by William Cockburn, D.C.
Introduction
The foundational principle which differentiates chiropractic from other primary healing arts is the detection and correction of the vertebral subluxation complex. The vertebral subluxation complex is not only misunderstood by the medical and scientific communities, but also by the chiropractic educational, regulatory and practice establishment. One component of the vertebral subluxation complex is the "Osseous Component," identified by palpation subjectively and x-ray analysis (spinography) objectively. It is incumbent upon the chiropractic clinician to accurately, objectively and quantifiably detect the osseous component of the vertebral subluxation complex for the following reasons:
1. To establish the factual basis of the presence or absence of spinal subluxation. 2. To measure quantitatively, the osseous component of the subluxation complex in order to: a. determine direction of treatment and case management b. rule out contraindications to spinal adjustments c. arrive at a clinical decision (diagnosis, analysis) d. assist in the prognosis of the patient e. document reliably, pre and post changes in vertebral motor unit stability and position for purposes of progress evaluation, apportionment or for medical legal purposes, demonstrate any change in spinal biomechanics configuration, such as: 1. new and further trauma 2. correlative forensics of such trauma 3. lack of progress requiring long term ongoing chiropractic care not to be considered maintenance but necessary managed supportive care. f. assist in the determination of impairment when applicable, related to the AMA and other established impairment guidelines.
It is imperative that clear definitions be adopted and utilized so that semantics based error does not create or add to the existing confusion in the chiropractic profession relative to the separateness of Vertebral Subluxation Complex Components and the ability to quantitatively differentiate them with modern objective techniques and technologies
Some chiropractic colleges teach that you can not see a subluxation on an x-ray: Many spurious arguments and philosophies have developed because of these concepts, which is wholly based on a semantics error in the definitions of the terms, "subluxation," and "vertebral subluxation complex."
An attempt is made here, to resolve this error and make it clear that subluxation in fact, does exist as revealed by plain film, and more appropriately, endpoint motion films, and that these "osseous findings" reveal the true subluxation as described by most chiropractic, all medical and all legal literature. Subluxation, def: (1) Path: A partial dislocation, a sprain Subluxation, def: (2) Path: A particular incomplete dislocation. A loss of juxtaposition between two articular surfaces. A misalignment of contiguous joint or articular surfaces. Subluxation, criteria (3) 1. Loss of juxtaposition of a vertebra with the one above the one below or both. 2. Occlusion of an opening. 3. Nerve impingement. 4. Interference with the transmission of neural impulses.
There is a vast difference between the accepted (Oxford) definition of the term subluxation, and the criteria for the vertebral subluxation complex (Palmer), which are completely separate conditions which may or may not relate to each other in every patient's case. For example, a subluxated talocrural articulation will not occlude and inter vertebral foramen.
The fear of many early chiropractors that the concept of a pinched nerve and decreased transmission of neural impulses (as described by the Palmers) could not be objectively identified and quantified by plain film x-ray is the fundamental source of error in confusing the term subluxation with the criteria for vertebral subluxation complex.
It is well accepted and referenced in the medical, scientific and law literature that subluxations, the osseous component of the VSC, can and must be demonstrated on plain film x-ray , and thus is measurable and quantifiable with significant meaning to the clinician as an outcome assessment tool.
It is also clear that subluxation as viewed by the chiropractic profession, is a multifaceted and complex condition which includes the following well accepted components: 1. Spinal Kinesiopathology 2. Neuropathology 3. Myopathology 4. Histopathology
In combining the measurable osseous component with the manifestations listed above, one begins to understand the devastating potential of this pathologic process, and thus the importance of demonstrating its components objectively, not anecdotally, which has been a principle problem within chiropractic due to the lack of technological excellence in the field, as well as the lack of access to technology by the medical and scientific communities until only the past few years.
Spinographic measurement
A considerable decrease in spinographic usage in the past twenty years has greatly contributed to the lack of technical certainty and technical proficiency of many modern day chiropractic clinicians. This has occurred due to the lack of teaching these methodologies in chiropractic colleges based on the above discussion, and the inaccuracy of hand mensuration or measurement reported for example in the literature (5).
Spinal biomechanical measurements are vital, if not critical to the appropriate diagnosis, analysis, treatment and prognosis in the chiropractic clinical environment.. With accurate and quantitative measurement a foundational baseline is determined which can then be further explored by other quantitative criteria, for an accurate and reliable assessment of the patient's condition and outcome potential.
Definitions
Without measurement of the osseous component of the vertebral subluxation complex, one can only guess about, or ignore, this essential component of subluxation pathology. This leads to inter and intra professional squabbling and bickering, to the admissibility in courts of law of contradictory hearsay evidence by those opposed to chiropractic who may have stronger or more recognized credentialing and ultimately to the patient being denied access to appropriate and necessary care. This is not tolerable.
Digital radiographic imaging technology
This is also more commonly known as X-ray Digitization or X-ray Digitizing.
A modern definition has been proposed for this procedure which can be applied universally throughout the health care community, and thus end controversy, disparity and lack of interexaminer agreement.
D.R.I.T. {Digital Radiographic Imaging Technology} def: A specific detailed mensuration of the structural relationships of the parts of the spinal column and pelvis, from any type of radiograph, usually weightbearing, for the purpose of detecting and quantifying abnormal spinal biomechanics and the osseous component of the vertebral subluxation complex.(6)
Purpose: Computerized Digital Radiographic Imaging Technology is a procedure which is performed on plain film spinal radiographs in order to provide accurate, quantitative and objective data concerning spinal biomechanics in trauma cases. In this way, the reliability of x-ray diagnosis is enhanced due to decreasing subjective interpretation of radiographic film.
Procedure: X-ray films are placed and secured in the X/Y axis to a digitizing tablet capable of producing measurement to an accuracy of .001 inch. The x-ray film is then digitized and stored in computer memory, allowing a graphic representation of the x-ray with its biomechanical mensurations (measurements) to be viewed by the physician, or hard copied to print media for evaluation and diagnosis.
As most of the medical literature supports that subluxation pathology exists in the 1.0-3.5 mm range, and as the accuracy of the software is translated to 0.1 mm, a highly objective, quantified and reliable measurement is obtained.
Reliability of D.R.I.T.
Members of the American Academy of Digital Radiographic Imaging as well as users of digital x-ray imaging technology report accuracy ranges for test retest reliability at 0.0-0.2 mm for inter and intraexaminer reliability making this procedure an extremely accurate and reliable instrument.
Methodologies of Spinal Subluxation Utilizing D.R.I.T.: The measurements provided by these systems are based on the peer reviewed and refereed medical and chiropractic literature. Present technology allows for a wide variety of measurements that can be obtained instantaneously on the following type of x-ray plates:
AP cervical, thoracic, lumbar-neutral, left and right bending. Lateral cervical, thoracic, lumbar-neutral, flexion, extension. AP open mouth cervical. AP pelvis. AP and Lateral full spine.
Current technology has not advanced to the degree of certainty at this time for oblique films, however, any spot AP or Lateral film can also be digitized, older technologies requiring the full section of film (i.e.: Occiput-T1 for lateral cervical). If T1, or for that matter C7 can not be visualized due to girth of the shoulders, then C6 can be selected as the foundation level for digitizing, thus providing accurate and reliable information from this film.
Types of reliable measurements obtained from D.R.I.T.
The following is a partial list of reliable measurements that can be obtained from digital radiographic imaging technology:
Anteriolisthesis, Retrolisthesis, Lateralolisthesis, Vertebral offsets, Disc height, Disc angle, Line of weightbearing, Jackson's Angle, Cobb Angle, George's Line, Gravitational Stress Lines, Templating features, Motion Studies, etc.
Outcome assessment with D.R.I.T.
This procedure should be performed on all spinal x-rays to determine appropriateness of treatment, evaluation of new and further injury, lack of progress and for establishing impairment criteria based on biomechanics.
The American Medical Association Guidelines to Permanent Impairment, (third Ed. {revised}) has for example whole body impairment factors for the spine: cervical 7%, thoracic 4% and lumbar 8% for listhesis measurements when combined with a history of trauma and medically documented pain for a period of six months. In the 4th edition of the guides, measurements between cervical flexion and extesnion views for loss of motion segment integrity (translational and angular) are rated at 20% per level to a max impairment of 35% for cervical spine (whole person).
While pain should never be a criteria for evaluating objective impairment, the criteria provided for assessing whole body impairment based on spinal biomechanics is rewarding and refreshing.
It should be noted here, that no procedure should be utilized as a stand alone procedure, for neither diagnosis, treatment or impairment evaluation.
Other procedures such as PSEMG, SSEP, NCV, MRI, CPT, etc. should always be correlated to clinical history, physical examination and radiographic findings for a more comprehensive and complete picture of the patient's actual status.
Conclusion
D.R.I.T. is a reliable tool for the quantitative assessment of the osseous component of the vertebral subluxation complex, a well established manifestation of the chiropractic model of the VSC, as well as the medical pathologic model of subluxation as a ratable impairment.
D.R.I.T. has shown reliability, accuracy and benefit unparalleled to this time in history with respect to spinal radiographic analysis. In determining need for treatment, type of treatment to be administered, monitoring of changes during treatment resulting from reinjury and for prognosis, D.R.I.T. is an effective outcome assessment device and methodology for chiropractic practice.
References
1. The Oxford English Dictionary (utilized by courts in Judicial Notice Issues) 2. Cockburn, William:, "Objective and Factual Documentation of Soft Tissue Trauma" text, Austin, TX 1989 3. Stephensen, R.: "Chiropractic Textbook", Davenport, IA, The Palmer School of Chiropractic, 1927 4. Fleisha, J.: "Rennaisance-A Psychoepistemological Basis for the New Renaissance Intellectual" Colorado Springs, CO Renaissance International 1982 5. Sigler, D.C. & Howe J. "Inter and Intra Examiner Reliability of the Upper Cervical X- ray Marking System" JMPT 8(2);75 1985 6. Cockburn, William: "Chiropractic Spinography-a Historical Overview" Chiropractic Showcase Magazine, Parker Chiropractic Research Foundation 1992
William Cockburn, DC is a graduate of Cleveland Chiropractic College at Los Angeles, and is a former associate professor and department chair in the clinical sciences divison. A founding member of the American Back Society, he is a certified clinical thermographer. and a Diplomate of the American Board of Forensic Examiners. Dr. Cockburn. is available for speaking engagements and for questions by contacting by email at docbill@earthlink.net
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