Imaging

Imaging 3 Radiographic and Other Imaging
RECOMMENDATION

Diagnostic imaging procedures may be utilized to characterize the biomechanical manifestations of vertebral subluxation, and to determine the presence of conditions which affect the safety and appropriateness of chiropractic care.

Sub-Recommendation

Plain film radiography is indicated: to provide information concerning the structural integrity of the spine, skull and pelvis; the misalignment component of the vertebral subluxation; the foraminal alteration component of the vertebral subluxation; and the postural status of the spinal column. Imaging procedures, including post-adjustment radiography, should be performed only when clinically necessary. It is common for lines of mensuration to be drawn on radiographs to assess subluxation and alignment. These procedures may be done by hand, or the chiropractor may utilize computerized radiographic digitization procedures.

Rating: Established

Evidence: E, L

Commentary

In considering the use of imaging methods employing ionizing radiation as a component of patient assessment, the clinician should determine if the methods of subluxation correction, patient safety, and management require the use of such procedures. The patient should be asked about any conditions which may contraindicate certain imaging procedures.

Reliability studies of several systems of biomechanical analysis, including radiographic marking systems, have been published. Imaging is a necessary component of a number of different chiropractic analyses. The preponderance of evidence supports the reliability of these procedures when properly performed.(1-8, 12, 15-27, 29-32, 36-39, 42-61, 64-68, 70-79, 153)

Moreover, radiographic imaging has revealed statistically significant changes in the direction of atlas positioning following chiropractic adjustment(s).(14, 28, 33-35, 146-148) The effect of chiropractic care on lateral curvature of the cervical spine has been investigated, with significant changes in the cervical curve noted in patients receiving chiropractic care.(9, 62, 63, 69, 149-152, 156-158)

Sub-Recommendation

Imaging procedures employing ionizing radiation should be performed consistent with the principles of obtaining films of high quality with minimal radiation. This may include the use of gonad shielding, compensating filters, and appropriate film-screen combinations.

Rating: Established

Evidence: E, L

A number of dosimetry studies using supplemental filtration and single-speed screens have revealed that in the case of 14 x 36 inch AP full-spine radiographs, the radiation levels were less than sectional films of like-sized subjects. Shielding of radiosensitive structures may be used when it does not obliterate structures of clinical interest. Such shielding results in a reduction of radiation exposure.(10, 11, 13, 160)

Conclusion

The judicious use of spinographic techniques can be valuable in characterizing aspects of the biomechanical manifestations of vertebral subluxation.(146, 154, 155, 187-193) The use of post-adjustment radiographs may also assist the chiropractor in determining effects of chiropractic adjustments on the spine when other less hazardous examination techniques cannot reveal the desired information.

VIDEOFLUOROSCOPY

Sub-Recommendation

Videofluoroscopy may be employed to provide motion views of the spine when abnormal motion patterns are clinically suspected. Videofluoroscopy may be valuable in detecting and characterizing spinal kinesiopathology associated with vertebral subluxation.

Rating: Established

Evidence: E, L

Commentary

A videofluoroscopic system consists of an x-ray generator capable of operating at low (1/4 to 5) milliamperage settings, an x-ray tube assembly, an image intensifier tube, a television camera, a VCR, and a monitor. The heart of the system is the image intensifier tube. This tube permits imaging at very low radiation levels. It is used instead of intensifying screens and film as a image receptor.

The role of videofluoroscopy in the evaluation of abnormalities of spinal motion has been discussed in textbooks, medical journals, and chiropractic publications.(19, 20, 23, 80-83, 140, 145, 163, 164, 168-170, 172-179, 186, 220) Studies have appeared in the literature comparing the diagnostic yield of fluoroscopic studies versus plain films, as well as reporting abnormalities detected by fluoroscopy which could not be assessed using plain films.(161, 165-167, 171, 180, 183-185)

Reliability has been addressed in a number of studies.(162, 181, 182, 214) Additionally, in a study evaluating the interexaminer reliability of fluoroscopic detection of fixation in the mid-cervical spine, two examiners reviewed 50 videotapes of fluoroscopic examinations of the cervical spine. The examiners achieved 84 percent agreement for the presence of fixation, 96 percent agreement for the absence of fixation, and 93 percent total agreement. The Kappa value was .80 (p .001). The authors concluded, The current data indicate that VF determination of fixation in the cervical spine is a reliable procedure. (181, 214)

Conclusion

Observational and case studies support the use of videofluoroscopy to evaluate vertebral motion when this information cannot be obtained by other means.

Sub-Recommendation

Magnetic Resonance Imaging (MRI)

MR imaging may be employed to assess suspected neoplastic, infectious and degenerative conditions of the spine and related tissues as well as the stages of subluxation degeneration. Its use is generally restricted to instances where the desired information cannot be obtained by less costly procedures.

Rating: Established

Evidence: E, L

Commentary

Magnetic resonance imaging enables clinicians to obtain clear images of the human body without ionizing radiation.

Literature supports the use of MR imaging for the detection and characterization of numerous manifestations associated with subluxation degeneration.(84-107, 141-143, 194-198, 212) These studies cover a spectrum of phenomena, including:

1. Osseous malalignment

2. Intervertebral disc desiccation and degeneration

3. Osteophytosis

4. Corrugation/hypertrophy of the ligamentum flava

5. Spinal canal stenosis

6. Foraminal stenosis

7. Disc herniation and disc bulging

8. Facet asymmetry

9. Facet degeneration

10. Altered cerebrospinal fluid dynamics

11. Cord compression

12. Gliosis and myelomalacia

13. Spinal cord atrophy

Conclusion

MRI may be employed to disclose manifestations of vertebral subluxation when this information cannot be obtained by more cost-effective means. MRI is also appropriate for evaluating patients with clinical evidence of conditions which may affect the safety and appropriateness of chiropractic procedures.

Sub-Recommendation

Computed Tomography (CT)

CT imaging may be employed to assess osseous and soft tissue pathology in the spine and contiguous tissues. Its use is generally restricted to instances where the desired information cannot be obtained by less costly procedures.

Rating: Established

Evidence: E, L

Commentary

Computed tomography (also referred to as CT or CAT scanning) is an imaging technique which produces axial (cross sectional) images of body structures using x-radiation. Computer reconstruction methods may be used to depict other planes.

Manifestations of subluxation degeneration which may be demonstrated by CT scanning include disc lesions, spinal canal stenosis due to infolding of the ligamentum flava, osteophytosis, and bony sclerosis.(108-139, 144, 199-201, 210, 211, 213, 220) In addition, CT may be used to evaluate developmental variance and pathologies which could affect the chiropractic management of a case.

Conclusion

CT may be employed to disclose manifestations of vertebral subluxation when this information cannot be obtained by more cost-effective means. CT is also appropriate for evaluating patients with clinical evidence of conditions which may affect the safety and appropriateness of chiropractic procedures, particularly fractures, degenerative changes, and osseous pathology.

Sub-Recommendation

Spinal Ultrasonography

Spinal ultrasonography may be used to evaluate the size of the spinal canal, and to detect pathology in the soft tissues surrounding the spine. Its applications in the assessment of the facet inflammation and nerve root inflammation remain investigational at this time.

Ratings: Established for determining spinal canal size.

Investigational for facet and nerve root inflammation.

Evidence: E, L

Commentary

Sonographic imaging is a technique which utilizes echoes from ultrasonic waves to produce an image on a cathode ray tube.

Sonographic techniques have been employed to measure the lumbar canal, as well as determining focal stenosis and disc disease.(202-209, 221, 222)

A small study compared sonographic results in patients with back pain previously examined by MRI, x-ray and standard orthopedic examination. The study concluded that the correlation with MRI, x-ray, orthopedic and neurologic examination was approximately 90 percent.(207)

Conclusion

The low cost, availability, ease of application, and noninvasive nature of sonographic imaging make it an attractive addition to the chiropractor's armamentarium. Furthermore, it has the potential to image various components of the vertebral subluxation. However, caution must be exercised in evaluating the claims of promoters of sonographic equipment, particularly those relating to the assessment of nerve root inflammation or facet joint disease. Further research toward the establishment of chiropractic protocols should be undertaken to explore the clinical utility of spinal sonography in chiropractic practice.

Sub-Recommendation

Radioisotope Scanning (Nuclear Medicine Studies)

Radioisotope scans performed by qualified medical personnel may be used by a chiropractor to determine the extent and distribution of pathological processes which may affect the safety and appropriateness of chiropractic care when this information cannot be obtained by less invasive means.

Rating: Established

Evidence: E, L

Commentary

In this procedure, bone-seeking radioisotopes are injected, and an image is produced demonstrating the degree of uptake of the radioisotopes. The examination is sensitive to regional changes in osseous metabolism, but is not specific. Abnormal bone scans may be due to metastasis, infection, fracture, osteoblastic activity or other pathology.(215-219) No studies or case reports were found linking abnormal bone scans with vertebral subluxation. Bone scans may have limited value in determining the safety and appropriateness of chiropractic procedures.

Conclusion

Radioisotope scans have a limited role in chiropractic practice. Bone scans are a sensitive, but nonspecific indicator of abnormal metabolic activity in bone.

References

1. Rochester RP. Inter- and intra-examiner reliability of the upper cervical x-ray marking system: A third and expanded look. Chiropractic Research Journal 1994; 3(1):23-31.

2. Seemann DC. Observer reliability and objectivity using rotatory measurements on x-rays. Upper Cervical Monograph 1986; 4(1):1, 68.

3. Seemann DC. A reliability study using a positive nasium to establish laterality. Upper Cervical Monograph 1994; 5(4):7, 8.

4. Rochester RP, Owens EF. Patient placement error in rotation and its affect on the upper cervical measuring system. Chiropractic Research Journal 1996; 3(2):40-53.

5. Suh CH. The fundamentals of computer aided x-ray analysis of the spine. J Biomechanics 1974; 7:161-169.

6. Suh CH. Minimum error point search for spinal x-ray analysis. Chiropractic Research Journal 1988; 1(1):4-12.

7. Suh CH. Displacement analysis of the spine with use of x-rays. Chiropractic Research Journal 1988; 1(2):5-16.

8. Grostic JD. Some observations on computer-aided x-ray analysis. Internat Rev Chiropr, July-September 1979, pp. 38-41.

9. McAlpine JE. Subluxation induced cervical myelopathy: A pilot study. Chiropractic Research Journal 1991; 2(1):7-22.

10. Dickholtz M. Comments and concerns re x-ray radiation (A guide for upper cervical x-ray). The Upper Cervical Monograph 1989; 4(8):7-9.

11. Eriksen K. Reducing x-ray exposure. The Atlas 1996; 1(2):2, 3.

12. Eriksen K. Comparison between upper cervical x-ray listings and technique analyses utilizing a computerized database. Chiropractic Research Journal 1996; 3(2):13-24.

13. Eriksen K, Owens EF. Upper cervical post x-ray reduction and its relationship to symptomatic improvement and spinal stability. Chiropractic Research Journal 1997; 4(1):10-17.

14. Grostic J. Roentgenographic measurement of atlas laterality and rotation: A retrospective pre- and post-manipulation study. J Manipulative Physiol Ther 1982; 5(2)63.

15. Hadley L. Anatomical and roentgenographic studies of the spine. CC Thomas, IL, 1981.

16. Hass M, Nylendo J. Lumbar motion trends and correlation with low back pain. A roentgenographic evaluation of quantitative segmental motion in lateral bending. Proc 1991 World Chiro Congr Toronto, 1991.

17. Plaugher G, Cremata E, Phillips R. A retrospective consecutive case analysis of pre-treatment and comparative static radiological parameters following chiropractic adjustments. J Manipulative Physiol Ther 1990; 13(1)57.

18. El-Sayyad M. Comparison of roentgenography and moirŽ topography for quantifying spinal curvature. Phys Ther, 1986; 66(7):1078-1082.

19. Armstrong P, Wastic ML. Diagnostic Imaging, 2nd Ed. Blackwell Scientific Publications, Oxford, 1987.

20. Ball and Moore: Essential physics for radiographers, 2nd Ed. Blackwell Scientific Publications, St. Louis, Mo., 1987.

21. Hildebrandt RW. Chiropractic Spinography A manual of technology and interpretation. Hilmark Publication, Des Plains, IL, 1977.

22. Kent C, Gentempo P. The documentary basis for diagnostic imaging procedures in the subluxation-based chiropractic practice. International Chiropractors Association, 1992.

23. Kent, C. Contemporary technologies for imaging the vertebral subluxation complex. ICA Review 1989; 45(4): 45-51.

24. Selman J. The fundamentals of x-ray and radiation physics, 7th Ed. CC Thomas Publ, 1986.

25. X-ray examinations (A guide to good practice). U.S. Dept. of Health, Education, and Welfare. USPHS, 1971.

26. Plaugher G, Hendricks A, Doble R, et al. The reliability of patient positioning for evaluating static radiologic parameters of the human pelvis. J Manipulative Physiol Ther 1993; 16(8):517-522.

27. Taylor, J. Full-spine radiography: A review of the literature. Transactions of the Consortium for Chiropractic Research 1992; 7:190-216.

28. Sherwood K, Brickner D, Jennings D. Postural changes after reduction of the atlantal-axial subluxation. Chiropractic Research Journal 1989; 96-100.

29. Haas M, Nyiendo J, Peterson C, et al. Interrater reliability of roentgenological evaluation of the lumbar spine in lateral bending. J Manipulative Physiol Ther 1990; 13(4)179-189.

30. Hon T, Smith R. Interrater reliability of roentgenological evaluation of the lumbar spine in lateral bending. J Manipulative Physiol Ther 1991; 14(2)158.

31. Lane, M. A radiographic study of the movement of the innominate with respect to the sacrum about the sacroiliac joint. Bull Eur Chiro Union 1976; 24(1)41-47.

32. Lantz, C. Interrater reliability of roentgenological evaluation of the lumbar spine in lateral bending. J Manipulative Physiol Ther 1991; 14(5)329-331.

33. McGregor M, Mior S, Shannon H, et al. The clinical usefulness of flexion-extension radiographs in the cervical spine. Topics in Clinical Chiropractic 1995; 2(3)19-28.

34. Mior S, Clements D. A comparison of x-ray and electrogoniometric derived Cobb angles: A feasibility study. Proc of the Int'l Conf on Spinal Manip 1992; 115.

35. Jirout, J. Roentgen studies of the cervical spine. Radiologic Clinic, Dept of Neuroradiology, Charles Univ Prague, Czechoslovakia. Gustav-Fischer-Verlag, Stuttgart, Germany (translated to English by author).

36. Dailey E, Buehler M. Plain Film Assessment of Spinal Stenosis: Method Comparison with Lumbar CT. J Manipulative Physiol Ther 1989; 12:192-199.

37. Zengel F, Davis B. Biomechanical analysis by chiropractic radiography: Part II. Effects of x-ray projectional distortion on apparent vertebral rotation. J Manipulative Physiol Ther 1988; 11(5): 380-389.

38. Zengel F, Davis B. Biomechanical analysis by chiropractic radiography: Part I. A simple method for determining x-ray projectional distortion. J Manipulative Physiol Ther 1988; 11(4): 273-280.

39. DeVilliers PD, Booysen EL. Fibrous spinal stenosis, a report of 850 myelograms with a water-soluble contrast medium. Clin Orthop 1976; 115:140-144.

40. Larsen JL. The lumbar spinal canal in children: II. The interpedicular distance and its relation to the sagittal diameter and transverse pedicular width. Eur J Radiol 1981; 1:312-321.

41. Eisenstein S. Measurement of the lumbar spinal canal in 2 racial groups. Clin Orthop 1976; 115:42-46.

42. Dailey EJ, Buehler MT. Plain film assessment of spinal stenosis: Method comparison with lumbar CT. J Manipulative Physiol Ther 1989; 3:192-199.

43. Burns S, Mior S, McGregor M, et al. Identifying errors in cervical spinal canal measurements. Proc of the World Chiro Congress, 1991.

44. Deboer K. Inter- and intra-examiner reliability of the upper cervical x-ray marking system. J Manipulative Physiol Ther 1985; 8(4): 285-286.

45. Grostic J, Marshall W. Accuracy of an upper cervical measuring system: A validity study. Proc of the Int'l Conf on Spinal Manip 1992; 146-147.

46. Jackson B, Barker W, Bentz J, et al. Inter- and intra-examiner reliability of the upper cervical x-ray marking system: a second look. J Manipulative Physiol Ther 1987; 10(4):157-163.

47. Jackson B. Reliability of the upper cervical x-ray marking system: A replication study. Chiropractic Research Journal 1998; 1(1):10-13.

48. Keating J. Interexaminer/intertechnique reliability in spinal subluxation assessment: a multifactorial approach. Am J Chiro Med 1989; 2(1):30.

49. Keating J. The precision and reliability of an upper cervical x-ray marking system: lessons from the literature. Chiropractic Research Journal 1988; 4:32-42.

50. Moroney S, Plaugher G, Cremata E, et al. An analysis of the accuracy of a biplanar radiographic algorithm: The simulated motions of a mathematical model and the calculated motions of a calibrated physical model. Proc of the Int'l Conf on Spinal Manip 1990; 99-101.

51. Owens E, Hosek R. Structure location errors in an upper cervical x-rays analysis. Chiropractic Research Journal 1988; 1(1): 13-20.

52. Owens E. Line drawing analyses of static cervical x-ray used in chiropractic. J Manipulative Physiol Ther 1992; 15(7): 442-449.

53. Owens E, Hoirris K. Cervical curvature assessment using digitized radiographic analysis. Chiropractic Research Journal 1990; 1(4):47-62.

54. Palmer J. Inter- and intra-examiner reliability of the upper cervical x-ray marking system. J Manipulative Physiol Ther 1985; 8(4):285.

55. Plaugher G, Hendricks A. The Inter- and intra-examiner reliability of the gonstead pelvic marking system. J Manipulative Physiol Ther 1991; 14(9):503-508.

56. Rochester, R. Inter and intra-examiner reliability of the upper cervical x-ray marking system: A third and expanded look. Chiropractic Research Journal; 3(1):23-31.

57. Sansone M, Wooley J, Grannis G. Inter- and intra-examiner reliability of upper cervical x-ray marking system. J Manipulative Physiol Ther 1986; 9(4):285.

58. Schram S, Hosek R. Error limitations in x-ray kinematics of the spine. J Manipulative Physiol Ther 1982; 5(1): 5-10.

59. Schram, S. Analysis of errors in x-ray measurements of cervical vertebrae. Proc of the Biomechanics Conf on the Spine 1980; 93-111.

60. Sigler D, Howe J. Inter- and intra-examiner reliability of the upper cervical x-ray marking system. J Manipulative Physiol Ther 1985; 8:75-80.

61. Sigler, D. Inter- and intraexaminer reliability of the upper cervical x-ray marking system: A second look. J Manipulative Physiol Ther 1988; 11(3):228-229.

62. Mears, D. Adjustment of subluxations as analyzed on lateral cervical x-rays. Digest Chiro Econ 1972; 14(6):14-15.

63. Mears, D. Analysis and adjustment of the occiput and cervical spine. Digest Chiro Econ 1970; 12(4):52-53.

64. Beekman C. Variability of scoliosis measurement from spinal roentgenograms. Phys Ther 1979; 59: 764-765.

65. Bellamy N, Newhook L, Rooney P. Perception�A problem in the grading of sacro-iliac joint radiographs. Scand J Rheumatol 1984; 13:13-120.

66. Carman D, Browne R, Birch J. Measurement of scoliosis and kyphosis radiographs. J Bone Joint Surg 1990; 72A(3):328-333.

67. Cockshott W, Park W. Observer variation in skeletal radiology. Skeletal Radiol 1983; 10:86-90.

68 Dailey E, Buehler M. Plain film assessment of spinal stenosis: Method comparison with lumbar CT. J Manipulative Physiol Ther 1989; 12(3):92-199.

69. Herring C. Static cervical x-ray analysis as utilized in Herring technique. Transactions of the Consortium for Chiropractic Research 1991; 121-139.

70. Herzog R. Imaging corner: The goal of spinal imaging. Spine 1994; 19(21):2486-2488.

71. Mannello D. Inter-rater agreement of basic technique radiographic analysis. Transactions of the Consortium for Chiropractic Research 1993; 8:158-159.

72. Mick, T. The use of functional radiographs in diagnosis: A literature review. Transactions of the Consortium for Chiropractic Research 1992; 7:108-167.

73. Morrissy R, Goldsmith G, Hall E. Measurement of the Cobb angle on radiographs of patients who have scoliosis. J Bone Joint Surg 1990; 72A(3):320-327.

74. Portek I, Pearcy M, Reader G, et al. Correlation between radiographic and clinical measurement of lumbar spine movement. BR J Rheumatol 1983; 22:197-205.

75. Rupert, R. Anatomical measures of standard chiropractic skeletal references (a preliminary report). Proc of the Biomechanics Conf on the Spine 1980; 11:83-92.

76. Taylor J, Clopton P, Bosch E, et al. Interpretation of abnormal lumbosacral spine radiographs: A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic. Spine 1995; 20(10):1147-1154.

77. Taylor J. Full-spine radiography: A review of the literature. Transactions of the Consortium for Chiropractic Research 1992; 7:190-216.

78. Thorkeldsen A, Breen A. Gray scale range and the marking of vertebral coordinates on digitized radiographic images. J Chiro 1994; 17(6):359-363.

79. Yamagata M, Inoue S, Moriya H, et al. Three-dimensional measurement of the scoliotic spine using biplanar radiographic method. J West Pac Orthop Assoc 1990; 27:95-100.

80. Wallace H, Pierce W, Wagon R. Cervical flexion and extension analysis using digitized videofluoroscopy. Chiropractic: J Chiro Research and Clinical Investigation 1992; 7(4)94-97.

81. Bushong SC. Radiologic science for technologists, 4th Ed. The C.V. Mosby Company, St. Louis, Mo. 1988; 1-621.

82. Kent C. The role of videofluoroscopy in chiropractic practice. ICA Review 1990; 46(1):41-45.

83. Mauer E. Biological effects of x-ray exposure. Am J Chiro Med 1988; 1(3):115-118.

84. Kent C, Holt F, Gentempo P. Subluxation Degeneration in the Lumbar Spine: Plain Film and MR Imaging Considerations. ICA Review 1991; 47(1):55-59.

85. Kent C, Gentempo P. Subluxation degeneration in the cervical spine: Plain film and MRI findings. ICA Review 1991; 47(4):47.

86. Kent C, Gentempo P. MR imaging of subluxation degeneration. Chiropractic Research Journal 1990; 1(4):39.

87. Bishop PB. Intervertebral disc magnetic resonance image: Correlation with gross morphology and biochemical composition. J Can Chiro Assoc 1993; 37:77-84.

88. Abdelwahab IF, Kenan S, Hermann G, Klein MJ, Lewis MJ, Lewis MM. Periosteal ganglia: CT amd MR imaging features. Radiology 1993; 188:245-248.

89. Parkkola R, Rytokoski U, Kormano M. Magnetic resonance imaging of the discs and trunk muscles in patients with chronic low back pain and healthy control subjects. Spine 1993; 18:830-836.

90. Buirski G, Silberstein M. The symptomatic lumbar disc in patients with low-back pain: Magnetic resonance imaging appearances in both a symptomatic and control population. Spine 1993; 18:1808-1811.

91. Major NM, Helms CA, Genant HK. Calcification demonstrated as high signal intensity on T1-weighted MR images of the disks of the lumbar spine. Radiology 1993; 189:494-496.

92. Ross JS, Ruggieri P, Tkach J, Obuchowski N, Dillinger J, Masaryk TJ, Modic MT. Lumbar degenerative disk disease: Prospective comparison of conventional T2-weighted spin-echo imaging and T2-weighted rapid acquisition relaxation-enhanced imaging. AJNR 1993; 14:1215-1223.

93. Ciricillo SF, Weinstein PR. Lumbar spine stenosis. West J Med 1993; 158:171-177.

94. Schnebel B, Kingston S, Watkins R, et al. Comparison of MRI to CT in the diagnosis of spinal stenosis. Spine 1989; 14:332-337.

95. Gaskill M, Lukin R, Wiot G. Lumbar disc disease and stenosis. Radiol Clin North Am 1991; 29:753-764.

96. Modic MT, Masaryk TJ, Mulopulos GP, et al. Cervical radiculopathy: Prospective evaluation with surface coil MR imaging, CT with metrizamide, and metrizamide myelography. Radiology 1986; 161:753-759.

97. Modic MT, Masaryk TJ, Ross JS, et al. Cervical radiculopathy: value of oblique MR imaging. Radiology 1987; 163:227-331.

98. Hedberg MC, Drayer BP, Flom RA, et al. Gradient echo (GRASS) MR imaging in cervical radiculopathy. AJR 1988; 150:663-689.

99. Van Dyke C, Ors JS, Tkach J, et al. Gradient-echo MR imaging of the cervical spine: Evaluation of extradural disease. Am J Neuroadiol 1989; 10:627-632.

100. Kent DL, Haynor DR, Larson EB, et al. Diagnosis of lumbar spinal stenosis in adults: A metaanalysis of the accuracy of CT, MR, and myelography. Am J Radiol 1992; 158:1135-1144.

101. Rydevik B. Spinal stenosis � conclusions. Acta Orthop Scand 1993; 64:81-82.

102. Deyo RA. Magnetic resonance imaging of the lumbar spine. [editorial]. N Engl J Med 1994; 331:115-116.

103. Bowen V, Shannon R, Kirkaldy-Willis WH. Lumbar spinal stenosis: A review article. Childs Brain 1978; 4:257-277.

104. Frymoyer JW. Backpain and sciatica. N Engl J Med 1988; 318:291-300.

105. Wiltse LL, Kirkaldy-Willis WH, McIvor GWD. The treatment of spinal stenosis. Clin Orthop 1976; 115:83-91.

106. Kirkaldy-Willis WH, Paine KW, Cauchoix J, et al. Lumbar spinal stenosis. Clin Orthop 1974; 99:30-50.

107. Spengler DM. Degenerative stenosis of the lumbar spine. J Bone Joint Surg (Am) 1987; 69A:305-308.

108. Lee CK, Hansen HT, Weiss AB. Developmental lumbar spinal stenosis: Pathology and surgical treatment. Spine 1978; 3:246-255.

109. Epstein JA, Epstein BJ, Lavine L. Nerve root compression associated with narrowing of the lumbar spinal canal. J Neurol Neurosurg Psychiatry 1962; 25:165-176.

110. Schonstrom NS, Bolender NF, Spengler DM. The pathomorphology of spinal stenosis as seen on CT scans of the lumbar spine. Spine 1985; 10:806-811.

111. Weinstein PR. Diagnosis and management of lumbar spinal stenosis. Clin Neurosurg 1983; 30:677-697.

112. Herkowitz HN, Garlin SR, Bell GR, et al. The use of computerized tomography in evaluating non-visualized vertebral levels caudad to a complete block on a lumbar myelogram, a review of thirty-two cases. J Bone Joint Surg (Am) 1987; 69A:218-224.

113. Quencer RM, Murtagh FR, Post JD, et al. Postoperative bony stenosis of the lumbar spinal canal: Evaluation of 164 symptomatic patients with axial radiography. Am J Roentgenol 1978; 131:1059-1064.

114. Gonzalez EG, Hajdu M, Bruno R, et al. Lumbar spinal stenosis: Analysis of pre- and postoperative somatosensory evoked potentials. Arch Phys Med Rehabil 1985; 66:11-15.

115. McAfee PC, Ullrich CG, Yuan HA, et al. Computed tomography in degenerative spinal stenosis. Acta Orthop Scand 1981; 52:427-433.

116. Dublin AB, McGahan JP, Reid MH. The value of computed tomographic metrizamide myelography in the neuroradiological evaluation of the spine. Radiology 1983; 146:79-86.

117. Williams DM, Gabrielson TO, Latack JT, et al. Ossification in the cephalic attachment of the ligamentum flavum: An anatomical and CT study. Radiology 1984; 150:423-426.

118. Arroyo IL, Barron KS, Brewer EJ. Spinal cord compression by epidural lipomatosis in juvenile rheumatoid arthritis. Arthritis Rheum 1988; 31:447-451.

119. Urso S, Postacchini F. The value of transverse axial tomography in the diagnosis of lumbar stenosis. Ital J Orthop Traumatol 1978; 4:213-221.

120. Simeone FA, Rothman RH. Clinical usefulness of CT scanning in the diagnosis and treatment of lumbar spine disease. Radiol Clin North Am 1983; 21:197-200.

121. Postacchini F, Petteri G. CT scanning versus myelography in the diagnosis of lumbar stenosis, a preliminary report. Int Orthop 1981; 5:209-215.

122. Lee BCP, Kazam E, Neuman AD. Computed tomography of the spine and spinal cord. Radiology 1978; 128-95�102.

123. Hammerschlag SB, Wolpert SM, Carter BL. Computed tomography of the spinal canal. Radiology 1976; 121:361-367.

124. Burton CV, Kenneth BH, Kirkaldy-Willis W, et al. Computed tomographic scanning and the lumbar spine: II. Clinical considerations. Spine 1978; 4:356-368.

125. Lancourt JE, Glenn WV, Wiltse LL. Multiplanar computerized tomography in the normal spine and in the diagnosis of spinal stenosis. A gross anatomic-computerized tomographic correlation. Spine 1979; 4:379-390.

126. Jacobson RE, Gargano RP, Rosomoff HL. Transverse axial tomography of the spine: 2. The stenotic spinal canal. J Neurosurg 1975; 42:412-419.

127. Keim HA. Diagnostic problems in the lumbar spine. Clin Neurosurg 1979; 25:184-192.

128. Pleatment CW, Lukin RR. Lumbar spinal stenosis. Semin Roentgenol 1988; 23:106-110.

129. Kaiser MC, Capesius P, Roilgen A, et al. Epidural venous stasis in spinal stenosis�CT appearance. Neuroradiology 1985; 26:435-438.

130. Helms CA. CT of the lumbar spine�stenosis and arthrosis. Comput Radiol 1982; 6:359-369.

131. Gaskill MF, Lukin R, Wiot JG. Lumbar disc disease and stenosis. Radiol Clin North Am 1001; 29:753-764.

132. Hyman RA, Merten CW, Liebeskind AL, et al. Computed tomography in ossification of the posterior longitudinal ligament. Neuroradiology 1977; 13:227-228.

133. Crawshaw C, Kean DM, Mulholland RC, et al. The use of nuclear magnetic resonance in the diagnosis of lateral canal entrapment. J Bone Joint Surg (AM) 1984; 66:711-715.

134. Modic MT, Massaryk T, Boumphrey M, et al. Lumbar herniated disk disease and canal stenosis: Prospective evaluation by surface coil MR, CT, and myelography. AJR 1991; 147:757-765.

135. Resnick D. Synovial cysts, Imaging techniques in intraspinal diseases. In Haughton V (ed): Bone and joint imaging. WB Saunders, Philadelphia, 1989, p. 146.

136. Phytinen J, Lahde S, Tanska EL, et al. Computed tomography after lumbar myelography in lower back and extremity pain syndrome. Diagn Imaging 1983; 52:19-22.

137. Ho E, Upadhyay S, Chan F, et al. New methods of measuring vertebral rotation from computed tomographic scans. An intraobserver and interobserver study on girls with scoliosis. Spine 1993; 18(9): 1173-1177.

138. Reinke T, Jahn W. Spinal diagnostic imaging: Computerized axial tomography vs. magnetic resonance imaging. Am J Chiro Med 1988; 1(14):181-184.

139. Brightbill T, Pile N, Eichelberger R, et al. Normal magnetic resonance imaging and abnormal discography in lumbar disc disruption. Spine 1994; 19(9):1075-1077.

140. Brodeur R, Hansmeier D. Variability of intervertebral angle calculations for lateral cervical videofluoroscopic examinations. Proc of the Int'l Conf on Spinal Manip 1993; 37.

141. Byrd R, Kahler J, Leaman S, et al. Reliability of magnetic resonance imaging for morphometry of the intervertebral foramen. Proc of the Int'l Conf on Spinal Manip 1990; 79-82.

142. Cantu J, Cramer G, Dorsett R, et al. Magnetic resonance imaging of the cervical intervertebral foramina: Comparison of two techniques. Proc of the Int'l Conf on Spinal Manip 1994; 101-103.

143. Cramer G, Cantu J, Greenstein J, et al. The accuracy of magnetic resonance imaging in determining the vertical dimensions of the cervical intervertebral foramina. Proc of the Int'l Conf on Spinal Manip 1993; 38-40.

144. Eldevik O, Dugstad G, Orrison W, et al. The effect of clinical bias on the interpretation of myelography and spinal computed tomography. Radiology 1982; 145:85-89.

145. Wallace H, Wagon R, Pierce W. Inter-examiner reliability using videofluoroscope to measure cervical spine kinematics: A sagittal plane (lateral view). Proc of the Int'l Conf on Spinal Manip 1992; 7-8.

146. Jackson BL, Bunker WF, Bentz J, Gamble AG. Inter and intra examiner reliability of upper cervical x-ray marking system: a second look. J Manipulative Physiol Ther, 1987 10:157-63.

147. Seemann DC. A reliability study using positive nasium to establish laterality. The Upper Cervical Monograph, 5(4):7-8.

148. Sigler DC, Howe JW. Inter- and intra examiner reliability of the upper cervical x-ray marking system. J Manipulative Physiol Ther 1985;8:75-80.

149. Grostic JD, DeVoer KP. Roentgenographic measurement of atlas laterality and rotation: a retrospective pre- and post manipulation study. J Manipulative Physiol Ther 1982;5:63-71.

150. Gay RE. The curve of the cervical spine: Variations and significance. J Manipulative Physiol Ther, 199316(9):591-594.

151. Owens EF. Line drawings analyses of static cervical x-ray used in chiropractic. J Manipulative Physiol Ther, 1992; 15:442-449.

152. Rochester RP. Inter and intra-examiner reliability of the upper cervical x-ray marking system: A third and expanded look. Chiropractic Research Journal 1994; 3(1).

153. Plaugher G, Hendricks AH. The interexaminer reliability of the Gonstead pelvic marking system. Proc of the Int'l Conf on Spinal Manip. Arlington, VA, 1990. p. 93-8.

154. Zengel F, Davis BP. Biomechanical analysis by chiropractic radiography: Part II. Effects of x-ray projectional distortion on apparent vertebral rotation. J Manipulative Physiol Ther 1988; 11(5):380-9.

155. Zengel F, Davis BP. Biomechanical analysis by chiropractic radiography: Part III. Lack of effect of projectional distortion on Gonstead vertebral endplate lines. J Manipulative Physiol Ther 1988; 11(6):469-73.

156. Leach RA. An evaluation of the effect of chiropractic manipulative therapy on hypolordosis of the cervical spine. J Manipulative Physiol Ther 1983; 6(1):17-23.

157. Troyanovich S, Robertson G, Harrison D, Holland B. Intra- and interexaminer reliability of the Chiropractic Biophysics lateral lumbar radiographic mensuration procedure. J Manipulative Physiol Ther 1995; 18(8):519-524.

158. Jackson B, Harrison D, Robertson G, Barker W. Chiropractic biophysics lateral cervical film analysis reliability. J Manipulative Physiol Ther 1993; 16(6):384-391.

159. Phillips RV. The use of x-rays in spinal manipulative therapy. In Halderman S (ed) Modern Developments in the Principles and Practice of Chiropractic. Norwalk, CT. Appleton-Century-Crofts, 1980.

160. Buehler MT, Hrejsa AF. Application of lead-acrylic compensating filters in chiropractic full spine radiography: a technical report. J Manipulative Physiol Ther 1985; 8(3):175-80.

161. Shaff AM. Video fluoroscopy as a method of detecting occipitoatlantal instability in Down's syndrome for Special Olympics. Chiropractic Sports Medicine 1994; 8(4):144.

162. Wallace H, Wagnon R, Pierce W. Inter-examiner reliability using videofluoroscope to measure cervical spine kinematics: a sagittal plane (lateral view). Proc of the Int'l Conf on Spinal Manip May 1992:7-8.

163. Van Mameren H, Sanches H, Beursgens J, Drukker J. Cervical spine motion in the sagittal plane II. Spine 1992; 17(5):467.

164. Ochs CW. Radiographic examination of the cervical spine in motion. US Navy Med 1974; 64:21.

165. Buonocard E, Hartman JT, Nelson CL. Cineradiograms of cervical spine in diagnosis of soft-tissue injuries. JAMA 1981(1):143, 1966.

166. Jones MD. Cineradiographic studies of abnormalities of high cervical spine. AMA Arch Surg 1967; 94:206.

167. Tasharski CC. Dynamic atlanto-axial aberration: a case study and cinefluorographic approach to diagnosis. J Manipulative Physiol Ther 1981; 4(2):75.

168. Woesner ME, Mitts MG. The evaluation of cervical spine motion below C-2: a comparison of cineroentgenographic methods. Am J Roent Rad Ther & Nuc Med 1972; 115(1):148.

169. Bard G, Jones MD. Cineradiographic recording of traction of the cervical spine. Arch Phys Med 1964; 45:403.

170. Bard G, Jones MD. Cineradiographic analysis of laminectomy in cervical spine. AMA Arch Surg 1968; 97;672.

171. Brunton FJ, Wilkerson JA, Wise KS, Simonis RB. Cineradiography in cervical spondylosis as a means of determining the level for anterior fusion. J Bone Joint Surg 1982; 64-B(4):399.

172. Jones MD. Cineradiographic studies of collar immobilized cervical spine. J Neurosurg 1960; 17;633.

173. Jones MD. Cineradiographic studies of various joint diseases in the cervical spine. Arthritis & Rheumatism 1961; 4:422.

174. Jones MD. Cineradiographic studies of degenerative disease of the cervical spine. J Canad Assoc Radiol 1961; 12:52.

175. Jones MD, Stone BS, Bard G. Occipitalization of atlas with hypoplastic odontoid process, a cineroentgenographic study. Calif Med 1966; 104:309.

176. Gillet H. A cineradiographic study of the kinetic relationship between the cervical vertebrae. Bull Eur Chiro Union 1980; 28(3):44.

177. Henderson DJ. Kinetic roentgenographic analysis of the cervical spine in the saggital plane: a preliminary study. Int Review of Chiro 1981; 35:2.

178. Howe JW. Observations from cineroentgenological studies of the spinal column. ACA J of Chiro 1970; 7(10: 75.

179. Leung ST. The value of cineradiographic motion studies in diagnosis of dysfunctions of the cervical spine. Bull Eur Chiro Union 1977; 25(2):28.

180. Shippel AH, Robinson GK. Radiological and magnetic resonance imaging of the cervical spine instability: A case report. J Manipulative Physiol Ther 1987; 10(6):316.

181. Antos J. Robinson GK, Keating JC, Jacobs GE. Interexaminer reliability of cinefluoroscopic detection of fixation in the mid-cervical spine. Proceedings of the Scientific Symposium on Spinal Biomechanics, International Chiropractors Association, 1989, p. 41.

182. Taylor M, Skippings R. Paradoxical motion of atlas in flexion: a fluoroscopic study of chiropractic patients. Euro J Chiro 1987; 35:116.

183. Betge G. The value of cineradiographic motion studies in the diagnosis of dysfunction of the cervical spine. J Clin Chiro 1979; 2(6):40.

184. Masters B. A cineradiographic study of the kinetic relationship between the cervical vertebrae. Bull Eur Chiro Union 1980; 28(1):11.

185. Mertz JA. Videofluoroscopy of the cervical and lumbar spine. ACA J Chiro 1981; 18(8):74.

186. Robinson GK. Interpretation of videofluoroscopic joint motion studies in the cervical spine C-2 to C-7. The Verdict, February 1988.

187. Akeson WH, Woo SL, Taylor TK, Ghosh P, Bushell GR. Biomechanics and biochemistry of the intervertebral discs. Clin Orthop 1977; (122):133.

188. White AA, Johnson RM, Panjabi MM, Southwick WO. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop 1975; (109):85.

189. Vernon H. Static and dynamic roentgenography in the diagnosis of degenerative disc disease: a review and comparative assessment. J Manipulative Physiol Ther 1982; 5(4):163.

190. Ressel OJ. Disc regeneration: reversibility is possible in spinal osteoarthritis. ICA Review 1989; 45(2):39.

191. Posner I, White AA, Edwards WT, Hayes WC. A biomechanical analysis of the clinical stability of the lumbar and lumbosacral spine. Spine 1982; 7:374.

192. Nachemson A. Towards a better understanding of low back pain; a review of the mechanics of the lumbar disc. Rheumatol Rehabil 1975; 14(3):129.

193. Huelke DF, Nusholtz GS. Cervical spine biomechanics: a review of the literature. J Orthop Res 1986; 4(2):232.

194. Karnaze MG, Gado MH, Sartos KJ, Hodges FJ 3d. Comparison of MR and CT myelography in imaging the cervical and thoracic spine. AJR 1988; 150(2):397.

195. Kulkarni MV, Narayana PA, McArdle CB, Yeakley JW, et al. Cervical spine MR imaging using multislice gradient echo imaging: comparison with cardiac gated spin echo. Magn Reson Imaging 1988; 6(5):517.

196. Takahashi M, Sakamoto Y, Miyawaki M, Bussaka H. Increased MR signal intensity secondary to chronic cervical cord compression. Neuroradiology 1987; 29(6):550.

197. Grenier N, Kressel HY, Scheibler ML, Grossman RI, Dalinka M. Normal and degenerative posterior spinal structures: MR Imaging. Radiology 1987; 165(2):517.

198. Richards G, Thompson J, Osterbauer T, Fuhr A. Use of pre- and post-CT scans and clinical findings to monitor low force chiropractic care of patients with sciatic neuropathy and lumbar disc herniation: A review. J Manipulative Physiol Ther 1990, 13:58.

199. Walker B. The use of computer-assisted tomography of the lumbar spine in a chiropractic practice. Journal of the Australian Chiropractic Association 1985; 15:86.

200. Koentges A. Computerized axial tomography of the spine in the differential diagnosis of vertebral subluxations. Annals of the Swiss Chiropractors' Association 1985; 8:25.

201. Kent C. Contemporary technologies for imaging the vertebral subluxation complex. ICA Review 1989; 45(4):45.

202. Aldrete JA. Diagnostic ultrasound in pain management: an overview. Am J Pain Management 1994; 4(4):160.

203. Anderson DJ, Adcock DF, Chovil AC, Farrell JJ. Ultrasound lumbar canal measurement in hospital employees with back pain. Br J Ind Med 1988; 45(8):552.

204. Chovil AC, Anderson DJ, Adcock DF. Ultrasonic measurement of lumbar canal diameter: a screening tool for low back disorders? South Med J 1989; 82(8):977.

205. Engel JM, Engel GM, Gunn DR. Ultrasound of the spine in focal stenosis and disc disease. Spine 1985; 10(10):928.

206. Suzuki S, Yamamuro T, Shikata J, Shimizu K, Iida H. Ultrasound measurement of vertebral rotation in idiopathic scoliosis. J Bone Joint Surg 1989; 72-B(2):252.

207. Moore RE. Blind study: comparison of sonographic results in patients with back pain previously diagnosed by MRI, x-ray and standard orthopedic exam. American Journal of Clinical Chiropractic May 1995; 5(2):34.

208. Mandell G. Radionuclide imaging. In: Kricun ME. Imaging modalities in spinal disorders. W.B. Saunders Company, Philadelphia, PA. 1988.

209. Bates D, Ruggieri P. Imaging modalities for evaluation of the spine. Radiologic Clinics of North America 1991;29(4):675-690.

210. Carmichael, J. Clinical case reports in the use of computed tomography for the quantification of leg length inequality. The CT Scanogram. Proc of the Int'l Conf on Spinal Manip. FCER, Arlington, VA. 191, April 1991.

211. Cramer G, Howe J, Glenn W, et al. Comparison of computed tomography to magnetic resonance imaging in evaluation of the intervertebral foramen. Proc of the Int'l Conf on Spinal Manip. FCER, Arlington, VA. 186, 1991.

212. Dreyer P, Lantz CA. Chiropractic management of herniated disc restoration of disc protrusion and management of disc integrity as substantiated by MRI. Proc of the Int'l Conf on Spinal Manip. FCER, Arlington VA. 57, 1991.

213. Richards G, Thompson J, Osterbauer P, et al. Use of pre-and post CT scans and clinical findings to monitor low force chiropractic care of patients with sciatic neuropathy and lumbar disc herniation: A Review. J Manipulative Physiol Ther 1990; 13(1):58.

214. Antos J, Robinson K, Keating J, et al. Interrater reliability of fluoroscopic detection of fixation in the mid-cervical spine. Chiropractic Technique 1990; 2(2):53-55.

215. Krishnamurthy GT, Blahd WH. Technetium-99m polyphosphate bone image for early detection of skeletal metastasis. Correlation with other diagnostic parameters. Nucl Med (Stuttg) 1975; 13(4):330-40.

216. Wetzel LH, Engelbrecht DE, Baxter KG, et al. Comparison of MR imaging and bone scintigraphy for detection and evaluation of osseous spinal metastases. Nineteenth Annual Meeting of the American Roentgen Ray Society. May 13-18, 1990, Washington, DC.