The Changing Role of DiagnosticImaging in Chiropractic

Cynthia (Cindy) Peterson, RN, DC, DACBR, M.Med.Ed.Departments of Chiropractic Medicine and Radiology

Orthopaedic University Hospital Balgrist,University of Zürich, Switzerland

Chiropractic started in 1895 the same year that Roentgen discovered x-rays

Chiropractors marked their‘subluxations’ on full spine radiographs

and treated accordingly.

The dangers of ionizing radiation were not known for many years.

• We now know that…..• Radiation is dangerous• Radiation dose is cumulative over a lifetime

• The inter-rater reliability of the marking systems is not good.

• Therefore the validity is not good.

• «Interrater reliability of roentgenological evaluation of the lumbarspine in lateral bending»

• Haas M, Nyiendo J, Peterson C, Thiel H, Sellers T, Cassidy D, Yong Hing K. JMPT 1990;13:179-89.

WALL FELL ON MAN AT WORK. DC ANALYZED FILMS USING GONSTEAD AND ADJUSTED THE SPINE. THE PT

WAS WORSE!

The word ‘subluxation’ was stolenfrom Medicine where it had a very

specific meaning

2017:Seeing It Differently: Chiropractors

as Spinal Imaging Experts

6 year old Swiss boy with Trisomy 21, acute trauma andtorticollis for 2 weeks. Radiographs read as normal by

the hospital radiologist. Chiropractor disagreed.

20 year old male evaluated for fitness for military service. Radiographs read as normal by radiologist.

Chiropractor disagreed.

1. Chiropractors MUST be the expertsat reading routine radiographs

• WHY?– Medical radiologists are not being trained to read

routine radiographs.

– Focus is on advanced imaging and interventionalprocedures.

– Losing the knowledge/ appreciation of the value ofroutine radiographs for many conditions!!

– 20 – 40% of statements on imaging reports are wrong.

– «If you want to fail someone on the radiology boardexams, give them a routine radiograph.»

Gruber M, Dinges J et al. Fortschr Röntgenstr 2013; 185: 1074-1080.

UK chiropractor requested that I review the routine radiographs of an

11 year old girl with 8 months ofincreasing left hip pain and a limp.

The medical radiology report stated‘No fractures’ – that was all.

From. C. Peterson, DC, DACBR, M.Med.Ed. Chiropractic Medicine Department, Faculty of Medicine, University of Zürich, Switzerland

What are the abnormal findings? What is the diagnosis or DDX? What should be done next?

Follow up

• Many weeks later the child was able to get an MRI on the UK national health service. She has cancer and is now referred to oncology.

• The mother was very grateful to the chiropractor for not relying on the x-ray report and seeking a second imaging interpretation.

• This is another example of how important it is to be able to read routine radiographs!

Do Not Rely on the Imaging Reports! Look at the images yourselves.

60 year old female presented to the AECC clinic with groin pain after tripping over the carpet. Her GP and an orthopaedic surgeon diagnosed

DJD. No films were taken. She is on corticosteroids for asthma.

52 year old female fell 3 weeks ago and continues to have groin pain and limp. Presented to CMCC

clinic

Case of the week 50Courtesy of Christof Schmid, DC

(Zürich)50 year old male with chief complain of bilateral inguinal pain, radiating into the genital region. Aggravated with walking and

partially relieved when lying down. He has seen several urologists who could not find anything wrong. He presented to the ER

because he could barely walk. After further blood and urine tests they suggested he see a psychologist.

Dr. Schmid examined him and took this radiograph, quickly making the correct diagnosis! (and telling him to cancel the psychology appointment.) What are

the abnormal findings? What is the DX? What should be done next?

Here are the T1-weighted and STIR (fat suppressed) coronal slices through the hips.

T1-weighted STIR (fat suppressed)

Modern, Evidence-based Chiropractorsuse Diagnostic Imaging properly

• Evidence-based guidelines to determine whenimaging is needed and when it is not.

• Evidence-based selection of appropriate imagingmodality for suspected condition.

• Linking imaging findings with clinical findings todetermine which abnormalities, if any, are clinicallyrelevant.

• Bussières A, Peterson C, Taylor J. Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults – An Evidence-based Approach: Part 2: Upper Extremity Disorders. J Manipulative Physiol Ther 2008;31:61-89.

•• Bussières A, Taylor J, Peterson C. Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults – An Evidence-based Approach:

Part 3: Spine Disorders. J Manipulative Physiol Ther 2008;31:3-60•

• Bussières A, Peterson C, Taylor J. Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults – An Evidence-based Approach: Introduction. J Manipulative Physiol Ther 2007;30:617-683

•

• Bussières A, Taylor J, Peterson C. Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults – An Evidence-based Approach: Part 1: Lower Extremity Disorders. J Manipulative Physiol Ther 2007;30:684-717

Chiro Holland; pt cervical collar; tingling and cold hands; dx HNP

Exam – Raynaud’s; 2 chiro tx; symptom free.

Clinical Relevance of Disc Herniations

• Imaging NOT indicated acutely in absence of cauda equina symptoms or unless deteriorating neurology!!!!

• CT and MRI are nearly equal in diagnostic accuracy in the lumbar spine.

• MRI offers more levels than CT.

• MUST LINK THE CLINICAL FINDINGS WITH THE IMAGING FINDINGS.

Many False Positive Findings with both CT and MRI

• The literature states that there is a 1 in 3 chance of having a surgically treatable lesion on CT or MRI in ASYMPTOMATIC individuals!

Should we be treating symptomaticdisc herniation patients with SMT?

An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc

herniation with radiculopathy.D. Scott Kreiner, MD, Steven W. Hwang, MD, John E. Easa, MDc, Daniel K. Resnick, MD et al.

The Spine Journal 14 (2014) 180–191.

• Question 8: what is the role of spinal manipulation in the treatment of lumbar

• disc herniation with radiculopathy?

• Ans. Spinal manipulation is an option for symptomatic relief in patients with

• lumbar disc herniation with radiculopathy [37–39].

• Grade of recommendation: C

• There is an insufficient evidence to make a recommendation for or against

• the use of spinal manipulation compared with chemonucleolysis in patients

• with lumbar disc herniation with radiculopathy [38].

• Grade of recommendation: I (insufficient evidence)

• [37] Santilli V, Beghi E, Finucci S. Spine J 2006;6:131–7.

• [38] Burton AK, Tillotson KM, Cleary J. Single-blind randomised controlled

• trial of chemonucleolysis and manipulation in the treatment

• of symptomatic lumbar disc herniation. Eur Spine J 2000;9:202–7.

• [39] McMorland G, Suter E, Casha S, et al. J Manipulative Physiol Ther 2010;33:576–84.

SMT for Symptomatic CDH and

Radiculopathy

•8. Vernon, Humphreys and Hagino. J Manipulative Physiol Ther 2005;28:443-8.

• Systematic Review: conservative treatments for acute neck pain not

• due to whiplash.

9. Brontfort, Haas, Evans, et al. Spine J 2004;4:335-56.

• Systematic Review and best evidence synthesis: Efficacy of SMT for LBP

• and NP

10. Gross, Hoving, Haines et al. Spine 2004;29:1541-8.

Cochrane review of SMT and mobilization for mechanical neck disorders.• Above 3 Systematic Reviews on SMT for various neck pain

disorders found insufficient evidence to support SMT for NP

and radiculopathy.

Featured on MDLinx

Background:

• SMT for symptomatic disk herniation (sDH) is

controversial

• Only moderate evidence supporting SMT to treat

sLDH

• Even though widely used by Chiropractors and

Manual Therapists

Research Questions:

• Short-, medium- and long-term outcomes of SMT for

sLDH?

• Do outcomes differ for acute vs. Chronic patients?

Methods:

• Prospective cohort outcomes study LB and leg pain

• OM:

• PGIC scale for improvement,

• 2 NRS for back and leg pain intensity,

• Oswestry Pain and Disability Questionnaire

Inclusion Criteria

• Age: 18 to 65

• LBP + moderate to severe leg pain in a

dermatomal pattern & at least 1 of the

following:

• Decreased SLR

• Deficit in cold detection

• Reduced response to pinprick

• Decreased muscle strength in corresponding myotome

• Decreased or absent DTR corresponding to involved segment

• MRI-proven LDH at corresponding

symptomatic spinal segment

Spinal Manipulation Procedure

• Standardized Treatment

• Side-posture HVLA thrust

• Depending on MRI location and exam.

• Intraforaminal DH:

• Modified Push SMT w/a kick

• Paramedian DH:

• Pull SMT with a kick

Acutes vs. Chronics: ‘Improvement’ (primary outcome)

PGIC 2 Wks 1 Month 3 Months 6 Months 1 Year

ACUTES 80.6% Impr.1.5% Worse

84.6% Impr.1.3% Worse

94.5% Impr.1.4% Worse

90.9% Impr.1.3% Worse

86.3% Impr.3.8% Worse

CHRONICS 46.7% Impr.3.3% Worse

70.6% Impr.0% Worse

81.8% Impr.0% Worse

88.6% Impr.2.9% Worse

89.2% Impr.2.7% Worse

What about comparing chiropracticSMT with another treatment for LDH

patients?

Symptomatic MRI-Confirmed LDH Patients: A Comparative Effectiveness ProspectiveObservational Study of 2 Age- and Sex- Matched Cohorts Treated with either High-Velocity, Low-Amplitude SMT or Imaging-Guided Lumbar Nerve Root Injections. JMPT 2013;36:218-225

Results at 1 Month:

• Chiropractic SMT Patients: 76.5% significantly‘improved’

• Nerve Root Injection Patients: 62.7% significantly ‘improved.’

• Costs:

• SMT = CHF 533.77

• NRI = CHF 697.00

How do patients with sCDH and radiculopathy respond to Chiropractic SMT?

Background:

• Evidence supporting SMT for sCDH is lacking

• 3 Systematic Reviews found insufficient evidence for

SMT for NP and radiculopathy

• Chiropractors and Manual Therapists use SMT in

spite of lack of supporting evidence

Research Questions:

• Investigate the clinical outcomes of HVLA SMT for

patients with sCDH & radiculopathy in chiropractic

practice

Methods:

• Prospective cohort outcomes study of Neck and arm

pain

• OM:

• PGIC scale for improvement,

• 2 NRS for neck and arm pain intensity,

• Neck Disability Index (NDI)

Spinal Manipulation Procedure

• HVLA SMT with rotation

away and lateral flexion

towards the side of the arm

pain

Results: acute vs. subacute/chronic

What about comparing chiropracticcervical SMT with another treatment

for patients with disc herniation?• Symptomatic, MRI Confirmed Cervical Disc

Herniation Patients: A comparative effectiveness prospective observational study of two age and gender matched cohorts treated with either imaging-guided indirect cervical nerve root injections or spinal manipulative therapy.

• JMPT March/April 2016.• Peterson C, Pfirrmann C, Hodler J, Schmid C, Leemann S, Anklin B,

Humphreys BK

What were the Results?

• 3 month Outcomes:

• 86.5% of SMT patients ‘improved’

• 49.0% of NRI patients ‘improved’

• However, NRI patients were more likely to bechronic (77% compared to only 46% of SMT patients)

What about comparing the Non-acutepatients only?

• SMT patients: 78.3% ‘improved’

• NRI patients: 37.5% ‘improved’

SYMPTOMATIC, MRI CONFIRMED, LUMBAR DISCHERNIATIONS: A COMPARISON OF OUTCOMESDEPENDING ON THE TYPE AND ANATOMICALAXIAL LOCATION OF THE HERNIA IN PATIENTSTREATED WITH HIGH-VELOCITY, LOW AMPLITUDESPINAL MANIPULATION

Marco Ehrler, B. Med.,M.Chiro.Med., Cynthia Peterson, DC, M.Med.Ed., Serafin Leemann, DC, Christof Schmid, DC,Bernard Anklin, DC, and B. Kim Humphreys, DC, PhD

JMPT 2016

Conclusions

• sLDH treated with side-posture HVLA SMT

Patients’ short term outcome:

• patients with sequestration have greater leg pain relief than patients with extrusion.

Patients’ long term outcome:

• clinically relevant “improvement”, regardless of location, level or morphology of the disc herniation.

Relationship between Diagnostic Imaging findings of Stenosis and Symptoms

• Radiological severity of stenosis is not associated with preoperative disability and pain, or clinical outcomes 1 year after surgery.

• The radiological severity of LSS has no clear clinical correlation and should not be overemphasized in clinical decision making.

• Weber C, Giannadakis C et al. Spine 2015 Sept 5.

Is There An Association Between Pain andMagnetic Resonance Imaging Parameters in

Patients with Lumbar Spinal Stenosis?

• «We could not identify a relevant association between any of the MRI parameters and buttock, leg and back pain, quantified by the Spinal Stenosis Measure (SSM) and the Numeric Rating Scale (NRS).»

• Burgstaller JM, Schüffler PJ, Buhmann JM et al. Spine 2016; doi: 10. 1097/BRS.0000000000001544

Case of the Week 167

49 year old female with severe LBP which worsens over time.

T1 and T2-weighted sagittal MRI slices

and an axial T2-weighted slice from

08.01.2010.

What are the abnormal imaging findings

and diagnosis?

ANSWERS

ABNORMAL FINDINGS:

A right, posteromedial disc herniation is noted at L5-S1 with slight displacement of the right S1 nerve root.

A rounded area of high signal intensity is present in the body of L3 on both the T1 and T2-weighted images.

Slight dehydration of the L3-4 disc is evident with a mild posterior bulge.

DIAGNOSIS:

1. Posteromedial disc herniation as described above.

2. Haemangioma L3.

3. Disc degeneration L3-4.

Here are the same slices from a follow-up

MRI done on 20.07.2010.

What has changed since the previous

exam? What is the significance?

A 3rd MRI was done on 01.10.2010 showing further

progression of the Modic type 1 changes at L5-S1.

This is a beautiful example of new Modic changes

linked to disc herniation appearing very quickly.

Obviously not all patients with disc herniation

develop Modic changes. The question is: Do

these Modic changes make treatment more

difficult? This is not yet known.

Modic Changes and Disc Herniations

• Disc degeneration, bulges and herniations areassociated with the development of newModic changes over time.

• At the age of 40, these findings had twice theodds of new Modic changes occurring at age44 compared with disc levels having normal disc contours or no degeneration.

• Jensen TS, Kjaer P, Korsholm L et al. Eur Spine J 2010;19:129-135

Do Modic Changes influenceTreatment Outcomes?

(Nguyen C, et al. BMJ 2015 & Ann Rheum Dis 2015;74:1488-94.

• Or should we be giving all of these patientsAntibiotics?

• Treatments which can accelerate Modic 1 conversionto Modic 0 or Modic 2 could be of therapeuticinterest.

• Several studies (but not all) have shown a positive association between various types of solid surgicalfusion and reduced LBP in Modic 1 patients alongwith conversion to Modic 2 or Modic 0. Modic 1 patients had better overall outcomes compared toother patients.

What about Non-Surgical Treatments for Patients with Modic Changes?

• 1. Intradiscal corticosteroid injections:– 3 non RCTs found that patients with Modic 1

reported better clinical responses than Modic 2 orno Modic patients.

• 2. Intravenous Bisphosphonates:– RCT found significant improvement at 1 month.

– Second RCT is ongoing

• 3. Exercise Therapy:– Few studies so far. Two found that the presence of

Modic changes had no influence on outcomes.

Do Modic changes influence outcomesof other LBP treatments?

• «Are Modic changes related to outcomes in lumbar DH patients treatedwith imaging-guided lumbar nerve root blocks?» (Peterson C, Pfirrmann C, Hodler J. Eur J Radiol 2014;83:1786-92.)

• Patient could have more than 1 cause for their LBP. DH and Modicchanges.

• 346 pts with MC present in 57%.

• A higher % of patients without Modic changes reported ‘improvement’ and a higher % of patients with Modic changes reported ‘worsening’ at 1 month but this did not reach statistical significance.

Are the Presence of Modic Changes on MRI Scans Related to‘Improvement’ in Low Back Pain Patients Treated with LumbarFacet Injections? (Bianchi M, Peterson C, Pfirrmann C, Hodler J, Bolton J. BMC

MSK Disorders 2015;16:234)

• More than 1 source for the LBP?

• 226 patients. 141 Modic positive (62.4%)

– (83 = Modic 1; 58 = Modic 2).

• At 1 month post injection 45.2% of patientswithout Modic changes reported clinicallyrelevant ‘improvement’ compared to 34.2% of patients with Modic changes.

• This did not reach statistical significance (p = 0.23).

Comparison of outcomes in MRI confirmed lumbar disc herniation patients with and without Modic

changes treated with high velocity, low amplitude spinal manipulation. JMPT March/April 2016. Annen M, Peterson C,

Leemann S, Schmid C, Anklin B, Humphreys BK.

• 72 LDH patients.

• 76.5% of Modic + pts ‘improved’ at 2 weeks compared to53.3% Modic – pts. (p = 0.09)

• Modic + pts had greater reduction in leg pain at 2 weeks (p = 0.02).

• Modic + pts had greater reduction in disability scores at 2 weeks (p = 0.012).

• Modic + pts had greater reductions in disability scores at 3 (p = 0.049) and 6 (p = 0.001) months.

• However, at 1 year MC 2 did significantly better compared toMC 1 (p = .001).

Primary Outcome ‘Improvement’ Yes/No

% Improved P value

2 WeeksModic PresentModic Absent

76.5% (n = 26/34)53.3% (n = 16/30)

0.09

1 MonthModic PresentModic Absent

68.4% (n = 26/38)64.5% (n = 30/31)

0.93

3 MonthsModic PresentModic Absent

84.2% (n = 32/38)89.3& (n = 25/28)

0.82

6 MonthsModic PresentModic Absent

87.2% (n = 34/39)92.0% (n = 23/25)

0.85

1 YearModic PresentModic Absent

81.1% (n = 30/37)96.4% (n = 27/28)

0.14

% Improved P value

2 WeeksModic 1Modic 2Modic Absent

69.2% (n = 9/13)81.0% (n = 17/21)53.3% (n = 16/30

0.118

1 MonthModic 1Modic 2Modic Absent

46.7% (n = 7/15)82.6% (n = 20/31)64.5% (n = 20/31

0.067

3 MonthsModic 1Modic 2Modic Absent

80.0% (n = 12/15)82.6% (n = 19/23)89.3% (n = 25/28)

0.696

6 MonthsModic 1Modic 2Modic Absent

87.5% (n = 14/16)87.0% (n = 20/23)92.0% (n = 23/25)

0.833

1 YearModic 1Modic 2Modic Absent

57.1% (n = 8/14)95.5% (n = 22/23)96.4% (n = 27/28)

0.001

Comparison of outcomes in MRI confirmed Cervical disc herniation patients with and without Modic changes treated

with high velocity, low amplitude spinal manipulationM. Kressig, C. Peterson, C. Schmid, S. Leemann, B. Anklin, B.K. Humphreys

• 44 patients. 13 with Modic changes. 5 = Modic 1, 6 = Modic 2. 2 = nocategory as no T1-weighted images.

• Modic + pts had significantly higher baseline NDI scores but not baselineneck pain or arm pain scores (p = 0.02).

• NDI change scores: Modic + pts had higher change scores at all time points which nearly reached significance (p = 0.07) at 6 months.

• Modic + pts also had higher NRS change scores at all time points whichnearly was significant at 6 months (p = 0.07)

• Comparing Modic 1 (n = 5) with Modic 0 pts found higher NRS changescores at all time points and higher NDI change scores at all time points. (P = 0.06 NRS change 1 month; P = 0.07 NDI change 1 year).

• 1° Outcome measure ‘Improvement’ Yes/No.– @ 2 weeks 75.0% of Modic + pts reported ‘improvement’ compared to 45.5% of

Modic – pts. (p = 0.17). (underpowered)- 100% of Modic 1 and 2 patients reported ‘improvement’ at 1 month, 3 months, 6 months and 1 year!!

Although small sample sizes for Modic 1 and 2 patients, strong and surprising trends were notedfavouring Modic positive and in particular Modic 1

patients!!!

WHY?

Modern Chiropractors are aware ofwhich imaging findings are clinically

relevant and which are not.