Recent medical literature, including several citations in journals such as SPINE and the Journal of Spinal Disorders, support the importance of dynamic motion x-ray for the evaluation of the cervical spine.
American Academy of Pain Management Practical Guide to Clinicians, Fifth Edition states, "...digital motion radiography is currently a valuable diagnostic method in evaluating painful hyper-mobility and instability of capsular and axial ligaments in the cervical spine."
The American Medical Association, Guides to the Evaluation of Permanent Impairment Fifth Edition states, "Alteration of motion segment integrity is defined from flexion and extension radiographs as a least 3.5 mm of translation of one vertebra on another, or angular motion of more than 11 degrees greater than each adjacent level..." as a criteria to determine the "Impairment of the Whole Person".
The Occupational Medicine Practice Guidelines, Second Edition 2004 (American College of Occupational and Environmental Medicine) states, "If probable ligamentous injury with persistent pain, consider fluoroscopically directed flexion study."
Donald Resinck: Professor of Radiology, University of California, San Diego. Diagnosis of Bone/Joint Disorders: 1988, chapter 3. "Videofluoroscopy is useful in the evaluation of joint movement. Used during R.O.M., (range of motion) it identifies the level of Instability secondary to ligamentous damage."
The Cervical Spine: the Cervical Spine Research Society: 1989, page 260. "Video fluoroscopy is a dynamic technique that allows precise positioning during R.O.M. studies. Anterior gapping of a disc space sudden translation of a vertebral body on another may indicate intersegmental instability."
Buonocare, Edward, MD et.at.k Cineradiograms of Cervical Spine in Diagnosis of Soft-tissue Injuries, Journal American Medical Association. The author concludes that cineradiography adds another diagnostic method of evaluating suspected soft-tissue injuries of the cervical spine by demonstrating its motion during exercise. Furthermore, the cineradiographic study will have its greatest value if it can detect abnormal motion in patients who show normal spines on standard roentgenograms and before degenerative changes have occurred.
John Bland: Disorders of the Cervical Spine: 1987, page 144.
"Video fluoroscopy is the most valuable technique in analyzing cervical spine motion."
Jones, Malcomb, D., MD, Cervical Spine Cineradiography After Traffic Accidents, Archives of Surgery. Cineradiographic studies demonstrated 1 or more abnormalities in 43 of 50 patients involved in rear-end vehicle collisions."
John Bland: Professor of Medicine, University of Vermont. Disorders of the Cervical Spine: 1987, page 134. "The Stability of the cervical spine depends on bony structures only to a minor degree; stability depends to a major degree on the ligamentous structures." Such injury is not always detected on static plain film x-rays (standard roentgenograms). The next best medically reasonable diagnostic tool for determining ligamentous injury (a biomechanical source of pain) is the fluoroscopic exam.
Ruth Jackson: instructor of Orthopedic Surgery; Baylor University, the Cervical Syndrome: 1977 "Video fluoroscopy shows areas of limited or unstable motion resulting from ligamentous and capsular injuries."
Robert Baily: Professor of Orthopedic Surgery, University of Michigan, Ann Arbor. The Cervical Spine 1974, chapter 3. Dynamic Anatomy and Cineradiography of the Cervical Spine. "Video fluoroscopy shows abnormal secondary to soft tissue (ligamentous) damage. Stability is dependent on ligaments."
Jones, Malcomb, D., MD, Cineradiographic Studies of Abnormalities of the High Cervical Spine, Archives of Surgery. The author begins by noting cineradiography is becoming widely available and reports of its use in orthopedic problems, particular those of the cervical spine. Cineradiography, it was concluded that the use of cineradiography has elucidated abnormalities seen on plain roentgenograms of the cervical spine.
Woesner, Merlin, E., MD, and Mitts, The Evaluation of Cervical Spine motion below C2: A comparison of Cineroentgenographic and Conventional Roentgenographic Methods. A Comparison study of 40 randomly selected patients who had roentgenographic investigation of the cervical spine by both cineradiography and conventional lateral roentgenograms in flexion, neutral position, and extension was made for the analysis of motion. In 14 of the 40 patients, abnormal motion was detected in the spine that was not seen on the plain roentgenograms.
It is further appropriate to determine the level of this individual's long-term prognosis related to injury. Ligamentous instability is recognized as "whole person" impairment by the American Medical Association (AMA). Any translation of one vertebral body on another in the Cervical Spine is abnormal, and as little as 3.5mm is considered grounds for 25% whole person impairment. It should be noted that the ACCR and Committee on Scientific Affairs has determined that the utilization of Fluoroscopy is useful imaging modality for the demonstration of spinal intersegmental joint dysfunction.
Spinal Impairment Categories: AMA Guides (Diagnosis Imaging of the American Chiropractic Association/Position Statement of 6/13/91). "With the publication of these guidelines...the American Council of Chiropractic Radiology no longer considers Spinal Video fluoroscopy as investigational within the chiropractic profession."
Fluoroscopy is supported by the ACOEM (American College of Occupational and Environmental Medicine) Guidelines.
Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers, second Edition. "If probable ligamentous injury with persistent pain, consider fluoroscopically directed flexion study."
Also in this regard, the 1993 Mercy Center consensus Conference rated Video fluoroscopy as Promising, with evidentiary ratings of Class II and III and a consensus rating of #1 (the highest level).
Excerpt from the proceedings of the Mercy Center Consensus/Section on Video fluoroscopy procedures. 1993. Scott Haldeman D.C., M.D., PhD. Commission Chairman. These Video fluoroscopy procedures are effective for evaluation for the quality of spinal motion. It is unique in this respect since, unlike stress vies, it not only provides a view of total excursion, but also how the segments arrived there.
The Centers for Medicare and Medicaid Services further support the appropriateness of fluoroscopy as an examination technique utilized to determine biomechanical abnormalities (subluxation). Medicare coverage database; LCD for Chiropractic Service (manual spinal manipulations) ( L15759).
Dr. Michael Weir is the clinic director at Bellevue Whiplash Center at Back in Action Chiropractic. We will also be hosting a variety of relevant guest bloggers to help you understand your injuries better.