The Importance of Radiographic Analysis In Today s Chiropractic Practice

Transcription

1 X-Ray Protocols Taking X-rays has been part of chiropractic history for many decades. In reality much of the science-based evidence of the spinal subluxation takes its origin in x-ray analysis. Most of the proven scientific treatment methods utilized by chiropractors have as their basis pre and post x-rays of the spine. In the current economic climate practitioners are often told one of or more of the following: 1. make an AP full spine 2. Make an AP full spine and AP cervical. Both have some postural and diagnostic advantages but are not considered routine protocol. Often those who advocate making those x-rays also told the chiropractors to build their practices by advertising free x- rays or discounted x-rays. We are not implying that doing so is wrong but time will tell if an idea or concept is right and has no adverse effects. With that in mind we begin this dimension with some questions that many chiropractors have asked us. Question: The coaching group I ve belonged to advocated low fees, no x-rays or minimal x-rays - only AP full spine and sometimes a lateral cervical neutral, low cost x-rays or using coupon or discounts other than when a car accident or workers comp injury comes in then we are taught to take lots of x-rays. This is what builds a practice. Is that true? Answer: 1. At times, low cost and minimal x-rays may initially increase patient volume, but the lower the fees the lower the quality of patients you attract it also telegraphs that we place little value on those services and ourselves. 2. The same holds true with not x-raying new patients or taking minimal or no x-rays. (Less than what the Board of Examiners would consider usual and customary). 3. The opposite advice to take lots of x-rays on car accident and work related injuries is wrong unless the patient s symptoms and responses to examinations indicate their necessity. 4. An AP full spine and lateral cervical neutral is also insufficient because protocol suggests an AP cervical, AP cervical open mouth. Refer to X-Ray Log. 5. Not taking those films predisposes one to miss issues that the AP closed and open mouth could reveal causing a disservice to the patient and also increasing your risk management barometer. Question: Are there down sides to no or minimal spinal x-rays, low fees and use of coupons? Answer: Yes and they include the following: 1. Low fees not only attract low quality patients and low quality patients bring other non- health related issues with them usually wanting the doctor to keep them off work or do illegal things with their automobile accident insurance company. 2. No or minimal x-rays increase the risk management barometer for missed diagnosis therefore increasing the possibility of malpractice suits. 3. Using some/some incentive attracts people looking for a deal and if they are still patients, as soon as another better deal comes along they are gone. Most will not be in your practice very long as most are looking for a crack in the back and will not follow through with regular care. With that in mind let s review the X-RAY PROTOCOL The Importance of Radiographic Analysis In Today s Chiropractic Practice Regardless of your belief the public is confused. Much of the profession has succumbed to the ranks of treating people based solely on symptoms. Some DC s are conveying the wrong message and doing a disservice to their patient s, the community and themselves. The American Chiropractor - Tim Miggs, DC Some Do Some Don t Many don t x-ray Some x-ray but not adequately Many films are of poor quality Many do not send x-rays out for second opinion Some rely on interpretation by medical rather than chiropractic radiologists. Those who do not x-ray before treatment open themselves to malpractice and other legal ramifications (MBCE).

2 No x-rays - No x-rays before treatment: Malpractice Other legal ramifications (MBCE) Misdiagnosis Possible mistreatment Loss of patient confidence Poor practice growth Lack of Due Diligence - X-rays Failure to X-ray is #1 issue in malpractice issues. Failure to obtain a second opinion is almost always an issue. Failure to take/order universally accepted views. Failure to explain and give patient copies of the radiologists report Many Chiropractors who do take x-rays take an AP Full Spine, sometimes a Lateral Full Spine and nothing else which is often interpreted by Boards of Chiropractic Examiners as insufficient. Structural Management X-Ray Protocol The CATBITES System This system looks for indications of the following when reviewing x-rays: C congenital abnormalities A arthropathy and alignment T tumors B blood I infection T trauma E endocrine/metabolic irregularities S soft tissue abnormalities X-rays also provide the opportunity to: Assess ongoing gravity on the spine Rule out pathology Determine biomechanical defects DFN (Departure From Normal) where the millimeters of vertebral rotation are marked. Improve communication Treatment plan Referrals The Spinal Structural Fingerprint Consisting of or one or more of the following: Flat Plate Digital MRI - Upright MRI CT Scan Routine Protocol Non-radicular: Cervical Views: A-P open mouth Closed mouth Lateral cervical neutral Thoracic Views: A-P and lateral thoracic

3 Lumbar Views: A-P and lateral lumbar AP and lateral full spine - postural or diagnostic? In complaint and malpractice issues it s easy to find expert witnesses who will find untold poor technique and poor quality issues, failure to diagnose and who are critical of full spine x-rays. We are judged by the gold standards of the day. We re looking for: Cervical Spine AP Open Mouth (Open mouth AP Cervical/Thoracic is unacceptable) Subluxations Alignment of odontoid process with C2 spinous process Equal atlanto-axial joint spaces/alignment Equal atlanto-odontoid spaces/alignment Atlanto/occipital alignment and balance of occiput with spine - occipital shift AP Cervical dextroscoliosis/levoscoliosis Ligament Nuchae/spondylothesis/spina bifida occulta Muscle spasm and tendon irregularity Carotids/vertebral Temporal mandibular joints Lateral Status of cervical lordosis Center of gravity bisecting each bone so each bone can share in the distribution of the weight of cranium (approx. 10% of body weight) Status of discs, intervertebral foramina and facets Biomechanical Imbalances This biomechanical imbalance predictability increases stress of the C5/6 and C6/7 joint space over time, encouraging increased demands and premature degenerative changes in height of discs at those levels. Is there foramina encroachment, anterior bone growth with this type of biomechanical finding, as a reflection of Wolff s Law in action? Thoracic Spine AP Subluxations Muscle status Relationship of ribs to transverse processes Relationship of spine to heart and lungs Thoracic levoscoliosis/dextroscoliosis Lateral Normal kyphosis Excess kyphosis Loss of kyphosis Status of discs Status of intervertebral foramina Spondylosis

4 Lumbar Spine AP Subluxations lumbar ilium sacrum coccyx AP curve Dextroscoliosis/levoscoliosis Obturator equality - low, anterior/posterior Crests of ilium - level, imbalanced, anterior, posterior, internal, external, rotation, subluxation Alignment between spine and symphysis pubes Femur head levels Muscle spasms Lateral Subluxations Ferguson s Gravity Line - bisecting the anterior 1/3 of sacral base (center of gravity from side) Sacral base angle degrees AP curve Dextroscoliosis/levoscoliosis Status of discs Status of intervertebral foramina X-Rays - Whiplash Non-Radicular Cervical AP closed and open mouth Lateral cervical neutral Thoracic AP and Lateral Lumbar AP and Lateral X-Rays Whiplash Radicular Cervical Davis Series AP open and closed mouth Lateral neutral Flexion and extension Right and left oblique Thoracic AP Lateral Right and left oblique (Right and left oblique are for ribs) Lumbar AP Lateral Lateral right and left flexion Lateral right and left extension Right and left oblique Flexion, extension and lateral bending views uncover hypo or hyper mobility, any transitional defects and/or soft tissue irregularities.

5 Sacrum & Coccyx Sacrum - AP and lateral Coccyx AP and lateral Full Spine X-Rays AP and lateral Complaint panels and plaintiff s malpractice attorneys often consider them postural x-rays - not diagnostic. They may attack the lack of AP Open Mouth (and other routine x-rays and diagnostic tests) or views taken but that are not of diagnostic quality. Will enter as exhibits Chiropractic/medical radiology textbooks and articles that prove the doctor was negligent in performing due diligence. by not taking usual and customary views for a particular region. Films must be free of non-surgical artifacts. Shoulder Symptoms Right/Left Shoulder Internal rotation External rotation Baby Arm Tangential Projection Right/Left Clavicle - PA Acromial Clavicular - Bilateral Also Advisable X-rays appropriate to other extremity injuries Weight bearing MRI Neurological Consult Credibility/Due Diligence Scientific credibility and due diligence is always a major issue in all malpractice cases and complaint panel reviews. Your opinion is one thing. Expert opinions of others are another. Juries, judges, arbitrators and regulatory boards are yet another. Plaintiff and prosecuting attorneys are hiring MD s and DC s to testify to what usual and customary x-rays should be as well as the quality of the x-rays that the DC made or had made at another office. X-Ray Log Following is a sample x-ray log or checklist of items that must be completed for every patient x- rayed. These items are required by the Minnesota Department of Health (MDH) X-Ray Unit. Your x-ray log will be reviewed when the MDH X-Ray Unit conducts its inspection of your facility. Failure to be in compliance with its Rules and Regulations can result in a $10,000 fine for each violation.

6 It is essential that the following be included on the x-ray log for every patient x-rayed. A copy of each patient s information must be maintained in your X-ray Log Book and a copy kept in the patient s file. Date of X-Ray(s) Patient Name X-Ray/Clinic Number Pregnant, Hysterectomy, Menopause Gender, Age, Date of Birth Pacemaker or other implanted device Patient Authorization to make x-ray Does the patient require a person of the same sex to be in attendance while he/she is being x-rayed? Patient s Signature TFD Film Size View(s) CM, KVP, MAS, MA Reasons why x-ray is being made - including one or more of the following: Rule out joint instability, Rule out fracture, Evaluate to withstand osseous adjustment, Rule out foraminal encroachment, Assess biomechanical alignment, Evaluate for DJD, Rule out anomalies, Other Doctor s Signature.

7 X-RAY RECORD DATE: X-RAY/CLINIC NUMBER: NAME: M F AGE: LAST MENSTRUAL PERIOD: DATE OF BIRTH: PREGNANT: Y N HYSTERECTOMY: Y N MENOPAUSE Y N NO Do you have a Pacemaker or any other implanted devices? NO I authorize Drs. Lalla or Jensen to make the following x-rays of me. NO I have been informed of the potential hazards of radiation and have been offered gonadal protection. NO I require a chaperone to be in attendance while I am being x-rayed. PATIENT SIGNATURE: NO. TFD B FILM VIEW CM KVP MAS MA NB SIZE X12 CERVICAL AP X12 CERVICAL AP OPEN MOUTH X12 CERV. LAT. NEUTRAL X12 CERV. LAT. EXTENSION X12 CERV. LAT. FLEXION X12 CERV. OBLIQUE RIGHT X12 CERV. OBLIQUE LEFT X17 DORSAL AP X17 DORSAL LATERAL X 17 DORSAL OBLIQUE RIGHT X17 DORSAL OBLIQUE LEFT X17 LUMBAR/SACRAL - AP X17 LUMBAR LAT. RIGHT X17 LUMBAR LAT. FLEXION RIGHT X17 LUMBAR LAT. FLEXION LEFT X17 LUMBAR LAT. OBLIQUE RIGHT X17 LUMBAR LAT. OBLIQUE LEFT X17 SACRUM AP X17 SACRUM LAT X17 COCCYX AP X17 COCCYX LAT X36 FULL SPINE AP x36 FULL SPINE LAT. Rule out joint instability Rule out foraminal encroachment Evaluate for DJD Rule out fracture Assess biomechanical alignment Rule out anomalies Evaluate to withstand osseous adj. Other Doctor s Signature: -OVER-

8 NO. TFD B FILM SIZE VIEW CM KVP MAS MA NB X12 SHOULDER INT. ROT. RIGHT X12 SHOULDER EXT. ROT. RIGHT X12 SHOULDER BABY ARM RIGHT x12 SHOULDER TANGENTIAL PROJ X12 SHOULDER INT. ROT. LEFT X12 SHOULDER EXT. ROT. LEFT X12 SHOULDER BABY ARM LEFT X12 SHOULDER TANGENTIAL PROJ X12 CLAVICLE PA RIGHT x12 CLAVICLE PA LEFT X12 A/C RIGHT & LEFT (2 FILMS) X12 ELBOW - AP RIGHT X12 ELBOW - LAT. RIGHT X12 ELBOW MED. OBLIQUE RIGHT X12 ELBOW - JONES VIEW RIGHT X12 ELBOW - AP LEFT X12 ELBOW LAT. LEFT X12 ELBOW - MED. OBLIQUE LEFT X12 ELBOW - JONES VIEW LEFT X12 WRIST PA RIGHT X12 WRIST ULNAR FLEX. RIGHT X12 WRIST LAT. RIGHT X12 WRIST OBLIQUE RIGHT X12 WRIST PA LEFT X12 WRIST ULNAR FLEX. LEFT X12 WRIST LAT. LEFT X12 WRIST OBLIQUE LEFT X12 HAND PA RIGHT X12 HAND OBLIQUE RIGHT X12 HAND BALL CATCHERS RIGHT X12 HAND PA LEFT X12 HAND OBLIQUE LEFT X12 HAND BALL CATCHERS LEFT -OVER-

9 X-RAY RECORD DATE: X-RAY/CLINIC NUMBER: NAME: M F AGE: LAST MENSTRUAL PERIOD: DATE OF BIRTH: PREGNANT: Y N HYSTERECTOMY: Y N MENOPAUSE Y N NO Do you have a Pacemaker or any other implanted devices? NO I authorize Drs. Lalla or Jensen to make the following x-rays of me. NO I have been Informed of the potential hazards of radiation and have been offered gonadal protection. NO I require a chaperone to be in attendance while I am being x-rayed. PATIENT SIGNATURE: NO. TFD B FILM VIEW CM KVP MAS MA NB SIZE x12 FINGER PA RIGHT x12 FINGER OBLIQUE RIGHT x12 FINGER LAT. RIGHT x12 FINGER PA LEFT x12 FINGER OBLIQUE LEFT x12 FINGER LAT. LEFT x12 THUMB AP RIGHT x12 THUMB OBLIQUE RIGHT x12 THUMB LAT. RIGHT x12 THUMB AP LEFT x12 THUMB OBLIQUE LEFT x12 THUMB LAT. LEFT X12 HIP AP RIGHT X12 HIP FROG LEG RIGHT X12 HIP AP LEFT X12 HIP FROG LEG LEFT X12 KNEE. AP RIGHT X12 KNEE LAT. RIGHT X12 KNEE INTERCONDYLAR RIGHT X12 KNEE TANGENTIAL PATELLA RT X12 KNEE AP LEFT X12 KNEE LAT. LEFT X12 KNEE INTERCONDYLAR LEFT X12 KNEE TANGENTIAL PATELLA LT. Rule out joint instability Rule out foraminal encroachment Evaluate for DJD Rule out fracture Assess biomechanical alignment Rule out anomalies Evaluate to withstand osseous adj. Doctor s Signature: Other -OVER-

10 NO. TFD B FILM VIEW CM KVP MAS MA NB SIZE x12 ANKLE AP RIGHT x12 ANKLE MEDIAL OBLIQUE RIGHT x12 ANKLE LAT. RIGHT x12 ANKLE AP LEFT x12 ANKLE MEDIAL OBLIQUE LEFT x12 ANKLE LAT LEFT x12 FOOT AP RIGHT x12 FOOT MEDIAL OBLIQUE RIGHT x12 FOOT LAT. RIGHT x12 FOOT AP LEFT x12 FOOT MEDIAL OBLIQUE LEFT x12 FOOT LAT. LEFT x12 TOES AP (DORSAL PLANTAR)RT x12 TOES MEDIAL OBLIQUE RIGHT x12 TOES PA (HAMMER TOE) RIGHT x12 TOES AP (DORSAL PLANTAR)LT x12 TOES MEDIAL OBLIQUE LEFT x12 TOES PA (HAMMER TOE) LEFT x12 CALCANEOUS AXIAL RIGHT x12 CALCANEOUS LAT. RIGHT x12 CALCANEOUS AXIAL LEFT x12 CALCANEOUS LAT. RIGHT X17 CHEST APICAL X17 CHEST PA X17 CHEST LAT x12 RIBS AP x12 RIBS PA x12 RIBS ABOVE DIAPHRAGM x12 RIBS BELOW DIAPHRAGM x12 SKULL SUBMENTOVERTEX x12 SKULL LAT x12 SKULL PA (CALDWELL) x12 SKULL OCCIPITAL (TOWNE) x12 SINUS PA (SINUS) -OVER-