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Ultrasound - Good for & NOT good for...
- Not good for gas or air
- Good for soft tissue: carotid aa, liver, etc
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Sequestered disc:
chiropractic care not indicated
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disc fragmentation
can potentially cause cauda equina
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Ionizing radiation:
Which forms of Imaging use it?
CT scans, xray, electron beam tomography, etc
Ultrasound and MRI do not
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Management Annular tears?
You can still adjust: this is not a contraindication
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spondylolytic (pars defect) or anterior spondylolisthesis:
tight hamstrings, must stretch
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Posterior limbus bone:
due to disc fragment
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Two indications to refer for MRI
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Vertebral artery aneurism/tortuosity:
seen on arteriogram (not on US)
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Rovsings sign:
appendicitis
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71 yr old white mail, sciatica for 2 mo, worse at nightprostate CA, clinical & ortho tests equivocal, no improvement after 3 wks of care all imaging done (-)
continue to adjust & refer out
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Cancer (CA) was Ruled Out (R/O) but disc lesion found does not correlate w/ level found on exam
Concerned cause may actually be Piriformis Syndrome
What test could help clarify discrepancy?
SSEP
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30 yr old asian male bartender, N & T in R hand, aggravated by work
(+) Phalen’s & Tinel’s
how to DDx b/w CTS & VSC?
SSEP
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Pt not improving, suspect disc lesion
How to R/O disc lesion?
MRI
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29 yr old male w/ ankle pain & ↓ ROM
unresolved after inj. 4 wks prior,
X-Ray shows DJD & ossicles
suspect OCD, adjusted & rehab ongoing
what imaging do you use to R/O joint mice, insidious processes, see joint space & surfaces, & ligaments?
MRI
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57 yr old male falls of 15’ ladder, strikes head, loses consciousness for <1 min., seekscare at your office 1st.
Pt is dizzy, sluggish, has a headache
which modality to quickly R/O fracture & internal bleeding?
CT
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35 yr old male “bad” hit in Rugby, dizziness, HA’s, vision changes, numbeness in Lshoulder, atrophy of L supraspinatus & fatigue
4 wks prior grade 2 A-C separation, X-Rays of C-Spine neg.,Concerned for brain inj.
To which MD do you refer & which tests are indicated?
Neurologist & MRI
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35 yr old male “bad” hit in Rugby, dizziness, HA’s, vision changes, numbeness in Lshoulder, atrophy of L supraspinatus & fatigue
4 wks prior grade 2 A-C separation, X-Rays of C-Spine neg.,
Importance of asking the right questions: If atrophy of supraspinatus is of concern, which instrument would you use to determine if muscle is denervated?
Needle EMG
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27 yr old male cheerleader
(+) Lachman’s, Appley’s compression & Valgus Stress
Which modality would you use to image the meniscus, medial collateral & ACL?
MRI
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38 yr old female w/ N & T in L forearm following MVAaggravated by computer wk, worsens w/ C-spine Rotation
(+) foraminal compression on the L, no weakness
X-ray – post. Spur & ↓ disc C5-C6
DDx? Modality to visualize IVF during motion?
- DDX:
- Subluxation
- TOS
- foraminal encroachment
- Visualization during motion:
- Video Flouroscopy
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Modality for neurological component of VSC especially during rotation?
SSEP (nerve signal should not change by motion)
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Pt develops weakness in L hand during care
modality to R/O cervical herniation?
MRI
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56 yr old female w/ neck pain & history of RA
X-rays show ↑ADI, which ligament is implicated?
During VF, which movement would show ↑ in ADI?
Transverse ligament
Flex/Ext views would show ↑ in ADI
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30 yr old male injured during Rugby, hyperflexion & “stinger” (head goes one way, bodygoes the other), numbeness lateral to aspect of both hands
Davis series- ↓ curve, mild IVF encroachment, mild DDS, multiple fixations, previoushistory of similar inj.
Which modality if symptoms persist & concern is radiculopathy?
CT
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Which modality if more concerned about myelopathy w/ disc herniation &/or cordcontusion?
MRI
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12 yr old male Right elbow swollen & painful
history: fell out of tree
modality?
Plain film X-ray
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gold standard for spine & extremity trauma?
Plain film
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gold standard for disc ?
MRI
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20 yr old female volleyball player, complains of shoulder pain w. overhead movement,such as serving or spike
(+) supraspiatus test, pain on Abduction
how do you evaluate for a partial rotator cuff tear, impingement, or bursitis?
MRI
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42 yr old female, chronic thoracolumbar pain
(-) plain film x-ray, family history of CA & previous smoker
not resolving w/ care & want to R/O pathology
What is the starting point, cheapest, & gives evidence of ↑ metabolic activity?
Bone Scan
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48 yr old male, heel pain, limps into office after a 1 story fall.
Plain film equivocal
modality to R/O fracture?
CT
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Explain findings & recommendations
Pt. says “ I don’t know if this is important of not, but..."
Broke foot/ankle/lower leg 3 yrs before
Hip/pelvis/groin/femur head/buttock?
If NO new fractures, bone scan would most likely be (-) b/c?
90% of Bone scans are neg after 2 yrs of injury
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54 yr old female, transient pt., parent of student
routine x-ray – portion of postior 7th rib is missing
Modality for extent of metastasis?
Bone Scan
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Breast 1° site of CA
Metastasis suspected to R kidney
Which imaging modality to image kidney, knowing the pt can not lay still for long?
Which modality to image kidney if pt is morbidly obese?
Can't lay still? CT
Morbidly Obese? Open MRI
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24 yr old female falls in grocery store 2 wks before & complains of LBP
compression fracture of L2 seen on film
pt has legal counsel & seems to be looking for a “free Lunch”
You suspect it's an old fracture, how do you age the break & why do you choose that modality?
MRI, b/c bone marrow edema will show for 6 wks
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Wellness practice wants to quanify components of VSC on a routine basis. How?
- Physiology & ANS - thermography
- Kinesiopathology - VF
- Neurological, motor division - surface EMG
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61 yr old female, severe LBP, progressive low extremity weakness, pain aggravated by neck flex
X-Ray – facet arthrosis, poss. Tropism & central canal stenosis.
Modality to evaluate these bony elements?
CT
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75 yr old male w/ LBP
x-rays look like young spine
ortho & neuro disc herniation
marked palpable abdominal pulse, large area of artherosclerosis on LL
Modality to R/O or R/I disc & aneurysm?
MRI
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30 yr old female, LBP w/ L sciatica
(+) well leg raiser, SLR & valsalva’s
responds well but slowly, 50% in 3 wks
which modality?
None (but probably should have done film on initial visit)
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42 yr old female, R leg pain to foot w/ N & T
unable to stand on Rt toes,
previous disc surgery w/ similar S & S, probable “failed back surgery”
Modality to DDx scar & recurrent disc?
MRI w/ contrast
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21 yr old female, whiplash from MVA,
very slow progress over 3 wks
ROM improved but not the pain
Concern for occult fract./IVF encroachment.
Modality to R/O concerns?
CT
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68 yr old female w/ L shoulder pain,
fell on elbow,
shoulder ROM is ↓ & painful,
painful lock when attempting flexion
Plan of action?
X-ray & refer out
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43 yr old male w/ R hip pain, correlates w/ exercise,
already seen MD, extensive imaging already done,
care yields no improvement,
concern for underlying pathology, especially AVN.
Plan at this point?
Adjust & refer out
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Axial loading with nerve root compression
increased likelihood for pain
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Cross sectional area of dural/thecal sac
canal open when pt is in flexion
Significance?
Less Pain (closes in extension)
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Transient synovitis
- Most common cause of pain in 12 y/o age group
- Resolved with rest and adjusting
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Dessication
drying out of the IVD
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T2 = CSF appears...
bright
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Myelomalacia:
- Associated with stenosis and DJD
- Adjust these patients
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Ligamentum flavum hypertrophy (redundancy)
- associated with Canal Stenosis
- Common cause of back & leg pain in the elderly
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Microdisectomy:
- removal of small portion of the disc
- procedure to stabilize the segment
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Which motions open and close the IVF?
- IVF opens in flexion
- IVF closes in extension
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When do you order contrast w/ MRI?
Post surgery for scar tissue identification and to look for tumors/growths/etc
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Modic Endplate Changes
Type 1: Decreased T1, Increased T2
Type 2: Most common – Increased T1, slightly hyper-intense T2
Type 3: Bony proliferation – osteophytes – Hemispherical spondylosclerosis
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T1 weighted SE (spin echo) image =
Fat Image
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Why do initial CT and not MRI with acute head trauma?
CT is much faster
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Why CT vs MRI for children?
Would have to sedate child with MRI (dangerous)
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Stork Test is evaluating for...
spondylolisthesis
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Active spondylolysis –
no pars defect yet
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Technetium bone scan:
sensitive but not specific
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Stark Law
Not allowed to refer patients to offices in which you have vested financial interest
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ACA & ICA guidelines on imaging:
full spine radiography
- AP can be done on 14x36
- Lateral should be taken in sections due to pt exposure
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ACA & ICA guidelines on imaging:
Computer assisted mensuration
Do a separate pathology report
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Stages of Disc Herniation
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Disc Protrusion
- Commonly called a disc bulge, a disc protrusion occurs with the spinal disc and the associated ligaments remain in tact, but form an outpouching that can press against the nerves.
- OR
- the greatest distance, in any plane, between the edges of the disc material beyond the disc space is less than the distance between the edges of the base in the same plane.
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Disc Extrusion
- A disc extrusion occurs when the outer part of the spinal disc ruptures, allowing the inner, gelatinous part of the disc to squeeze out. Disc extrusions can occur with the ligaments intact, or damaged.
- OR
- in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base in the same plane, or when no continuity exists between the disc material beyond the disc spaceand that within the disc space.
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Disc Sequestration
- A disc sequestration occurs when the center, gelatinous portion of the disc is not only squeezed out, but also separated from the main part of the disc.
- OR
- Extrusion disc material has lost completely any continuity with the parent disc
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