Frequently Asked Questions
All answers provided are based on my clinical experience and clinical observations both as the practitioner in the field treating patients and as the owner of an X-Ray Digitization Service. This section is provided for your help and assistance only, and none of these answers may be true for you, as what is true for you is what you yourself have observed in your clinical application of this procedure. It is my hope that these examples may provide you with some help. Dr. Cronk
Q: What is x-ray digitization?
A: The word digitization comes from the root digit which is a finger or an Arabic numeral. To digitize means to measure or put a number to a special relationship, to measure. When a contractor is measuring out a room to remodel, he or she is digitizing it. X-Ray Digitization then means to very accurately measure the spacial relationships between the vertebrae, therefore our system can take your patients dynamic studies (flexion-extension films) and graphically measure and demonstrate whether an injury has altered spinal structures due to the trauma.
Q: What is “Alteration of Motion Segment Integrity” or “Loss of Motion Segment Integrity” (LMSI)?
A: Loss of Motion Segment Integrity occurs when you have ligament damage to injured spines. When a ligament that holds the spine together is damaged you loss the integrity of the motion segment and it slips in translation or it opens up too much in angular variation. Here is what the AMA says about it:
Loss of Motion Segment Integrity, TRANSLATION: Refers to the measured A-P movement of one vertebral body compared to its adjacent vertebral body in flexion vs. extension (lateral view).
Loss of Motions Segment Integrity, ANGULAR VARIATION: Refers to the difference in endplate angles measured in flexion.
The A.M.A. Guides to the Evaluation of Permanent Impairment, 5th Edition 2001, states that the following are the determining measurements, which when met or exceeded qualify for a DRE Category IV, which is assigned a Whole Person Impairment of 25% to 28%.
Translation is defined as antero-posterior motion of one vertebra over another that is:
>3.5 mm in cervical spine
>2.5 mm in thoracic spine
>4.5 mm in lumbar spine
Angular motion difference of two adjacent segments
>11 deg Cervical spine
>15 deg at L1-L2, L2-L3 & L3-L4
>20 deg at L4-L5
>25 deg at L5-S1
These same Guides tell us that:
“Motion of individual spine segments cannot be determined by physical examination but is evaluated with flexion extension roentgenograms” pg. 379 AMA 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.” Pg. 379 AMA Guides
Q: What is the clinical benefit of having a service analyze my patients x-rays for “alteration of motion segment integrity”?
A: The reason you would have this done is to clinically evaluate the probability and the severity of ligament damage to the spine. The spine has bone, muscle, nerve, and ligament that may be injured in an accident or trauma. Most doctors are very good at assessing damage to the bone, muscle and nerve, but virtually have no diagnostic work up for the spinal ligaments. (WE HAVE GONE FAR TOO LONG WITHOUT A GOOD LIGAMENT SCREENING PROCEDURE). As we all know the ligament tissue is the most debilitating tissue to damage. When ligaments are damaged the condition is usually permanent, progressive and either now or both now and in the future, painful. Doctors who utilize our service are utilizing it to accurately determine the intersegmental motion of each individual motion unit, by AMA Method of assessment. Remember the following which is a quote from a textbook on X-Ray Imaging out of textbook the physical therapist are now learning with:
Here is a quote from a PT Textbook called; Fundamentals of Musculoskeletal Imaging
“Although ligaments are of water density and generally do not possess enough radiodensitiy to be visible on radiographs the articular relationships that intact ligaments provide can be evaluated on conventional radiographs. Loss of normal articular relationships implies loss of ligamentous support" Pg 145
"If there is a history of trauma and joint instability or hypermobility, or if either is clinically suspected or needs to be ruled out, lateral flexion and extension stress views should be obtained. These two films are then evaluated to identify joint hypermobility revealed by misalignment (excessive angulations or excessive glide) of the injured segment." pg 167
Q: I have been told that x-rays cannot be accurately measured because patient positioning can influence the measurements?
A: This is not true; your patient’s x-rays (Plain film or DMX) are one of the most objective tests that we perform on injured patients in the clinical setting. In X-ray digitization we are looking for spinal misalignment due to ligament damage called “Alteration of Motion Segment Integrity” many times called “Loss of Motion Segment Integrity” or LMSI. On these measurements patient position either on initial films or follow up films has no bearing on the test. The beauty of this test is that the patient cannot control or influence the outcome. Flexion extension films have been called “Stress Radiography” for obvious reasons. The only criteria are good flexion and extension views with good technique so that the structures are adequately viewed. Ideally the views are taken at 72” FFD however if they are not we can calibrate for accurate measurements, but we must know the FFD that you shoot your films at.
Q: I was told that x-ray magnification makes the study inaccurate?
A: This is false; the AMA has set up the criteria for abnormal vertebral position called “Alteration of Motion Segment Integrity”. The cervical translation measurements for LMSI are greater than 3.5mm of combined slippage in the cervical spine. Combined means slippage on both flexion and extension film combined. The AMA has factored a 30% magnification error into its numbers to account for the film magnification factors.
Q: I was asked what protocol does my office follow to ensure that patient placement does not magnify or distort the x-ray image?
A: The protocol that your school taught you. There is no special protocol here, as the same protocol that is used in your office is used in every hospital in the country. So the answer to this question is the protocol that your school taught you. I would also ask whomever is asking the question if they are aware of a better protocol as you will use it if there is one?
Q: I was told that I should not take x-rays until after the first 2-4 weeks of care as spasm and inflammation can hide the findings of LMSI?
A: This again is false and is put forth by those who are not in the field treating hundreds of injured patients every year. First of all you want to take your x-rays of injured patients right away as you want to see what you are dealing with, i.e. misalignments, degenerative disc disease, spinal curvature problems, compression fractures, etc. You want to locate potential problems resultant from the injury as well as complicating factors so that you can better manage your patients. Some will say to not take stress views right away (flexion extension views), and again I say that this is not a good policy. I have treated thousands of patients and I have x-rayed the great majority of them. Flexion extension views allow you to see slippages due to ligament damage that are often missed on a neutral lateral films. Why would you not want to know that they are there right from the start and more importantly why would you want to miss them right from the start of care? I have seen large translations due to ligament damage right on the initial films that would have been missed if there were only neutral lateral film. When you see these it allows you to make better decisions as to which vertebrae you are going to adjust as well as how you want to go about active care with this patient. Lastly in today’s litigious environment I would not want to be without a full work up on any patient. Smith vs Yohe is a court case that is often cited regarding this issue:
Smith vs. Yohe, Supreme Court of Pennsylvania 10-9-63
“If a physician, as an aid to his diagnosis (i.e.: his judgment) does not avail himself of the scientific means and facilities open to him for the collection of the BEST factual data upon which to arrive at his diagnosis, the result is not an error of judgment but negligence in failing to secure an adequate factual basis upon which to support his diagnosis or judgment.”
You can never be at fault for being overly cautious as long as it is backed by good clinical rationale.
Q: Can the findings of “Alteration of Motion Segment Integrity” be hidden on initial films due to spasm and inflammation associated with the injury?
A: Yes they can, however it is not as common as some would lead you to believe and it is usually very easy to see clinically. When you take your initial set of stress radiographs, if you see that there is little flexion or little extension or you see vertebrae moving in a block and not individually, then you are probably dealing with spasm and inflammation causing this. You simply note this and let the patient know that pain, spasm and inflammation may be hiding ligament damage on the films, and that as soon as they have improved ROM, you are going to retake the films to have them tested for ligament damage and it will probably occur at our first re-exam period. You will periodically see this occurring, but not enough to stop you from doing stress radiography right away.
Q: I was told that in order to get true stress radiography to show up “alteration of motion segment integrity” it is best to have a technician press down on the patients head?
A: First of all I would not want that job as it would be a bit of a Madame Curie situation of too much exposure to x-ray for the technician. You do not need to have pressure on the patients head, however if you are a biomechanical CBP, Pettibon practitioner and you use head weights for rehab you could use the headweight on the patient to accentuate the misalignment if any. Use extreme caution when doing this as you can further traumatize the patient. I actually have never used this procedure and would recommend just taking the initial films with no addition pressure.
Q: What if I shoot my cervical at 40” FFD, can I still get my X-rays Accurately Digitized?
A: Yes you simply tell us that you shoot at that FFD and we will calibrate our system to compare your 40” to the standard 72” FFD. Now if you are going to be doing a lot of stress studies we recommend that you shoot your cervical views at 72” FFD. We would also tell you that if you are going to shoot your x-rays at 40" FFD than you definitely need to work with a company that has built in calibration for this.
Q: On my reports that are positive for “Alteration of Motion Segment Integrity” the reports state that there is a 25% Whole Person Impairment, what does that mean?
A: First of all Impairment means: A loss, loss of use, or derangement of any body part, organ system, organ function.
Further more:
Impairment percentages or ratings developed by medical specialist are consensus-derived estimates that reflect the severity of the medical condition and the degree that the impairment decreases and individual’s ability to perform common activities of daily living (ADL), EXCXLUDING WORK. Impairment ratings were designed to reflect functional limitations and not disability. Page 4 AMA Guides.
ADLS are the following:
Self Care-Personal Hygiene
Communication
Physical Activity
Sensory Function
Non-Specialized Hand Activities
Travel
Sexual Function
Sleep
So to continue when your patient has alteration of motion segment integrity (Values Defined Above) the AMA says that either now or in the future 25% of your patient’s ability to perform activities of daily living will be negatively affected. This is not your professional opinion; this is the AMA’s consensus opinion, as to how this condition may affect your patient’s life.
Q: Does an Impairment Rating have anything to do with a disability percentage?
A: No it does not directly, however you will never have a disability without impairment. Impairment ratings are for how the condition will affect the patient’s life outside of work. Disability is how the condition will affect the individual’s ability to earn a living or to work at their current job or any job for that matter. A disability exam takes into consideration the specific physical requirement of the job and matches them to any inability i.e., the patient has three herniated disc in the lumbar spine and his job requires that he lift with his low back 70 plus pounds, 60-90 times a day—there may be a disability—an inability to continue to do this job. Now all disability requires impairment, however having impairment does not necessarily mean that there is a disability;
Example: A man saws his left little finger off in the garage and it cannot be re-attached. He would have a 10% Impairment of the hand usage, 9% impairment of the upper extremity and 5% whole body impairment. This means that five percent of his activities of daily living would be negatively influenced. He may not golf well, use garden tools etc. Now if he were a right handed bank president, this injury would have no negative influence on his ability to do his job—0% Disability. However if this person was a professional pianist he may not be able to do his job at all, which would be 100% disability. I hope this helps you to understand the two terms.
Q: When I see and Impairment Rating it states based on an AMA DRE Category; what does DRE mean?
A: DRE means Diagnosis Related Estimate. There are two methods of impairment rating DRE and ROM Method. With DRE you simple look that diagnosis or level of functional loss up on and chart and the AMA Guides book tells you how much that condition will affect you patients life. If you cannot adequately place the patient into a DRE Category than the AMA has a ROM (Range of Motion) Method for spinal impairment, by which you take range of motion measurements of the spine. Combined with and diagnosis, such as spinal DJD, and combine this further with any spinal nerve deficit. DRE is what you will use with injured patients.
Q: Is this procedure under any set of guidelines?
A: Yes it is. It is listed in many guidelines, the ICA, CCP and PCCRP Guidelines to name a few.
Here Are Some Questions of Comments That Some Insurers or IME/ICE Reviewers Will State
Q: Why is this procedure needed as a means of diagnosis?
A: This procedure was utilized in order to get an accurate diagnosis of what is going on with my patient inter-segmental, which I do not have the ability to get in my clinic, as we do not have the equipment to accurately do this. We use an outside service for one reason; accuracy in determining what the patient has so that I may make my diagnosis as accurate as possible. Accuracy of diagnosis allows me the opportunity to provide my patients with optimal outcomes from their care and it also provides me with another level of patient safety. If there is a more accurate way for me to determine spinal instability, please send me the procedure and the mechanics of utilizing it and I will consider using it in the future. This procedure also allows you to better determine both active (care the patient does on thier own, i,e., stretches, exercises, spinal molding, pain avoidance techniques etc.) and passive care (care the patient receives in your office) needs of the patient once MMI is met for the body part involved.
Q: What are the reasons for referring the patient's plain film x-rays?
I have referred this patient’s films out for this procedure in order to assess accurately the status of my patient’s spine inter-segmentaly. “Alteration of Motion Segment Integrity” is just what is says it is, and to me a practitioner who utilizes spinal adjusting procedures, I want to accurately know what I have with the patient. I have basically four tissues in which I am working with when I am addressing a patient’s spine, Bone, Muscle, Nerve and Ligament. Internally I have adequate testing procedures in place in order to evaluate the Bone, Muscle and Nerve; however I have no adequate way to determine the status of the inter-spinal ligaments. I am not talking about a disc now, but rather inter-spinal ligaments. If I feel that there was disc involvement then we would refer out for an MRI. Again knowledge of what my patient has is of primary importance to my managing this patient, and providing the safest, most effective care that I can provide. That is all that I am interested in as a provider to my patient. This is why we refer out films on patients that we feel may have “alteration of motion segment integrity.” We also understand that we cannot accurately measure this in our clinic, nor do I even understand how the measurements are performed. This procedure is also geared towards the practitioner of manual medicine, or those involved in manually adjusting the spine, by hand or by instrument. The information provided in these studies is helpful in providing greater ability to manage the patient for optimal treatment outcomes and well as provides another level of safety for the patient.
Q: How have the findings of the report been utilized to modify the patient's course of treatment (medical regime)?
Doctors this is a question that in some ways you must take the time to answer for yourselves as there is a great variance in both techniques and approaches and you must use yours. Perhaps you have special or more advanced active care (home exercise programs), or you have physical therapy protocols for ligaments, laser protocols, or you have nutritional protocols, or you are going to switch the vertebral levels being adjusted, or you are going to expect to need longer 3x/wk, 2x/wk care. This is up to you. Here is how I would answer this question in my own clinic.
I use this procedure to confirm or deny and alter my treatment plan with the patient. It is painfully simple to understand that patients who have potentially ratable levels of ligament instability have a much more serious condition than those that do not. There has been a grading system of sprains which indicate that a patient who has a ratable level of sprain, those meeting the criteria for “alteration of motion segment integrity” as laid out in the AMA Guides to the Evaluation of Permanent Impairment, would be classified as a Grade III sprain or as serious of a sprain as you can get. Sprains by definition mean that the connective tissue is damaged, in this case the ligament, which by definition maintains spinal motion unit integrity. Knowing the status of my patient’s spine allows me to better communicate with my patient and set up treatment protocols that are more appropriate for a patient with this type of sprain or ligament condition. Knowing which level is most affected allows me to make judgment as to whether or not I should be adjusting these segments or segment, which immediately alters my care plan for the patient. Ligament injury also tells me that generally this patient will require more care and more active participation in their recovery through active care procedures, such as the home exercises that they have been given. It also alerts me to be more active in coaching this patient back to recovery if they get lax on either my care plan or my active care procedures, as by definition these patients can take longer to stabilize.
Knowing this information also allows me to better communicate to my patient what they have, so there is less confusion and better understanding by both myself and the patient.
My job rehabilitating patients with injuries is a tough and often very rewarding job that I take seriously, as it affects the lives of the patients that I treat. My ability to get knowledge and understanding of what I am treating with each and every patient is key, and that is why we utilize this service. It definitely makes a difference in what I am going to do with this patient.
Q: The x-ray findings from digitizing can be determined using manual techniques. Please explain why it was necessary to refer the patient's x-rays to ****?
I do not mean to sound rude, but according to who? Who says that x-ray finding from digitizing can be determined using manual techniques? If this were true I would simply perform them in my clinic myself. I am not an advocate of sending my patients out for unnecessary procedures just for the sake of the procedure. I take my job and my responsibility as a clinician seriously, as noted above. To explain my point further, I have attended and accredited school, and have a responsibility to obtain continuing education hours yearly in order to maintain my license. In all of this education I was never taught, nor could I perform this procedure accurately in my clinic and I am not aware of anyone else that can in private practice either as this is not a standard procedure that is taught, however X-ray Digitization and its utilization in well laid out as a valid procedure to use in our National Association Position Statements, as well as published guidelines.
I also understand that the difference between ratable and non-ratable “alteration of motion segment integrity” is in terms of hundredths of a millimeter. I simply cannot be that accurate with a x-ray pencil and a ruler. My x-ray marker line alone may be and average of 0.75 of a millimeter and I would have to draw four lines in order to calculate translation for on motion unit. This gives me three millimeters of line just with my marking pencil. There is no way I can accurately do this in my clinic.
If this procedure can be accurately performed by me in my clinic, by hand, please send me a copy of the written procedure, including how to accurately assess both angular and translational variations involved in “alteration of motion segment integrity.” Please also send me testing that has proven that this method is more accurate than one using a computer with sophisticated biomechanical mensuration software, that has the ability to zoom, scroll, magnify-down to the pixel, apply gray scale filters, negative reversal filter, red, blue and green filters, noise reduction, contrast and brightness control, mirror, invert, tilt by degrees, capture frame image, image distortion calibration and rotate the axis of digital images, in order to get a highly accurate study.
I would also ask you to go one step further and call on the next ten doctors who are practicing spinal adjusting techniques which are usually either a Doctor of Chiropractic of a Doctor of Osteopathy and ask them how they calculate accurately by hand the degree of spinal instability associated in the AMA Guides as alteration of motion segment integrity? I will be willing to bet that the next 100 doctors that you would ask that question could not answer it correctly, so where does it come from that this can be done by hand in my clinic? When I talk to medical radiologists I find that they were never taught in their formal education to accurately detect spinal instability, nor do many of them even know the parameters by which it is determined?
Again I am not in the habit of sending my patients out for an unnecessary procedure that I could easily do in my clinic. I cannot do in my clinic the evaluation that National Injury Diagnostics provides or for that matter any other X-ray Digitization service provider.
I also like the fact that I ma getting an independent, unbiased second opinion on the status of my patient's spine. In my opinion this increases my professionalism and my ability to properly manage my patient's.
Q: What about the studies that show that hand mensuration is very accurate, say with the Harrison or Pettibon studies?
A: I have the utmost respect for both of these pioneers and I have the utmost respect for those who practice these techniques as well as utilize the radiographic hand mensuration techniques. These mensuration techniques are highly reliable for postural analysis such as Jackson Cervical Curve Angles, Forward Head Posture Etc. There measurements can be off by a significant amount and it really does not matter as the practitioner is not relying on them for intersegmental ligament damage or impairment rating. they are rather being relied upon for general baseline and follow up outcome assessment of the treatment plan.
Now most of these techniques shoot their x-rays as a 40” FFD which makes the accuracy of translation measurements difficult to do by hand or on a CAD as the 40 FFD Magnification factor has to be added into the equation manually. There is also no way for any practitioner to take hospital DICOM Digital X-Ray Images or DMX images and perform and accurate translation or angular calculation in order to determine areas of potential ligament instability and ratable impairment. I also enjoy the fact that I am getting and unbiased second opinion of the status of my patients spine.
So there are accurate hand mensuration procedures for postural analysis, but these cannot be applied to AOMSI Measurements where 1/100 of a mm matters.
Q: What findings in your initial exam resulted in your decision to refer x-rays out to a digitizing service?
A: For this answer we must understand what the guideline for this procedure states. The guideline for the procedure is in the Council of Chiropractic Practice Clinical Practice Guidelines, which states:
Radiographic Digitizing Analysis - Added
Sub-Recommendation - Added
Computerized X-ray analysis may be used by chiropractors to objectively analyze the biomechanical and misalignment improprieties related to vertebral subluxation. Clinical necessity is justified for assessing the degree of insult and the effect upon the patient’s health and future well-being by way of impairment rating.
Rating: Established
Evidence: E, L
Commentary - Added
Diagnostic imaging methods may be utilized for obtaining information concerning the vertebral subluxation and other malpositioned articulations and structures, primarily the osseous misalignment component. Although advanced imaging can provide important information regarding foraminal alteration and possible nerve impingement, it is also possible to demonstrate aberrant motion and position which may impact upon the safety, appropriateness and outcome of chiropractic care.
Computer aided digitizing mensuration analysis software has demonstrated accuracy to 0.0023 mm. While hand mensuration should not be overlooked, it cannot approach the accuracy attainable with advanced computer technology. Computer aided digitizing mensuration analysis provides biomechanical analyses with a high degree of accuracy in order to make a chiropractic differential diagnosis and/or to determine care protocols. Mensuration also provides a definitive baseline for follow-up radiological examinations as an assessment of outcome.39-117
So the answer to this question is that in consultation the patient acknowledged that they were in a incident that may have caused ligament damage to the spine. Your examination finding further indicated that they may have received damage to the spine, so you had established necessity to have the study performed. Clinical necessity is justified for assessing the degree of insult and the effect upon the patient’s health and future well-being by way of impairment rating. Insult is a medical term for trauma or injury, so clinical necessity is established to assist you in determining the degree of injury to the spine.
To add to this please understand that CCP states the following on page 17 2003 CCP:
The American Medical Association, in its Guides to the Evaluation of Permanent Impairment, lists the following as acceptable means to rate impairment: 70
• Impairment due to loss of muscle power and motor function,
• impairment due to abnormal motion of the spine,
• impairment due to loss of motion segment integrity,
• impairment due to disc problems,
• impairment due to pain or sensory deficit, and segmental instability.
The above are, in fact, components of the Vertebral Subluxation Complex.71,72
Again clinical necessity is established to determine the degree of trauma as well as the degree of subluxation.
Q: I have taken note that CPT code 76499 "An unlisted diagnostic radiographic procedure" has been billed for this procedure. The plain film x-rays were analyzed, which included a radiographic analysis, and we have reimbursed your office for these charges. Please explain why both procedures were necessary?
I think I have fully explained to you why we utilized this service and how it is performing a diagnostic study for me that I cannot perform for myself, but need in order to better understand the patient that I am managing. This is a separate prescription service that I referred the patient out to, and I have no knowledge of their billing codes, nor does it concern me. I only know that this company provides a valuable service that allows me to get a more accurate diagnosis and allows me to better handle my patients. It also provides me with another layer of patient safety. As for the billing codes that they use you would have to take up with them, as I say I have no knowledge of their codes.
Q: You cannot see ligament damage on plain film x-rays can you?
A: No you cannot see the ligaments but you also cannot see cancer and other conditions that can be diagnosed by x-rays. You can only see the effects of cancer, by the appearance of bone wasting or modeling. You cannot see degenerative disc disease; you can only see the effect of it. Ligaments hold bones together and when those bones misalign to a certain threshold it s agreed that the ligament is impaired i.e., stretched, torn etc.
Here is a quote to help:
Here is a quote from a PT Textbook called; Fundamentals of Musculoskeletal Imaging
“Although ligaments are of water density and generally do not possess enough radiodensity to be visible on radiographs the articular relationships that intact ligaments provide can be evaluated on conventional radiographs. Loss of normal articular relationships implies loss of ligamentous support" Pg 145
"If there is a history of trauma and joint instability or hypermobility, or if either is clinically suspected or needs to be ruled out, lateral flexion and extension stress views should be obtained. These two films are then evaluated to identify joint hypermobility revealed by misalignment (excessive angulations or excessive glide) of the injured segment." pg 167
Q: When you have alteration of motion segment integrity, spinal ligament damage it cannot be treated, therefore it does not affect what you are going to do with the patient?
A: It is even amazing that this question or comment comes up but it does. First of all you take x-rays to see what you have, what you are dealing with, with the patient. Let’s say that the patient has an old compression fracture at C5 50%. You are not going to treat it however there is no way that it will not influence what you are going to do with that patient, and you are better off knowing it is there. This is also true with mild, moderate and severe pre-existing degenerative disc disease as well, as you are not going to correct it however it is definitely necessary to know in order to determine what and how you are going to treat the patient. Knowlege of ligament damage also allows you to better manage the patient that have it, both with active and passive care procedures, so there is no way that this condition is not being treated, as it is a part of the spine that I am treating.
Though my treatment may not correct the ligament condition it can reduce the effects for that condition significantly.
Here Are Some Questions or Comments That Come Up In the Field
Q: I was told that I could only have my films digitized within the first thirty days of taking them, is this true?
A: No it is not true, however this is a common line put out by a company that does pathology reviews as well, and they need the films to be thirty days or less or they may have a harder time getting paid for the pathology study read by the MD. This has to do with getting paid for the pathology study and not the digitization study or when it can be done. A digitization study can be performed at any time in the care of your patient. As we stated above it is recommended to do it right away so that you can know what your patient has and adjust your care plan accordingly. There are other times that you may want to digitize films if you do not do them initially. Lets say that the patient is 2, 3, 4 months under care and they are not responding the way you think that they should be. Perform the stress views and have them read at that time as they may have ligament injury that you have not identified. If it comes back positive adjust your treatment decisions accordingly. You may also want to do a study at the end of care—the patient has a lot of residuals and you want to do a spinal ligament study to see if it is positive as you want to understand what the future of this patient is and what you may or may not recommend for active and passive future care.
Q: It is better or necessary to have a MD Radiologist sign off on the report on the biomechanical report?
A: No not really, however there is a perceived credibility by some if they do. The most important thing it to get an accurate biomechanical report. An MD Radiologist provides you with a pathology report, or a pathology read, (Fractures and Disease) not a biomechanical report generally. If you are going to have a radiologist read your x-rays because you believe there is a pathology on your films you should do it right away. If you are using a company to have an MD sign off on your report and really do not need the path read there is really no need for the MD. Now the other thing to understand is that in my experience many of the medical radiologists that sign off on these reports do not know what they mean or how (The mechanics) they were performed, therefore they do not depose or testify well to the findings and their credibility at that point is shot. If you are having a medical radiologists sign off on your reports, you should speak to the doctor in order to make sure that they understand and can explain to you what the biomechanical report means, how they are produced and who produced it (what were there qualifications for being able to accurately perform the study).
Q: I was told that the impairment rating is not good or considered for “alteration of motion segment integrity” unless it is done by a medical radiologist?
A: This is a false line proposed by some service providers either now or in the past. X-ray digitization provides you with a finding that qualifies for a DRE placement into the Impairment Guides, just like a positive MRI may or a Positive EMG or an X-ray that shows a Compression Fracture etc. There are many findings or conditions that qualify for and impairment rating. Now and impairment rating is only considered when the patient’s body part has reached MMI (maximum medical improvement) which is defined as “a date from which further recovery or deterioration is not anticipated”. AMA Guides to the Evaluation of Permanent Impairment 5th Ed, page 19. What this means is though all of us can list a radiographic finding as meeting the criteria for a Category IV DRE Whole Body Impairment Rating, the Impairment Rating is not included or given any credence until MMI is achieved on the injured body part and a MD either examines and substantiates or signs off on the Impairment Rating through a paper review of the file. The only real value this has to the treating doctor is to get an unbiased second opinion as to the condition of your patient so that you and your patient may work out both future active and passive care schedules with the idea of continuing to improve your patient’s condition in the long run.
Q: What information did you anticipate receiving from the Diagnostic Service that would assist you with the treatment of the patient?
I would recieve information that allows me to determine the severity of the spinal ligament injury as well as the specific motion units that are most affected. This allows me to better formulate my care plan, and to manage my patient in order to ensure the most optimal results possible.
