Radiology Digitization Technology Utilization Basics
In the legal case, Smith vs. Yohe, SUPREME COURT, negligence was found on the part of the treating doctor because he did not use the "BEST factual data upon which to arrive at a diagnosis, and thus, treatment.
That being the introduction, doctor, once you are made aware of a technology, or a procedure that give you the best factual data by which can arrive at the most accurate diagnosis of your patient, you have the responsibility to use it.
There are four tissues involved in spinal injury, the Bone, Nerve, Muscle and Connective Tissues. Most doctors have a really good protocol for testing the Bone, Nerve and Muscles in their examination procedures, but what about the ligaments? How stable is the spine you are working on? How much ligament damage is there?
When doctors are re-aligning the spine in their rehab and adjusting procedures, it is very important to know the status of the spinal motion unit support ligaments. If they are damaged care can take much longer to complete and get the same result as the patient who displays no instability, due to ligament dysfunction.
Ligaments have a property called plasticity, which is the property of a material to permanently deform when loaded beyond its elastic range. If you take the plastic of a six pack of soda, put your fingers on either side of one of the circles and slowly pull, you will demonstrate to yourself the property of plasticity. At first the plastic will resist deformation, then as you overcome the visco-elastic stretch of the material it will give and and elongate quite severely without breaking. The plastic will deform and elongate quite a bit without breaking, however at this point it can never function as it was designed, to hold a single can of soda in a six pack organizer. This is the same thing that happens to spinal support ligaments and of course worse, because they can be torn apart as well. The bottom line though is that they will never be able to function again as they were designed and now other tissues must pick up the burden. This is important to know how much ligament instability your patient has, when you are going to help them optimally rehabilitate.
Radiological Digitization Technology is currently the most accurate way to determine Loss of Motion Segment Integrity (the amount of ligament instability). There is no other procedure that can accurately determine its presence and qualitatively measure its degree. You can utilize Videofluroscopy to determine alteration in motion segment integrity, but the degree of such has to be measured in order to be confirmed, and therefore even motion x-rays are digitized.
Now that the purpose of the procedure has been established, we will now go onto the best way to utilize this procedure.
Let’s start with this statement out of the A.M.A. Guides; “When routine x-rays are normal and severe trauma is absent, motion segment alteration is rare; thus, flexion and extension x-rays are indicated only when the physician suspects motion segment alteration from history or findings on routine x-rays.”
When you first start with any spinal trauma patient aren’t you trying to determine if the patients x-rays are normal and the severity of the trauma? When you have a hypolordotic cervical spine or a hypolordotic lumbar spine (i.e., a misaligned spine) are the routine x-rays normal? No they are not. Now you have abnormal x-ray findings and trauma, so you must take flexion extension views of the involved area in order to fully determine the intersegmental motion?
“Motion of individual spine segments cannot be determined by physical examination but is evaluated with flexion extension roentgenograms” pg. 379 AMA Guides
Now how to establish the whether severe trauma is involved? Is it determined by the perceived severity of the event? No it is not. If your patient relates to you that they sustained a severe trauma when they miss-stepped the last step on their porch, does that event tell you the severity of the trauma involved or do you need more information? Of Course you need more information. When you look down and see that the patient is an amputee of the right leg does that give you more information as to the severity of the trauma? Of course it does. When the patient tells you that when they miss-stepped that last step, they badly broke their right ankle in three places, the fractures separated, surgery was performed, infection ensued and the only option was amputation. Does that give you more information about the severity of the trauma and its ramifications to that patient? The answer to the question is obviously yes? Now the key question is did the perceived severity of the event determine the severity of the injury, and is that really good information to go off of when making an assessment as to the severity of the trauma involved with your patients? The answer to this question is obviously no, yet everyday the environment that we practice in, entices us to be unprofessional and do that very thing. We are enticed into believing that since the event of the trauma has the appearance of being harmless, we as the examining doctor responsible for making the call as to the severity of the trauma should look no further.
Who teaches us this? The insurance companies who are paying the bills and those (other doctors, ICE/IME doctors, accident reconstruction specialist’s, physicists, engineers ECT) who have been lead to believe that severity of event equals severity of injury. Haven’t you ever had the question asked of you, doctor there was less than a thousand dollars damage to the car (perceived minimal severity of the event), how could this patient possibly suffer so much trauma as you have indicated?
Please remember the above court ruling as I will get to how important that really is in a minute, and please also read the enclosed PDF file from the State of Florida, listed as a button, Low Impact Injuries, on our web site. In that report in 1999 there were 67,602 low speed car crashes. Low speed was defined as, “no vehicle was traveling over 10mph and did not involve bicycles or pedestrians. Now look in the “fatality” column and observe that same year there were 528 FATALITIES! I do not know about you doctor, but I do not think you would have to perform much of and evaluation, or have to be much of a clinical wizard to determine the degree of severity of trauma for those patients, it was DEATH, and in my book the severity of trauma does not get any worse. Now to beat a “dead horse” could you have made the call if all you looked at was the degree of perceived severity of the event? No, you sure could not; you would have to look further.
In clinical practice we have to look in order to determine if severe trauma is absent or present. For those of you who are good enough to determine the level of severity of trauma in your patients just by looking at them, we kindly beg to differ.
For those of you who want to be thorough, you must some how observe structures that are inside the body, as unless the patient is severely lacerated or bruised, there is not a lot to see on the outside, that will give you any definitive information as to the severity of the trauma that this patient received. Unless you have x-ray vision, you utilize diagnostic procedures in order to assist you with your evaluation, which would be minimally x-rays of all areas of the spine, including flexion extension views, as well as any other valid diagnostic test. Remember the A.M.A. Guides to the Evaluation of Permanent Impairment say,
“Motion of individual spine segments cannot be determined by physical examination but is evaluated with flexion extension roentgenograms”.
Doctor no one in the world could pass this test. If I took twenty cervical flexion extension views, and told you that somewhere in those twenty films there were two angular variations resulting in the diagnosis of Loss of Motion Segment Integrity, a diagnosis that those same Guides establishes the severity level to the patient to be a 25% - 28% permanent whole body impairment, and I am now going to put them up on your view box and have you tell me which ones they are, you could not do it. No clinician in the world could.
So since you need to evaluate the individual segments, and the guides say you cannot do by examination, but must be determined by flexion extension film, but with flexion extension film, you agree there are findings that you cannot determine with the clinicians eye what do you do next in order to complete a full examination in order to determine fully if severe trauma is present?
You take the next logical step clinically and ask yourself is there any other tests available to help me establish what is really going on with the patient. Is there something that can help me to establish if there is any ligament damage which I cannot see on my static films? The obvious answer to this question is yes.
Diagnostic Imaging of Wisconsin, Inc is a local service developed to answer the need for scientific radiographic analysis for Doctors treating and managing patients with spinal trauma. The analysis complies with requirements set forth by the 5th edition, AMA Guideline Measurement Standards. Translation and Angular Variation (also known as Loss of Motion Segment Integrity - LMSI) are the critical x-ray measurements factored into the impairment formula used in the AMA Guidelines. LMSI can only be measured on flexion / extension views in lumbar and cervical studies. Those measurements constitute factual evidence of significant spinal ligament damage and segmental instability.
So now we come to the procedures of suggested usage of this diagnostic tool called digitization. I am going to proceed in question answer format:
Question: Do I take flexion extension views and digitize all of trauma patients?
Answer: You as the treating doctor must decide what procedures that you need based on individual patient history, examination and clinical presentation. If the patient has been in a trauma such that you feel that the ligaments may have been injured then you would choose to do this type of study.
Question: What about “low impact” auto cases? Should I still have the radiographs digitized?
Answer: Ultimately, it is your clinical decision to make as you are the treating doctor. However with that being said please refer to the Low Impact Florida study, the perceived severity of the event does not relate to the severity of the possible spinal trauma that your patient receives. You will never know what is there unless you test. That being said, again we would also say that the patient should be pain expressive. If the patient is not pain expressive, then you probably would not have the films digitized. If the patient later became pain expressive or had other functional problems, you can digitize the films then.
Question: When should I send the patient’s film in to have them digitized?
Answer: Right away. You want to establish the severity of the trauma to the patient as soon as possible, as you are going to be treating the patient, and it is a good idea to know what you have. It is a good idea to know what you have, both so that you can adjust your treatment and treatment plan for the patient accordingly, and you can communicate with your patient right from the start, the severity of their condition. Now there is an exception and that is if when you take your films, you see little spinal motion in the flexion and extension films, then you have muscle spasm, and traumatic inflammation retarding the motion. In this case, wait two weeks or more and rex-ray the area, same films so that the films can now be assessed for true ligament damage.
Question: When I am finished with my treatment of this particular patient should I re-take my original films?
Answer: This is up to the clinical judgment of the doctor, but our opinion is yes, if you are using x-rays as part of your outcome assessment criteria in your clinical practice. Some techniques of rehabilitating the spine utilize re-x-ray to determine the new alignment. If your technique of care is designed to re-establish optimal alignment then we recommend that you re-digitize the films as you may have corrected the Loss of Motion Segment Integrity. If your technique does not dictate the shooting of re-x-ray as an outcome assessment test, then you would not re-digitize films. So it really depends on your technique
Question: If I have my patient’s films digitized right away and there is no “Loss of Motion Segment Integrity” noted is it safe to say that this patient does not have this finding, and we probably would not need to do any further testing, correct?
Answer: Yes and no. You want to digitize films right away, so that you can know what you have, in order to develop optimal treatment programs for the optimal success of your patient with your care. You also want to know so that you have as complete of a picture as possible of the state that your patient is in, when you start to work with them. However when you shoot flexion extension films right after the accident, sometimes there will be such loss of intersegmental motion due to the inflammation of injury, that it can retard the findings, i.e., Loss of Motion Segment Integrity will not show up. This is not common though. Now lets say that you have treated this patient and you are at MMI and the patient is still pain expressive, and as part of your outcome assessment of the patient you do re-shoot x-rays for determination of alignment at MMI. You may want to have the second (last) set of films digitized to see if there is Loss of Motion Segment Integrity. If now Loss of Motion Segment Integrity does show up your treatment did not create the finding; you are now merely getting the real findings of the intersegmental spinal motion without the inflammatory effects that was retarding motion in early treatment. For this reason you have clinical reason to order final testing on the case even if the first study was negative.
In some cases we will also find that the patient has “Loss of Motion Segment Integrity on the first tested films, but on the final films it no longer shows up. If your treatment of spinal trauma involves the re-establishment of the cervical and lumbar curve we will see this more often as you have stabilized the spine into a more optimal alignment.
Again both of these cases are rare, but do give you clinical reason to both re-shoot your original films at MMI and to have those radiographs digitized for a final report.
Question: In order to assess “Loss of Motion Segment Integrity” of the lumbar spine do I also take flexion-extension views, along with my neutral lateral?
Answer: Yes you do. You can take flexion and extension views of the lumbar spine either standing or sitting. The key is to get as much flexion or extension with the patients lumbar spine and not the hips. If sitting make sure their thighs do not come up in extension and if standing try to keep their pelvis neutral, not pushed forward in extension, or backward in flexion.
Question: If my patient has “Loss of Motion Segment Integrity”, other than the fact that they will have a Permanent 25-28% Whole Body Impairment if the finding is still present at MMI, how will this finding help me to establish my treatment program?
Answer: This will really depend on your technique and what you are trying to accomplish with the patient, but in general, any time you have a unstable spinal joint due to ligament functional compromise, it is important to incorporate some sort of muscle strengthening program, as the muscles and the tendons are now going to need to pick up the support that the ligaments can no longer provide. This can be accomplished through home exercise, in office therapy, physical therapy or can naturally occur as your care re-aligns the patient’s spinal alignment. The care guides lines for spinal trauma treatment for practitioners involved in manual adjusting or instrument adjusting of the spine for restoration of spinal motion segmental function and overall spinal alignment, come under the Guideline of The Croft Treatment Guidelines for CAD Injuries.
In 1993, Arthur Croft, D.C., M.S., M.P.H., F.A.C.O., F.A.C.F.E., published a set of management guidelines in the ACA Journal. These Guidelines have also been published in, Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome, 2nd Ed. 1995, and in a more recent Canadian Practitioner’s Guide to whiplash injuries, sanctioned by the Canadian Chiropractic Association.
The Croft Guidelines have been a part of our literature now for more than 12 years, and no competing guidelines have been published during that time, with the exception of the Quebec Task Force on WAD, but these are only applicable for patient’s who remain on disability.
For more information on the Croft Guidelines and how they are applied with “Loss of Motion Segment Integrity” click on the Croft Guidelines.
Question: How can I use this testing for separation of injury or apportionment of injury?
Answer: This is one of the best tools to separate and apportion the percent of injury with patients involved in multiple traumas. I will show you through a case example:
Case . Let’s a patient comes to you for the evaluation and treatment of an auto accident (this works for work comp as well, not the disability part in Wisconsin but to determine impairment, and using this to assist you with your disability assessment). Let’s further state that the patient was involved in an Auto Accident three years ago and was treated to full recovery, with no residuals. You do your work up, films are taken and sent out for Radiographic Digitization and it is determined that there is a Ratable translation variation at C6 of 3.7mm, ratable at 25%-28% Whole Body Impairment at MMI. In your history you would want to find out if the patient had flexion extension films of the last injury, get the x-rays and have them digitized as well, in order to determine which accident caused the ratable impairment. This would be conclusive and complete evidence of which accident caused what? If the earlier accident had no films then 100% of the Impairment is attributed to the current accident, as there is no valid clinical information to determine otherwise, and this finding is consistent with trauma.
Now let’s say this patient had no previous films and the current films showed no ratable impairment (i.e., Loss of Motion Segment Integrity) and you have treated this patient for six weeks, and they are doing well with treatment.
That day they are involved in another accident, come back to you, another full evaluation is performed including x-rays, films are digitized and now you have Loss of Motion Segment Integrity at C2. This new injury is 100% apportioned to the second accident conclusively. You would then treat to get them back to the pre-injury status of where the patient was at clinically when the second accident occurred. You would utilize ROM, Muscle Testing, Orthopedic Tests, Oswestry Pain Questionnaires or whatever other objective clinical outcome assessment tests you use to monitor the progress and functional improvement of the patient. These tests will tell you when you have arrived at pre-injury status of the second trauma to the first. At this point you then would note that the full impact of the ratable impairment was attributed to the second accident, making apportionment very easy.
We must finish by saying this, everything in here that has been said is a guideline from a practitioner who has used Spinal Ligament Assessment through x-ray digitization for the last 7 years. We cannot tell you how to practice or make clinical decision for you as you are the doctor and it is your patient. We do not seen the patient so ultimately you make the decisions. Please do not construe anything said here as clinical recommendations as ultimately only you the doctor can decide what is best for your patient.
National Injury Diagnostics
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info@nationalinjurydiagnostics.com
Represented Present or Past in:
International Chiropractic Association
Washington Chiropractic Association
Wisconsin Chiropractic Association
International Association for the Study of Pain
