment might be worthwhile. However, the patient did not appear for treatment the next day. A telephone call reported that he had returned to the hospital. Disc surgery subsequently showed posterolateral herniation on the left at L4.


Case Illustrating Classifications A-2,   A-2,   A-6,   A-9,   and C-1   A 57-year-old female presented herself to a DC's office with the primary complaint of low-back pain, which began approximately 6 days previously when she was bent over to dust furniture. She had a history of low-back pain approximately 10 years before this incident. The patient had a chronic complaint of stiff neck, suboccipital headache, tinnitus, and frequent paresthesias in both upper limbs, especially along the lateral aspect.

Physical examination showed:

(1) Blood pressure, 128/78.

(2) Pulse rate, 84.

(3) Auscultation of the heart and lungs revealed no abnormality,

(4) Abdominal palpation revealed no masses but some tenderness over the descending colon.

(5) Examination of the eyes, ears, nose and throat was unremarkable.

(6) On neurologic evaluation, the left patellar reflex was reduced. Other reflexes were normal. A mild hypesthesia was present along the lateral aspect of the right forearm and distally to the thumb. Passive elevation of the legs resulted in pain in the area of L4 and L5. Lasegue's SLR test was negative but restricted in range due to tight hamstring muscles.

(7) Because of a history of high serum cholesterol, blood was taken for this determination. Laboratory reports showed a cholesterol level of 257 mg%.

In the A-P film of the lumbar spine and pelvis (Fig. 6.32), a level pelvis and sacrum is seen.

Note, however, a mild left lumbar scoliosis, which is classed as a scoliosis secondary to muscle imbalance (C-1). In this case, it is probably chronic.




The next film, a lateral lumbar view (Fig. 6.33), disclosed an extremely marked hyperextension of the lumbar spine in general, with specific segmental hyperextension occurring especially at L4 on L5, L3 on L4, and L2 on L3.

This finding is noted by the marked approximation of the spinous processes and the sharp posterior convergence of the end-plate lines of the vertebral bodies (A-2). Calcific deposits in the abdominal aorta were also noted.




The cervical films reveal several deviations from normal spinal alignment, the most obvious of which is the retrolisthesis of the C5 segment (A-6).

This is noted by the break in George's line on the neutral lateral (Fig. 6.34) and by the bilateral foraminal narrowing at the level of C5 and C6 (A-9), which is seen in the oblique view (Fig. 6.35). In addition, the altered interosseous spacing caused by the degenerative disc of C5 can be seen. Foraminal narrowing due to joints of Luschka hypertrophy is present at C3-C4 on the left and at C4-C5 on the right.




The cervical films reveal several deviations from normal spinal alignment, the most obvious of which is the retrolisthesis of the C5 segment (A-6).

This is noted by the break in George's line on the neutral lateral (Fig. 6.34) and by the bilateral foraminal narrowing at the level of C5 and C6 (A-9), which is seen in the oblique view (Fig. 6.35).

In addition, the altered interosseous spacing caused by the degenerative disc of C5 can be seen.

Foraminal narrowing due to joints of Luschka hypertrophy is present at C3-C4 on the left and at C4-C5 on the right.




A diagnosis of lumbosacral myofascitis was made, with complications of facet involvement due to imbrication from marked hyperextension of the lumbar spine. A second diagnosis of cervical brachial radiculitis with extension to the radial nerve, predominantly on the right, was also entered. [Moderate chronic degenerative disc disease with foraminal encroachment and possible neural canal stenosis could also be included.] The patient was placed on conservative chiropractic management, and within 2 weeks, the low-back pain was completely alleviated. Continued treatment for 3 months resulted in correction of the tinnitus, paresthesias in the arms, and also the headaches. Her serum cholesterol was reduced to 222 mg%, and she was released from care. The symptoms referred to the head and neck, however, returned after 2 months, and she returned for monitoring monthly. At this time, her symptoms are under control.


Case Illustrating Classifications A-3  

The radiograph shown in Figure 6.36 reveals an easily demonstrable left lateral flexion subluxation of C3 upon C4 (A-3) and C4 on C5.

Observe that the lower cervical spine has retained good alignment in this A-P projection. C2 and C3 retained a good relationship with each other. However, when we compare the postural relationship between C3 and C4, a distinct left lateroflexion malposition of C3 as it relates to C4 can be seen.

This is further evident by increased approximation of the bodies on the left as opposed to the right, producing decreased articular spacing of the joint of Luschka on the left as compared to the right. Concomitantly, the articular processes at C3-C4 on the left are in much closer approximation than those on the right.




This A-P view is the preferred projection for demonstrating the lateroflexion type of subluxation. Multiple views of this 40-year-old female were taken and reviewed. No pathologic or architectural abnormalities were found, which suggests an acute subluxation. The history in this case bears out this observation. She had experienced no significant symptoms related to her neck until she awakened one morning with an extremely painful stiff neck.

She presented her head to the left in a fixed position and was unable to flex her head to the right or to extend her neck without severe pain. This observation, palpation, and muscle testing gave clinical evidence that fixation subluxation existed. Thus, the working diagnosis in this case was severe acute torticollis with a left lateroflexion subluxation of C3-C4. Conservative chiropractic adjustive therapy produced complete relief of symptoms after three treatments.

In acute cases such as this, it is not advisable to take follow-up x-ray films solely to show correction of the subluxation because is no benefit derived to warrant additional radiation exposure.


Case Illustrating Classifications A-3,   C-3,   C-4,   and D-1  

The lateral lumbar view shown in Figure 6.37 is that of a 57-year-old female. There is a loss of the normal lumbar lordosis.

The curvature is secondary to muscle imbalance (C-1). A moderate generalized degenerative condition.




The anteroposterior full-spine films (Fig. 6.38) exhibit several lateral flexion-type subluxations (C-3) and a rotational type at the level of L5 (C-4).

This patient presented with a history of acute pain in the left lateral rib cage about the level of the 3rd and 4th ribs. The back pain radiated around to the front of the chest wall and increased when she took a deep breath.

She had been previously told by a MD that she had pleuritis. This lady also complained of chronic lumbar pain following a snowmobile accident approximately a year previously.

Physical examination of the patient disclosed no significant findings relative to the respiratory system. Heart sounds were normal on auscultation, and the heart did not appear to be enlarged on auscultatory percussion. Her vital signs were not significantly altered. Palpation revealed severe tenderness over the heads of the 3rd and 4th ribs posteriorly, with intercostal tenderness between these two ribs that radiated around to the anterior. Orthopedic evaluation of the low back revealed restricted flexion of the lumbar spine although the patient could touch the floor with both palms. This was due to relaxed hamstrings and hypermobile hip joints. Her pain was aggravated on spinal hyperextension and Kemp's test bilaterally. Lasegue's and Goldthwait's tests were negative.

A diagnosis of intercostal neuralgia from thoracocostal facet subluxation was made. A second diagnosis of chronic lumbar sprain with degenerative complications was also recorded. A rib subluxation (D-1), though not readily determined via radiography, nevertheless can result in severe radiating chest pain --often mimicking cardiopathy, as could subluxations at T4--T6.

Under conservative chiropractic management, the acute chest pain was alleviated within a week, and the lumbar pain and restriction were asymptomatic in 4 months. This patient returns to her chiropractic physician four to six times a year for monitoring and supportive care.





Case Illustrating Classifications A-3

A 53-year-old male presented himself to a chiropractic office with a complaint of very acute lumbar pain with radiation into the right gluteal area and posterior thigh. His pain started at his place of employment when he had reached to the left in a slightly flexed position to pick up an object of less than five pounds. He felt a sharp stabbing pain in the lower back and was unable to straighten. He was taken to the plant infirmary where diathermy treatments were applied, but these did not alleviate the symptoms. On presenting himself for chiropractic care, he had great difficulty walking.

The A-P lumbopelvic film (Fig. 6.39) demonstrates an acute rotary and left lateral subluxation of L4 (A-3), and there is a slight left posterior body rotation of this segment relative to L5.

These findings in combination may suggest the presence of an acute disc rupture or protrusion. Degenerative change was also substantiated by a lateral view (not shown).

Physical examination revealed marked spasm of the erector spinae, especially on the left side. All ranges of motions were markedly restricted in the lumbar spine.

Kemp's, Lasegue's SLR, and Goldthwait's tests were all positive on the right side. Coughing and sneezing accentuated the symptoms. Other aspects of the physical examination were noncontributory.




The second film (Fig. 6.40), which was taken several days later, shows complete reduction of the L4 subluxation.

The acute pain was markedly relieved following the first chiropractic adjustment, and the patient was back at work within 10 days.





Case Illustrating Classifications A-4

This 53-year-old housewife presented herself with a complaint of neck stiffness when awakening in the morning that was associated with stiffness and discomfort in the right shoulder area. She said her problems brought on headaches and a decreased ability to move her neck comfortably. She reported episodes of this problem occurred frequently for a duration of more than 30 years. The length of her current problem was approximately 3 weeks.

In the past, she had obtained considerable relief from her symptoms through chiropractic manipulative therapy, but her usual doctor of chiropractic had retired. She said that medication prescribed by several medical doctors had been of no help. The MDs who had examined her had told her she had arthritis in her neck, and one told her "nine tenths of her body" was so affected. She reported that she had been in three automobile accidents: 1940, 1943, and 1965. Exercise seemed to aggravate her symptoms. Her only other presenting complaint was occasional low backache.

Her history revealed chronic eye strain and visual impairment. Chronic postnasal drainage, supposedly associated with sinusitis, an appendectomy at age 17, and partial hysterectomy at age 40 were revealed. She smokes 1-1/2 packs of cigarettes daily and drinks alcoholic beverages occasionally. No liver or gallbladder symptoms were expressed.

Physical examination showed normal vital signs and an abdominal scar from a hysterectomy but little else of significance. Orthopedic and neurologic evaluations showed no abnormalities except a slight decrease in rotatory cervical movements and some spasticity of the neck muscles. No orthopedic tests were positive. The neurologic examination was normal except for slight exaggeration of deep tendon reflexes in both arms and legs. A CBC showed normal values. The erythrocyte sedimentation rate and RA latex determinations were negative. Urinalysis revealed no abnormal findings.

Routine x-ray examination of the cervical spine showed a relative hypolordosis and a slight right convexity of the neck, with the head tilted slightly to the left in normal posture. No significant degenerative or other pathologic changes were noted. In fact, for her age and history, the lack of obvious degenerative changes was remarkable.

The lateral cervical film (Fig. 6.41) shows evidence of rotational disrelationships of the midcervical vertebrae (A-4). The axis and atlas show relatively little rotation, but the articular processes of C2 are superimposed over one another. To the contrary, C3 shows its articular processes to be quite distinctly not superimposed. C4 is similarly rotated but less markedly so. C5 and C6 show increasingly less rotation as evidenced by articular superimposition. C7 is also neutral in rotation; its articular processes are superimposed in the lateral view.

The A-P open-mouth film (Fig. 6.42) confirms the vertebral rotation. The left head tilt causes rotation of the axis with its spinous process right of central. This is the normal position for C2 with the head tilted left and no significant facial rotation.

The lower cervical A-P film (Fig. 6.43) shows increasing deviations of spinous processes to the right of central cephalad from C3 to C7 and the C3 vertebra shows the greatest deviation. The facets, as revealed by oblique films (not shown), appear to be adequately aligned, and the neutral foramina were patent.

To summarize the x-ray findings, we saw no demonstrable degenerative disease. Rotational subluxations (A-4) are apparent in the midcervical region.

Treatment by chiropractic manipulative therapy brought prompt relief of symptoms. She experienced a mild return of symptoms after 5 days, and returned for further treatment a week following her initial visit. Weekly visits for 2 weeks more and another after a 2-week interval found her to be comfortable, with no return of symptoms. She returned a month later with a mild recurrence of symptoms, which were quickly alleviated. Two months have elapsed without her return for further treatment. A telephone check showed her to be asymptomatic.


Classification of Radiologic Manifestations

Case Illustrating Classifications A-4 and C-2 A 62-year-old Caucasian male presented himself to a chiropractic office with the primary complaint of "gnawing" pain in the left hip. This condition had existed for about 6 months, and the history further revealed a weight loss of approximately 30 lbs since the previous October. At that time, he had experienced upper abdominal pain and, after hospitalization, had been diagnosed as having diabetes mellitus. He was placed on oral medication. The weight loss had occurred in the interim from October to June. He had received periodic "blood tests" that apparently were related to blood sugar evaluations.

Physical examination revealed:

(1) normal blood pressure and pulse rate,

(2) slight systolic murmur over the mitral area,

(3) normal and equal deep tendon reflexes,

(4) abdominal palpation found hepatic and splenic enlargement,

(5) bilateral pitting edema of the lower extremities was elicited, and

(6) prostatic examination revealed mild hypertrophy.


The orthopedic evaluation revealed:

(1) bilateral leg lowering, positive left;

(2) Patrick's test, positive left;

(3) Lasegue's SLR test for the right leg caused pain on the left side;

(4) deep tenderness to pressure was found at the level of L3 bilaterally; and

(5) the lumbar range of motion was normal, although there was some pain in the left hip on left side bending.


The A-P film of the lumbar spine and pelvis (Fig. 6.44) demonstrates a mild scoliosis due to structural asymmetry (a right lower-extremity deficiency a definite right rotary subluxation of L3 relative to L4 (A-4). Evaluation of the abdominal soft-tissues revealed an inferior displacement of both the splenic and hepatic flexures of the colon. The inferior border of the liver can be seen below the level of the iliac crest, and the inferior border of the spleen is seen at the level of the iliac crest. Although these films were taken in the upright position, the probability of splenomegaly and hepatomegaly existed.

The oblique spot film of the left hip reveals a very mild degree of degenerative joint disease (Fig. 6.45). The lateral lumbar film (Fig. 6.46) shows mild proliferative change but with good maintenance of lumbar disc spaces. There is a slight degree of lumbar hyperextension and osteoporosis.

The patient was instructed to return to his family physician for further laboratory evaluation, only to be told that his weight loss was due to the diabetes. During the interim, he received chiropractic care for his original complaint of hip pain. Within 2 weeks, a marked improvement in the symptom pattern was experienced, and he began to walk without favoring the left side. During the course of treatment, trigger-point therapy was given and the patient developed hematomas at the trigger-point sites. It was at this time that the DC insisted on drawing blood, even at his expense, to do a CBC. The report showed 386,000 WBCs. A diagnosis of probable myelocytic leukemia (chronic) was made, and the patient was again referred to the family physician --this time with full lab reports preceded by a phone call. The patient was treated for the leukemia by chemotherapy, and the DC continued to treat the hip disorder. The chiropractic diagnosis was one of L3 nerve root radiculitis, with extension to the left hip.

Following 3 months of chiropractic therapy, the second A-P film was taken. By use of a heel-lift, the pelvic tilt was somewhat corrected and the rotation of L3 over L4 was reduced. The patient was released completely asymptomatic relative to his primary complaint. He has not had a recurrence of this pain.


Classification of Radiologic Manifestations

Case Illustrating Classification A-5 (Spondylolisthesis) Another classification of subluxation is spondylolisthesis. In this case, we have a 46-year-old male who not only exhibits a classic spondylolisthesis but also manifests many problems encountered in the average chiropractic practice. These problems include a history of trauma involving litigation that eventually resulted in a permanent disability award under Social Security, which qualified him for Medicare coverage.

The patient stated that, while walking across a temporary ramp at a building under construction, he caught his heel on a nail and fell with a twisting motion. This resulted in immediate pain in the lower back and left buttock area. His lower back continued to hurt and steadily became worse, with the pain extending the full length of the left leg. He said he had never had symptoms of back trouble before this accident.

The patient was taken to a chiropractic office and was ambulatory with assistance. He had difficulty supporting his weight and undressing for the examination. He was unable to perform any mobilization test for the lower back. All passive tests for the low back were positive. There was severe trigger-point tenderness bilaterally from the lumbosacral joint, symptoms of left sciatic neuralgia, rigidity in the lower lumbar muscles, and the deep reflexes of the lower extremities were sluggish.

The lateral radiograph (Fig. 6.47) reveals a distinct anterior displacement of L5 in relation to another peculiarity of this case, a transitional lumbosacral segment. This transitional segment is immovable because of synostosis with the sacrum on the left. Therefore, the segment above (L5) becomes the lowest freely movable vertebra in the spine (Fig. 6.48).

This anterolisthesis subluxation (A-5) can be graded by several methods, one of which is a percentage evaluation of anterior body displacement. We value this as a 20% spondylolisthesis (Grade 1).

In typical cases, the predisposing factor toward spondylolisthesis is a defect where there is no osseous connection at the pars interarticulari. It may be bilateral or unilateral. A pars defect, a spondylolysis, is best visualized only on carefully positioned oblique views. Here, the spondylolysis is well demonstrated in both right and left views (Figs. 6.49 and 6.50).

Chiropractic treatment was started in an attempt to improve biomechanical function of the lower spine. This was accomplished to a great extent within 3 months. However, the spondylolisthesis and spondylolysis are irreversible and will result in continued instability. Periodic treatments as clinically indicated may be required, depending on the patient's activities.


Classification of Radiologic Manifestations

Case Illustrating Classifications A-5, A-6, A-8 and A-9 This case again shows coexistence of several classifications of subluxations and serious alteration of mechanical functioning of the neck. This 65-year-old female gave an extensive history of many illnesses and consulting many doctors of various specialties over several years. Her history revealed many complaints, both old and recent. She had experienced radical mastectomy of the left breast 21 years before her first consultation at a chiropractic clinic. Her chief complaint on the first visit was continuous neck pain of 4--5 weeks duration. She also complained of chronic occipital headaches, eye pain, pain radiating into the left shoulder, paresthesias of the neck and left arm, and pain sometimes extending to the left elbow.

Questioning revealed a history of "arthritis" affecting her neck and low back, gastritis and intestinal disturbances with discomfort after meals, nervousness, and pain on micturition on occasion for which she consults a urologist and periodically has urethral dilatation. These conditions were of several years duration and for which she takes prescribed medication. She had a L5 laminectomy 5 years ago, a hysterectomy at age 49, a cholecystectomy at age 30, surgery for an ectopic pregnancy when in her 20s, and an appendectomy while in her 20s. She suffered bronchopneumonia on one occasion in youth. A year before her visit to the chiropractic clinic, she had experienced viral pneumonia.

Physical examination showed her to be obese at 160 pounds for her height of 5 feet 2 inches. Her vital signs were essentially normal, with blood pressure of 130/78 left brachial; 136/80 right brachial. The significant abnormal findings were:

(1) Obvious postural distortion, especially in the neck, which carried toward the anterior. There was pain on the extremes of neck motion, with slight diminution in range of motion.

(2) The cervical compression test was positive bilaterally, worse on the left.

(3) Moderate lymphedema of the left arm.

(4) Absence of the left breast.

(5) Several scars over the abdomen and lower back consistent with the surgical history.

(6) Tenderness over the stomach and flexures of the colon. Other abnormal findings were apparent.


Cervical spine films revealed several abnormalities. Significant generalized osteoporosis was evident by the relative radiolucency of osseous structures and lack of trabeculations within the visualized bone. Spondylotic hypertrophy and spurring of vertebral body margins were not severe but present throughout the neck. Sclerosis of the articular facet surfaces is evidence of degenerative joint disease. The disc narrowing at C4-C5, C5-C6, and C6-C7 is noted. Several subluxations are apparent on the neutral lateral film alone (Fig. 6.51). C2 shows slight anterior displacement upon C3, with C4 (A-5) showing more anterior disrelationship relative to C5. C5 shows posterior displacement upon C6 (A-6). The anterior carriage of the head alters the cervical lordosis.

The lateral film taken during flexion of the neck fails to reveal significant overall reduction in flexion, but a little flexion is seen at the atlanto-occipital motion unit (Fig. 6.52). The anterior disrelationship of C2 upon C3 and C4 on C5 is not significantly altered during flexion, but the posterior disrelationship of C5 upon C6 is improved.

General extension of the neck is adequate with all motion units extending to the greatest degree allowed by structure (Fig. 6.53). In hyperextension, there is no apparent alteration of the anterolistheses at C2-C3 and C4-C5, but the retrolisthesis at C5-C6 is exaggerated as compared to the position in the neutral lateral film.

The open-mouth A-P film is essentially unremarkable, but the A-P of the lower cervical region (Fig. 6.54) shows considerable proliferative change of the posterior facets at C4-C5 on the right and less hypertrophy at other levels.

The oblique films (Fig. 6.55) show encroachment of the neural foramina at C3-C4, C4-C5, C5-C6, and C6-C7 on the left with similar changes on the right due to the uncovertebral arthrosis and uncinate hypertrophy (A-9).

X-ray examinations of the thoracic spine and the low back were also conducted. They showed severe osteoporosis and moderately severe spinal degenerative disease. The L5 laminectomy was demonstrable. These films and the chest studies (which were essentially normal except for the left mastectomy) are not shown here.

In summary of the cervical spine x-ray findings, we note generalized osteoporosis and spinal degenerative disease of moderate severity. The subluxations observed were:

(1) Anterolisthesis at C2-C3 and C4-C5 (A-5). Note that these are not the usual spondylolistheses seen in the lumbosacral area that show defects in the pars interarticulari. These anterolistheses are allowed by the disc and articular degenerative changes. They do not change significantly in flexion or extension of the neck.

(2) Retrolisthesis at C5-C6 (A-6), which is somewhat unstable and shows moderate hypermobility and abnormal motion on neck flexion and extension.

(3) Foraminal alteration or encroachment (A-9) at nearly every level in the neck bilaterally due to degenerative change and malposition of the vertebrae.

(4) Decreased interosseous spacing (A-8) from disc degeneration.

(5) Aberrant motion (B-3) with various motion abnormalities seen on stress study.


Blood chemistries and serology did not reveal significant deviations from normal. Hematology showed a slightly low hemoglobin (11.5 grams), but otherwise was essentially normal. Urinalysis did not show significant abnormality.

This patient was treated with conservative chiropractic care and encouraged to continue with the medical specialists who were attending her when she consulted the chiropractic clinic. She showed slow improvement in the neck and shoulder pain, and the headaches diminished in severity and frequency after only a few treatments. She continued under chiropractic care for almost 2 years, receiving frequent treatments for approximately the first 2 months of care, at which time she was advised that her problems would probably show little further improvement. She felt that she received benefit from the treatments and continued to present herself once or twice a month after that. Subsequent x-ray films of the spine were made after 14 months. They showed essentially no change. At her last visit, somewhat more than 2 years after the initial chiropractic examination, she was only slightly improved, having many complaints and experiencing only temporary relief following treatment.


Classification of Radiologic Manifestations

Case Illustrating Classification A-7 We see here an unusual complex of anomalies accompanied by a laterolisthesis type of subluxation (A-7) and a gross postural alteration.

This 55-year old pharmacist complained of severe, nearly constant, pain affecting the lower back. He had suffered from varying degrees of low-back pain for most of his life. The problem became progressively worse with advancing age.

The gross trapezoidal shape of the lower two lumbar segments shown in Figure 6.56 shows the result of anomalous segmentation. A hemivertebra may take varying forms. In this case, there are two half vertebrae forming the right portion of the upper trapezoidal segment and two half vertebrae forming the left portion of the lower segment. These are completely fused, resulting in a grossly unlevel superior surface of the lowest mobile vertebra. This causes a severe disrelationship combining rotational and lateral displacement (a laterolisthesis subluxation).

These gross abnormalities are expected to cause eventual degeneration despite proper maintenance care. In review, we can arrive at a diagnosis of double hemivertebra of the lower lumbar segments with a laterolisthetic subluxation (A-7).


Classification of Radiologic Manifestations

Case Illustrating Classifications A-1, A-3, A-4, A-7, and A-8 A 65-year-old male laborer presented himself for chiropractic care. He reported a primary complaint of acute low-back pain centering between L2 and S1 and was unable to work because of the pain. His history revealed very little low-back pain before this incident despite his heavy work. The pain was precipitated by a fall on ice.

Physical examination was relatively unrevealing except for the following orthopedic tests:

(1) Hyperextension of the lumbar spine produced increased pain.

(2) Lasegue's SLR and Goldthwait's tests were positive bilaterally.

(3) The lumbar ranges of motions were markedly restricted in all directions.

(4) The normal lumbar lordosis was flattened.


X-ray films of the lumbar spine were taken that revealed left lateral flexion of L5, which was best noted in the AP film (Fig. 6.57) by the approximation of the left transverse process of L5 to the left sacral ala (A-3). Severe rotational disrelationship of L4 to L5 (A-4) with slight right lateral flexion of L4 on L5 has produced a left laterolisthesis (A-7) of L4. L3 showed less rotation than L4, and L2 was in a position of reverse rotation (A-4) to the right so that an unusual left lower lumbar rotoscoliosis was formed with a slight right rotoscoliosis in the thoracolumbar area.

The lateral film showed decreased interosseous spacing (A-8) throughout the lumbar spine, with the least amount of disc narrowing noted at L4-L5. Loss of normal lumbar lordosis is also exhibited (Fig. 6.58). These changes have produced multiple flexion disrelationships (A-1), particularly in the upper lumbar area. Both A-P and lateral films showed marginal proliferative changes that were evidence of chronic disc degeneration. Moderate generalized osteoporosis is also present. By correlating these findings, a working diagnosis was made of lumbosacral strain with myofascitis superimposed on moderate spinal degenerative disease.

The subluxations noted are of several types, including:

(1) laterolisthesis of L4 on L5 (A-7);

(2) decreased spacing throughout (A-8);

(3) flexion malposition of the upper lumbar vertebra (A 1);

(4) left lateroflexion of L5 on the sacrum (A-3); and

(5) reverse rotation of L3 on L4 and of L2 on L3 (A-4).


Conservative chiropractic therapy was started. The patient was seen six times over a period of 4 weeks, with complete relief of symptoms. He could return to work after 10 days of treatment and was subsequently discharged with the advice that he should return for care as symptoms warranted. With the degree of degenerative changes present, he will likely have recurrent low-back problems.


Classification of Radiologic Manifestations

Case Illustrating Classification A-8 A 58-year-old housewife presented with a primary complaint of heavy aching pain between the shoulder blades, with a tendency toward sharp cutting pains to the front of the chest on awkward movement or coughing. She further complained of difficulty in breathing at times. These symptoms had occurred periodically over the past 5 years and were becoming more frequent and severe.

Physical examination did not show significant alteration of normal cardiovascular or pulmonary function. A detailed spinal examination revealed rigidity and tenderness of the thoracic paraspinal muscles, especially on the right in the lower thoracic area. Muscle testing against resistance demonstrated weakness of both divisions of the pectoralis muscles bilaterally.

The lateral film shows marked narrowing of the intervertebral disc spaces throughout the thoracic spine (A-8). Note reactive hypertrophic and sclerotic changes along the vertebral body margins, indicating a chronic condition (Fig. 6.59). This film definitely exhibits decreased interosseous spacing at multiple intervertebral levels. These subluxations, associated with thoracocostal myofascitis, and the other findings led to a working diagnosis of moderately severe thoracic degenerative disease.

Conservative chiropractic management was begun and, after six treatments over a period of 2 weeks, considerable symptomatic relief was obtained. After that, weekly adjustments were advised that resulted in continued improvement. She was relatively symptom free after 4 more weeks. The patient's diagnosis suggests that she will have periodic recurrence of symptoms requiring further treatment.


Classification of Radiologic Manifestations

Case Illustrating Classifications A-1, A-3, A-4, A-8, and A-9 The x-ray views presented next are those of a 69-year-old female (Figs. 6.60--6.62). There is foraminal narrowing at four levels on the right and two on the left due to proliferative changes (A-9). Flexion subluxation exists at C4 (A-1), and marked interspace narrowing is found at C5, C6, and C7 (A-8). A loss of normal cervical lordosis is evident. Rotary subluxation is present at C2 and C3 (A-4). Also note the generalized osteoporosis.

This lady complained of objective vertigo, tinnitus, and suboccipital pain and pressure. She had consulted her family physician 2 weeks previously, at which time she received an ECG, chest x-ray, and several blood tests. She was informed that nothing serious was wrong and her symptoms were related to a "weak chest."

Chiropractic examination revealed the following pertinent information:

(1) blood pressure, 190/110;

(2) pulse, 108;

(3) height, 5 feet 5 inches;

(4) weight, 123 lbs;

(5) cicatrix formation of the left tympanic membrane due to an old rupture;

(6) postnasal drip with hyperemia of the posterior pharynx;

(7) on auscultation, slight accentuation of the aortic sound; and

(8) the ranges of cervical motions showed restricted flexion and extension as well as in right lateral flexion; and

(9) a cervical compression test was positive bilaterally.


A working diagnosis of hypertension, possibly of neurogenic origin, was made. The patient was placed on a program of conservative chiropractic care, and after a month her blood pressure had stabilized in a range between 140/80 and 150/80. At the same time, her vertigo, tinnitus, and suboccipital pain were eliminated, and the ranges of cervical motions were increased. She was placed on supportive treatment at this time.


Classification of Radiologic Manifestations

Case Illustrating Classifications B-1, C-2, C-4, A-8, and A-9 The films of this case (Figs. 6.61--6.67) show alteration of the cervical lordosis in the neutral lateral film and lessened ability to flex the neck, coupled with slight hypermobility during neck extension (C-4).

As the cervical curve is naturally convex toward the anterior, alteration of this pattern usually means pathology or significant injury to the skeletal and/or supportive structures. Note in the neutral lateral film that there is flexion of the C3 and C4 motion units.

With neck flexion, near total fixation or hypomobility from C3 through C6 motion units (B-1) is demonstrated. The atlantoaxial and atlanto-occipital motion units show considerably diminished ability to flex (B-1).

Extension of the neck is accomplished, even to the point of hypermobility. All motion units extend as far as structure allows so that the posterior arches and spinouses approximate. By comparing the three lateral films (Figs. 6.63--6.65), we have an excellent example of abnormal mobility of a spinal section or region (C-5). Intervertebral hypomobility is present at several levels.

This case also exhibits manifestations of other radiologically evident subluxations. The decreased disc height at C4-C5, C5-C6, and C6-C7, due to the evident discopathy and spondylosis, is classified as decreased interosseous spacing (A-8). The rather marked intrusion and compromise of the neural foramina at C4-C5, C5-C6, and C6-C7, seen on the left anterior oblique film (Fig. 6.66), and similar alteration of the foramina at the same levels are shown on the right anterior oblique film (Fig. 6.67), also meet the criteria of subluxation under the classification of foraminal encroachment (A-9).

The patient is a strong 66-year-old male who has continued to work as manager of a solid-waste disposal plant though he had passed the age of retirement. He was suffering from pain in the neck, which radiated to the right shoulder. The duration of the complaint, at the time the x-ray films were made, was 3 weeks. He had this complaint on several previous occasions and each time had experienced an excellent remission of symptoms following chiropractic treatment. He had not had similar pain for about 3 years prior to the time he presented himself for chiropractic care for the current episode.

Views of the right shoulder, one of which is shown in Figure 6.68, were essentially normal. Physical examination was largely unrevealing, except that orthopedic testing showed grossly restricted ability to laterally bend the neck to either side, and foraminal compression tests were positive bilaterally.

The moderately severe degenerative disease the x-ray examination reveals in this man's neck are chronic. The relatively short duration of the present symptom complex suggests that his current pain is more related to neuralgia from functional disturbance in his neck than to a chronic neuropathy. The foraminal encroachment of sufficient magnitude and severity to suggest neural canal stenosis.

Chiropractic adjustment and reflex techniques brought marked relief in three treatments over a 1-week span. Two treatments the following week were able to bring a near total remission of the pain. He continued with weekly treatments for 2 more weeks, stating that he felt markedly better. Following the 4th week of care, he was discharged from active treatment and advised to return periodically as symptoms dictated. He has continued with monthly visits, at his request, since he feels much better under such a regimen.


Classification of Radiologic Manifestations

Case Illustrating Classifications C-1, A-1, A-3, and A-8 Frequently several subluxations of different classifications are demonstrable in spinal films of a specific patient. This case illustrates such a situation. Alteration in the lumbar lordosis and an antalgic lateral list of the lumbar vertebrae (both of which represent subluxations classified as C-1: alteration of the spinal curve secondary to muscular imbalance) are noted. Concurrently, flexion subluxation (A-1) is noted at L4 L5 and at L5-S1, narrowing of the disc interspaces (A-8) being evident at both these levels.

Right lateral flexion of L4 upon L5 (A-3) can be suspected from the A-P film (Fig. 6.69). Wedging of the disc interspace at L4-L5, narrow on the right, is seen; and although the L5-S1 interspace is only poorly depicted on the standard A-P film, it may be narrow on the left.

By use of the spot A-P film (Fig. 6.70), making the central ray approximately parallel to the sacral base, the L5-S1 disc is better seen and its wedging toward the left is more apparent. This projection gives an excellent view of the lumbosacral junction and the extent of degenerative spondylosis. The standard A-P and the lateral film (Fig. 6.71) showed the obvious marginal spurring of the vertebral bodies at the two lowest motion units.

Oblique projections gave an enhanced ability to visualize facet articulations and are especially valuable in determining subluxations. The left anterior oblique view is taken with the patient prone, then turned 45° with the left side near the film (Fig. 6.72). This case shows the approximation of L4 and L5 vertebral bodies and the extent of the spondylotic changes along the vertebral body margins from L3-L4 caudally and depicts the facet articulations. Note that the right L4-L5 facets show imbrication or downward displacement of the L4 articular process relative to those of L5, the discrepancy at the superior of the articulation being evident. Note also the sclerosis of articular surfaces at this facet, which is evidence of degenerative arthrotic changes. At L5-S1, there is also slight imbrication and definite arthrosis.

The opposite oblique film, the RAO, shows the left articular structure (Fig. 6.73). In this film, the L4-L5 articular processes do not show imbrication, but arthrosis is obvious. The presence of imbrication on the right facet is seen on the other film. The lack of it on the left of this motion unit verifies that there is right lateral flexion of L4 relative to L5. At L5-S1, the obliquity of the facet articulation makes the facet joints less easy to visualize. The marginal sclerosis of the articular processes shows a degenerative reaction to chronic stress. Observe that the superior articular process of S1 approximates the inferior surface of L5's pedicle on the left, which is evidence of imbrication and verifies left lateral flexion of the L5-S1 motion unit. Again, the spondylotic changes of the vertebral body margins are easily seen.

To summarize the roentgenographic findings, there are:

(1) Degenerative spondylosis, facet arthrosis, and disc narrowing.

(2) Alteration of the lumbar lordosis and listing or deviation of the lumbar vertebrae to the right, presumably due to asymmetrical muscular spasticity, and antalgic mechanisms.

Several classifications of subluxation are evident:

(1) Decreased interosseous spacing (A-8).

(2) Flexion subluxation at L4-L5 and L5-S1 (A-1), which is incidental to the flattened lordosis and disc narrowing.

(3) Lateral flexion subluxations at L4-L5 and L5-S1, opposite inclination (A-3).

(4) Alteration of spinal curves due to muscular imbalance is also considered a subluxation of the spinal region or section (C-1).


This patient has a chronic low-back problem and has had recurrent episodes of low-back pain for approximately 10 years. These usually result from prolonged or strenuous work. He is a retired lithographer whose work often required heavy lifting. His most recent complaints were of 2 weeks duration, with pain predominantly perceived at the lumbosacral junction No radiation of pain to buttocks or legs were reported. This disorder had been present since the patient shoveled snow, and it remained relatively constant and of moderate severity. Some relief was obtained while recumbent. He was in obvious discom- fort both while sitting and standing. He had consulted with his family MD but had not received satisfactory relief from the medication prescribed.

The physical examination findings were essentially within normal limits for a 66-year-old male. Orthopedic tests revealed some restrictions in all ranges of motion in the low back with no other significant positive findings. There were no abnormal neurologic responses. Imbalance of the low-back musculature was noted, especially weakness of the left psoas and quadratus lumborum muscles and bilateral spasticity of the erector spinae muscles.

Conservative chiropractic treatment provided some relief after the first treatment, and the patient was relatively asymptomatic after 10 days and three treatments. Because of the history of recurrent problems and of moderately severe spinal degenerative disease, the patient was advised that periodic treatment would be helpful in discouraging recurrence of his pain, and that exercises to strengthen the lower back and abdominal muscles, along with use of a lumbosacral support during strenuous activity, might be of value.


Classification of Radiologic Manifestations

Case Illustrating Classification C-1 and A-1 Acute subluxations are frequently caused by or at least associated with muscle spasm and imbalance following either major or minor trauma. The following case is an illustration of this and demonstrates a rapid return to normal after treatment alleviated the abnormal spasticity.

This patient first presented himself for chiropractic care after a minor auto accident, following which he experienced transient neck pain. The initial lateral cervical radiograph shows a normal to slight hyperlordotic cervical curve, with hyperextension subluxations at C3 and C4, and little else (Fig. 6.74).

The second lateral cervical film --also a neutral lateral, at least as nearly as his pain would allow, was taken 7 months after the first, the exposure was made 3 days after a severe auto accident when his neck was extremely painful (Fig. 6.75). Note the reversal of the lordosis (C-1) and the definite flexion disrelationship at C3-C4 (A-1).

The third neutral lateral was taken 5 weeks after the second. In it, a return to normal vertebral alignment is seen (Fig. 6.76). Chiropractic manipulative therapy gave thorough relief within a few days after the first accident.

The second, more serious accident, obviously caused more problems --both to the patient and to the management of his case. After the second accident, physical examination showed marked restriction of neck mobility and severe pain even when the neck was not moved. Relief occurred following especially careful chiropractic manipulation, and the patient was relatively asymptomatic by the 4th week following the accident. Improvement had been steady from the first treatment until that time. The diagnosis in this case was acute cervical sprain.


Classification of Radiologic Manifestations

Case Illustrating Classifications C-2 and A-3 A 50-year-old male entered chiropractic care with a complaint of sharp pain centering around the right hip and radiating down to the middle of the anterior aspect of the right thigh. His history revealed malaria and scarlet fever.

During the examination, it was determined that lateral flexion of the lumbar spine to the left was markedly restricted. Flexion and extension were adequate. Mild hypertension was encountered, though other vital signs were unremarkable. Palpation of the abdomen revealed an enlarged liver (approximately 3 cm). Since this man had recently received a CBC and liver profile, these tests were not repeated. Orthopedic testing of the lower spine was negative. However, trigger points were found in the gluteus medius and the tensor fascia lata on the right.

Roentgen evaluation of the right hip disclosed no pathology. During upright evaluation of the lumbar spine and pelvis, however, a scoliosis of the lumbar spine was noted. The convexity was directed to the left side. This scoliosis was secondary to a structural asymmetry in the form of a 13-mm deficiency of the left lower extremity (C-2). Compensatory right lateroflexion subluxations were evident at L3 and L2 (A-3). The illusion of right posterior rotation of the lumbar spine is due to left anterior pelvic rotation over the femurs (Fig. 6.77).

The lateral lumbar film shows mild degenerative change at the L3 disc, with other lumbar discs of normal vertical height. A small amount of calcific deposition is present in the abdominal aorta (Fig. 6.78).

A diagnosis of a short-leg syndrome, with nerve irritation at the L2-L3 and L3-L4 levels, was made. The extension neuralgia to the thigh was responsible for the patient's symptoms. With conservative chiropractic management, which included lift therapy, the patient's symptoms were completely relieved within a month. During this time, he received nine treatments, which resulted in partial correction of the leg deficiency. He has not had a recurrence of symptoms at this time.


Classification of Radiologic Manifestations

Case Illustrating Classifications C-4 and B-1 Another instance of altered vertebral mobility is shown in this case. The altered cervical curve (hyperlordosis) shown in the neutral lateral film is obviously associated with minor anomalies of the vertebral arches and articular processes at C2--C4 (Fig. 6.79). There is also obvious arthrosis of the facets throughout the neck, especially at C2-C3, and disc wedging to the posterior is evident at C3-C4.

Flexion of the neck (Fig. 6.80) is grossly abnormal, the motion occurring mainly as anterior bending of the neck as a unit --the lordosis remaining essentially unchanged compared to the neutral film (Fig. 6.79). This illustrates extreme hypomobility of nearly every cervical motion unit (B-1) and abnormal motion of the cervical spine as a whole (C-4).

Extension of the neck is fairly well accomplished overall. At individual motion units, however, one can see signs of restriction or hypomobility, especially at C6 and C7 (B-1) where a comparison with the neutral film shows little intervertebral extension (Fig. 6.81).

This 70-year-old male had a long history of neck pain and stiffness associated with frequent headaches and bilateral shoulder pain. Orthopedic tests showed diminished ranges of motion in all directions in the neck. Cervical compression tests were negative.

Manipulation and adjustments of the neck were painful to him unless very gentle techniques were used. Muscle stretching and postural correction gave him some measure of increased comfort. After several weeks of various manipulative approaches and changing intervals between treatment, it was found that a treatment every 2 weeks helped him to experience less neck discomfort and headache. He has remained on this schedule for several years.

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