Welcome to the Radiology Section @ Chiro.Org! This section contains charts and guides to help you perform radiolographic examinations, links to other radiology sites, and interesting articles on diagnostic imaging. This section is updated frequently.
Chiropractic Radiology
This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
Alternative Care ChiropracticOur thanks to G. Patrick Thomas, Jr., DC, DACBR for originally developing this page! We wish him well in his retirement! He donated several useful charts, articles, and a radiology report generator which shall be archived here permanently.
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For Musculoskeletal Complaints in Adults
Enjoy these 3 sets of guidelines for: Lower Extremity Disorders, Upper Extremity Disorders, and Spinal Disorders.
Chiropractic Line Analysis a.k.a Mensuration
Cervical Spine Mensuration
The Atlantodental Interspace (ADI)
Lumbar Spine Mensuration
Radiology Articles
Dynamic Chiropractic
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.
Dynamic Chiropractic ~ 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.
Chiropractic & Manual Therapies 2011 (Jan 11); 19: 2
Formerly known as: “Chiropractic & Osteopathy”
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.
Dynamic Chiropractic ~ March 26, 2010
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.
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.
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.
J Manipulative Physiol Ther 2004 (Nov); 27 (9): 554-559
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%).
Tracking Down Nonspecific Pain in Distance Runners
PHYSICIAN AND SPORTSMEDICINE 2003 (Feb); 31 (2)
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.
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).
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.
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.
There are already plenty of good books out there on introductory musculoskeletal radiology. Why did I write this syllabus? Because, it seemed to me that most of these books were doing a great job of telling one about diseases, but not how to approach their diagnosis. Most books tell you the names of lots of disorders and the findings you see in each of them. This is handy if you already know what disorder a patient has, and you just want to learn more facts about it.
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.
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.
Deborah Pate, DC, DACBR Articles
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.
Dynamic Chiropractic
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.
Dynamic Chiropractic ~ 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.
New Study Compares Surgical vs. Nonoperative Treatment
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.)
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.
The QUIZ Section
Diagnostic Imaging Case Reports:
Thanks to ChiroAccess for access to these quizzes, provided by Jack Henry, DC, DACBR
A 53-year-old female reports back pain and hip pain
A 53-year-old female reports severe low back pain and left hip pain. The patient has great difficulty walking. Orthopedic evaluation was limited due to severe pain.
A 67-year-old male reports with chronic back pain. The patient’s past medical history was not provided at the time of formal reading.
A 17-year-old male reports status post trauma secondary to “mild” flexion/extension type injury. ROM was somewhat limited. Neurological and orthopedic evaluations were unremarkable. REVIEW THE FILMS AND YOU MAKE THE CALL!
A 62-year-old female reports low back pain of four weeks. Pain is most intense in the early morning. No history of recent trauma was reported. The patient’s past medical history and physical exam findings were not provided.
A Forty-seven-year old male with neck pain and stiffness. The patient reports dizziness and a non-productive cough. No reported trauma. No fever. Orthopedic exam is unremarkable.
A 49-year-old African American male reports with chronic low back and hip pain. No history of trauma was reported. Physical exam findings were not provided.
A 41-year-old male reports with cervical spine pain and stiffness after recent flexion extension injury. The patient’s clinical findings and past medical history were not provided.
A 72-year-old male reported with right hand pain and swelling “on and off’ for the past two years. The patient does not have a primary care physician. The patient is diabetic and has hypertension.
A 77-year-old female reports pain and swelling of the right knee. The patient can not bear weight on the right knee. No history of recent trauma was reported. Physical exam was limited due to pain.
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