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January 2007, Vol. 17, No. 1
Table of Contents
• Are You Busy Selling Chiropractic or Correcting Subluxations
• BJ's House Needs Repairs • Another Look At Cell Phones
• Chiropractic R.I.P. • Colloca and CBP Nonprofit Study Wins Best Paper Award • Help Us Locate Allen Botnick • Letters to the Editor
• Michigan Chiropractic Society Sees Evidence of Growing Need For Chiropractic • Meeting With Success • A New Look At Mirror Image Exercise • Mourning The Loss Of Tony Keller • Past Present and Future In Chiropractic • Posture Study By UQTR Researchers and CBP® Published by JCO • PostureRay™, PosturePrint™ Helping Doctors Help Patients
• The Importance of A Clinically Relevant Presentation of Findings
• It's Pauls Opinion • Research Corner • Scoliosis: SpineCor Brace
• Triano and CCGPP's Will Give You Six Visits
• Clinical Indications for Videoflouroscopy
• Western States Chiropractic College Receives NIH Grant •
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Clinical Indications for Spinal Videoflouroscopy in the Chiropractic Practice
by Michael L. Underhill, DC, CCSP, CCST
Michael L. Underhill, DC, DABCT, CCSP, CCST is a 1981 graduate of Western States Chiropractic College. He is certified in Chiropractic BioPhysics® as well as certified as a sports chiropractor and has Chiropractic Certification In Spinal Trauma. He holds a diplomate in thermography. Dr. Underhill is a contributing author to both editions of the text, “Motor Vehicle Collision Injuries: Mechanisms, Diagnosis, and Management.” He has been in private practice in Beaverton, Oregon for the past 25 years and has served as part time instructor at WSCC teaching both post graduate and undergraduate classes.
Videofluoroscopy (VF) is also referred to as digital motion x-ray and cineradiography. Modern VF is a diagnostic procedure utilizing an x-ray generator and a capture device with image intensifier that allows for real time visualization of various internal body structures. With current technology, this information is viewed on a monitor during capture and as well as recorded in digital format to be analyzed at a later time. With the use of a computer, digital video tape or DVD recorder, high quality studies are produced with low x-ray exposure to the patient.
Of particular interest to chiropractors is the ability of VF to study dynamic spinal motions throughout its entire range of motion as well being able to observe the character of the motion. This type of study is ideally suited to evaluate intersegmental joint dysfunction (kinesiopathology) and ligamentous instability. Studies performed are often of the cervical spine but also the shoulder, wrist, TMJ and other structures.
Standard cervical views include occiput-C1-C2 nodding, lateral flexion/extension, oblique flexion/extension, AP rotation, lateral flexion and AP open mouth with lateral flexion. With a number of imaging modalities available to the clinician such as plain film x-ray, CT, MRI as well as dynamic flexion/extension and other types of MRI, the question then becomes proper test and patient selection protocol.
According to the International Chiropractic Association guidelines, “Observational and case studies have appeared in the literature comparing the diagnostic yield of fluoroscopic studies vs. plain films. In addition, studies have been published reporting abnormalities detected by fluoroscopy which could not be appreciated on plain films.” The ICA guidelines also note “Numerous applications for spinal fluoroscopy have been reported in the medical literature. These include recording the effects of cervical spine traction, evaluating cervical spine stenosis, laminectomies, examining athletes presenting with pain, to assist in surgical planning, evaluating atlanto-axial rotatory fixation, examining the effects of cervical collars, characterizing joint disorders in the cervical spine, studying degenerative disease of the cervical spine, and determining the effects of occipitalization and odontoid hypoplasia on spinal motion.” “Many investigators have reported that fluoroscopic studies revealed abnormalities (some potentially lethal) that could not be appreciated on plain films.”1
Plain film x-rays are the standard initial choice in visualizing the traumatically injured patient. The 7 view Davis series is often utilized to evaluate the cervical spine following trauma. This type of x-ray analysis has been well studied and provides considerable information for the clinician. However, like any other test, there are limitations. Only the neutral position and end-points of range of motion is observed. Also, it is not common or practical to obtain oblique flexion/extension views, rotational and lateral flexion views as well the APOM lateral flexion view in addition to the standard views.
CT is generally known to be useful when detailed evaluation of bony architecture is desirable. Although able to visualize disc and other soft tissues, it generally does not match the ability of the MRI in this area. MRI is excellent for disc herniation and evaluation of neurologic deficits such as nerve root impingement. In discussion with radiologists about MRI and flexion/extension MRI, the main focus is on cord compression and disc abnormalities. Ligamentous injuries oftentimes will not be visualized on MRI unless there is active inflammation present. (Again, this article deals with the chiropractic practice and does not address the many uses of these imaging tests useful in other areas of health care.)
As with any x-ray study or potentially invasive testing procedure, the clinician should ask:
Does the diagnostic information gained justify the exposure and cost? How will the information gained be used and will it change the treatment of the patient?
Videofluoroscopic studies are not utilized as a routine imaging modality but rather complimentary to and following other tests. Your decision to obtain a spinal videofluoroscopic examination should be based on your patient’s demonstrated clinical need. It should not be obtained without an appropriate history, clinical examination and other diagnostic imaging studies.
Both the ICA and ACA have published guidelines on the use of VF.1,2,3 In addition, the Canadian Chiropractic Association also has clinical practice guidelines discussing VF.4 They are similar in many ways as one would expect. The recommendations made are guidelines and not a standard of care. Ultimately, it is the clinical judgment of the attending chiropractor, made on a case by case basis in how to best manage the patient including what tests to order.
Indications for Spinal Videofluoroscopy:
VF may be indicated upon initial examination if instability is suspected from routine films or in cases of significant spinal trauma, direct injury, head trauma or disease.1
Persistent signs and symptoms with unsatisfactory response to care. The ACA recommends a reasonable period of treatment as generally exceeding 12 weeks.3 For the ICA, 4-8 weeks in a chronic case and 1-4 weeks for acute.1
Suspected persistent intersegmental joint dysfunction. Radiographic signs of intersegmental joint dysfunction: hyper or hypomobility, aberrant motion, instability, aberrant coupling, paradoxical motion and evaluation of spinal arthrodesis.3
Restriction of motion.1
Recurrent symptomatology of myelopathy or radiculopathy.1
Persistent pain patterns of vague distribution.1
Rule out malingering.1
VF may be warranted to assess effectiveness of the treatment program after reasonable period of treatment or following maximum chiropractic improvement.1
Inconclusive or equivocal evidence of intersegmental joint dysfunction from other imaging procedures.3
May be indicated when treatment has not been utilized or has been delayed and where inadequate explanation of findings of clinically evident joint dysfunction is documented.3
Cases of spinal stenosis.1
Scoliosis, structural and functional curvature evaluation.1
VF examinations may be performed for reevaluation if the patient fails to respond to management, or exacerbation of symptoms or progression of signs which are the result of intersegmental joint dysfunction. These studies should be limited to those views which previously demonstrated abnormalities.3
The ICA also suggests use of limited studies (any study less than a full study) in certain cases. “For routine procedures, these involve simple lateral view - flexion/extension, but for follow-up studies on prior full studies, these would include a repeat of all views which gave positive findings in the original study.”1
In addition to indications noted above, based on my experience, patients with traumatically induced unresolving headache and those with inadequately explained pain or increased pain upon spinal movement are good candidates for VF.
The American Chiropractic College of Radiology (ACCR) and the Council of Diagnostic Imaging recommends certain avoidances and contraindications be observed with the use of videofluoroscopy. In addition to pregnancy, they include (but are not limited to); avoiding studies until cessation of restrictive muscle spasm (which prohibits proper evaluation of joint function).
In conclusion, the judicious use of VF may provide useful clinical information improving the quality of patient care and treatment outcomes.
Table 1.
Summary of Common Indications for Spinal Videofluroscopy
• Suspected instability from routine films
• Cases of significant spinal trauma
• Unsatisfactory response to care after a reasonable course of treatment
• Suspected persistent intersegmental joint dysfunction
• Recurrent myelopathy or radiculopathy
• Persistent pain patterns of vague distribution
• Inconclusive evidence of intersegmental joint dysfunction from other imaging
• Assess effectiveness of treatment after a reasonable period of care
• Following maximum chiropractic improvement
• Unresolving post traumatic headache
• Unresolving pain noted upon spinal motion
REFERENCES
1. International Chiropractic Association. Board of Directors, Guidelines for use of Videofluoroscopy in Chiropractic. http://www.chiropractic.org/guidelines/ChapterFifteen.pdf
2. International Chiropractic Association. ICA Policy Statement. http://www.chiropractic.org/ica/policy.htm#VIDEOFLUOROSCOPY
3. American Chiropractic Association. American Chiropractic College of Radiology and Council on Diagnostic Imaging. Guideline for the use of musculoskeletal videofluoroscopy. June 1991 http://www.acatoday.com/level2_css.cfm?T1ID=10&T2ID=117
4. Canadian Chiropractic Association. Clinical Practice Guidelines, Chapter 4 - Diagnostic Imaging (1996 CPG). http://www.ccachiro.org/client/cca/cca.nsf/web/Chapter+4+-+Diagnostic+Imaging!OpenDocument
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