Shared by: webinfo@chiroviewpresents.com 11-15-01 What is a complete radiographic examination? Ian McLean, DC, DABCR CVP Department Head - Diagnostic Imaging imcleanDC@aol.com http://mcleanradiology.com/ The x-ray examination represents an important constituent in evaluating chiropractic patients. While the clinical evaluation substantiates the necessity for an x-ray examination, the practitioner should recognize that most radiographic imaging procedures are standardized. For instance, a minimum of two projections at 90 degrees to each other is required to evaluate an anatomical region such as the thoracic or lumbar spine. This allows accurate localization of structures since superimposition of anatomy is inherent in the x-ray examination. The cervical spine examination however requires a minimum of three views inclusive of lateral, AP lower cervical, and AP open mouth projections. Two AP radiographs are required in this study because of superimposition created by the mandible. Unfortunately, incomplete examinations of the cervical spine are relatively common with a solitary AP projections being obtained. Some practitioners get quite enterprising, even inventing an AP craniocervico-thoracic image! Not only does this type of imaging inherently decrease the ability to evaluate anatomy completely but also increases liability. Minimal views in each radiographic series can be found in most major radiographic texts, however, the following represents the most common examples. Cervical spine: AP, lateral, open mouth; Thoracic spine: AP, lateral; Lumbar spine: AP, lateral. Certainly, many other radiographic views of the spine exist inclusive of oblique and kinematic projections, however, these supplement the basic imaging studies. Specialized views unique to certain chiropractic techniques are also available. Again, these should supplement the standard examination, as critical anatomy will be incompletely evaluated if these were to be used alone. The radiographic examination should also include all the expected anatomy. For instance, the examination of the cervical spine must include the base of the skull to the level of T1. Imaging of the lower cervical spine can be problematic especially in ectomorphic patients. The literature is replete with circumstances of malpractice relating to incomplete examination of the cervical spine. Trauma to the lower cervical spine with resultant fracture occurs with relative frequency. This injury can be missed with a substandard examination. In this circumstance, a swimmer's projection or similar to must supplement the examination. While upright radiography is common in chiropractic practice, too frequently the patient¼s body habitus does not allow for a satisfactory radiographic image. When faced with a large patient the practitioner is tempted to crank up the kVp to compensate for body mass and an increasing time of exposure. The problem with this practice is that this will create an additional scatter radiation, which will subtract from the quality of the image. Preferably, this type of patient should be imaged in the recumbent position, which not only decreases the AP dimension of the patient but also lessens motion. Recumbent radiography should also be considered in patients who have suffered spinal trauma in which fracture is suspected. Even minute degrees of patient motion may obscure subtle cortical and trabecular disruption rendering a potential fracture invisible. Conclusion. 1. Know the basic radiographic series. 2. Perform a complete examination. 3. Ensure that all anatomy is included in the study. 4. Learn the swimmer's projection. 5. Seriously consider recumbent radiography especially in ectomorphic patients and if thoracic and lumbar spinal fracture is suspected. Images relating to this discussion can be found at: http://mcleanradiology.com/ and/ or http://mcleanradiology.com/WEB%20QUIZ.htm _________________________________________________ Canadian C-Spine Rule Could Safely Reduce Radiography Use Provided by: Warren Jahn, DC & Leanne N. Cupon, DC CVP Department Heads - Disability & Impairment Rating drwjahn@ix.netcom.com drlcupon@enter.net WESTPORT, CT (Reuters Health) Oct 16 - A newly derived clinical decision rule is highly sensitive in determining the need for cervical (C)-spine radiography in alert and stable trauma patients, Canadian investigators report in The Journal of the American Medical Association for October 17. "A physician can clear a patient's C-spine in about a minute" using the rule, Dr. Ian G. Stiell told Reuters Health. "Not only would it save the X-ray, but it would get the patient out from the immobilization restrains. Sometimes patients are stuck on the backboard for hours, even though they're pretty stable, just because they're waiting for an X-ray they don't even need." In their prospective cohort study, Dr. Stiell, of the Ottawa Health Research Institute, and colleagues collected data on 8924 adult patients from 10 large Canadian hospitals. All of the patients presented to the ED after sustaining acute blunt trauma to the head or neck. The researchers evaluated the accuracy and reliability of 25 clinical variables in predicting a clinically important C-spine injury. Statistical analysis yielded a three-question decision rule for detecting acute C-spine injury. The first question determines whether a patient has high- risk factors, such as age >65, paresthesias or a particularly dangerous mechanism of injury, which would mandate radiography. The second question asks if there are any low-risk factors that would allow safe assessment of range of motion. For example, has the patient been ambulatory at any time since the accident or able to sit upright? The third question determines whether the patient is able to actively rotate his neck 45 degrees to the left and right. If the answers to the second and third questions are positive, no radiography would be required. This rule identified all of the 151 patients who had sustained an important C-spine injury. The rule had a specificity of 42.5%. The investigators conclude that the Canadian Rule is clinically sensible, highly sensitive, and relatively specific. They estimate that its implementation could safely reduce the use of C- spine radiography between 25% and 50%. The authors point out that the National Emergency X-Radiography Utilization Study (NEXUS) criteria, used in the US, increases the use of radiography. "The Rule has quite different criteria from the NEXUS criteria," Dr. Stiell pointed out. "For example, NEXUS doesn't address patient age, the mechanism of injury, paresthesias, or the patient's ability to rotate the neck." "Validation of the Canadian C-spine Rule in other patient populations is the next step for improving the efficacy of C-spine imaging for patients with trauma," Dr. Richard H. Daffner, of Allegheny General Hospital in Pittsburgh, Pennsylvania, remarks in an accompanying editorial. At that point, physicians will have "a workable system" to evaluate patients thoroughly and safely, he concludes. Dr. Stiell agrees. "We are doing a concurrent prospective validation comparing the Canadian C-spine Rule to the NEXUS criteria in multiple sites. We think it should be done in as many places as possible." He noted that his group hopes to include 10,000 patients from nine study sites across Canada. JAMA 2001;286:1841-1848,1893-1894.