Page: 1 Spine Atlas Angle 7.24 S Atlas Angle 21.67 S The Atlas Angle is a measurement of the stability of the Atlas. The Atlas Plane Line is compared to true horizontal. Any increase or decrease of this angle may be the result of the Alar, Accessory, and/or Anterior/Posterior Longitudinal Ligament sub-failure. Alteration of the Atlas Angle demonstrates abnormal shearing forces on the ligamentous structures. Maintaining the proper position of this vertebra in relation to the skull and is critically important for biomechanical stability for the entire axial skeleton. An increased angle may represent torsional stress resulting in an increase (hyperlordosis) of the cervical curve. A diminished angle may represent torsional stress resulting in straightening (hypolordosis) or reversal of the cervical curve.
Page: 2 Spine Atlas/Axis Angle 20.12 A Atlas/Axis Angle 0.19 A The Atlas/Axis angle represents the angular relationship of C1 to. The atlas plane line is compared to a perpendicular line drawn from the posterior axis body line. The normal relationship is 1 to 2 degrees with the angle opening to the anterior. Increased flexion of Atlas on Axis causes mechanical alterations to weight transfer through the cervical spine and destabilizes normal spinal biomechanics. This angular increase is suggestive of an anterior superior fixed Occiput with resultant anterior head carriage, ligamentous laxity, failed biomechanics and altered weight bearing throughout the spine. Spine Atlas/Skull Angle 16.73 Atlas/Skull Angle 5.61 The Atlas/Skull Angle is an angular comparison of the plane line of C1 to the plane line of the base of the skull at the level of the foramen magnum. In the healthy spine, the angle is divergent to the posterior. An increase in the normal angle would indicate a flexion related subluxation. A reversal of the angle with divergence to the anterior of the spine indicates an extension subluxation. Both of these categories indicate failed biomechanics, abnormal stresses on the ligamentous structures and possible neurologic sequlae.
Page: 3 Spine Base Lines Base Lines The lateral Base Lines are drawn from the inferior epiphyseal plates of each vertebra. The lines should converge on the posterior of the lateral spine view and converge at a central point. This is a qualitative analysis used to assist the physician in determining fixed flexion or fixed extension of vertebra (e). When a base line intersects with the next superior base line, this indicates fixed flexion of the inferior vertebra (e) while a base line intersecting with the next inferior vertebra indicates fixed extension of the superior vertebra. If not corrected this may leads to biomechanical dysfunction, which may assist with or lead to premature degenerative changes. (Wolf's Law) Spine Center of Gravity Analysis 46.30 mm A Center of Gravity Analysis 0.00 mm A Center of Gravity Line analysis is constructed in the lateral cervical view; locate the anterior lip of the Sella Turcica. From there drop a vertical plumb line. This line should normally intersect at and anterior disk space at the center point. If it does not intersect at and disc space, then measure the horizontal distance to the vertical plumb line in millimeters. The mean deviation from the center gravity is +/- 5 mm. Pettibon 1997
Page: 4 Spine Lateral Neutral [ C7-Skull ] mm -6.00-4.50-3.00-1.50 AOP 1.50 3.00 4.50 6.00 C6 5.01 5.07 5.02 5.09 5.74 Lateral Neutral [ C7-Skull ] mm -9.00-6.75-4.50-2.25 AOP 2.25 4.50 6.75 9.00 C6 7.41 8.40 6.65 6.45 5.64 Disc Height Anterior Disc Height Anterior Spine Lateral Neutral [ C7-Skull ] mm -7.00-5.25-3.50-1.75 AOP 1.75 3.50 5.25 7.00 C6 5.66 6.72 6.07 6.06 5.97 Lateral Neutral [ C7-Skull ] mm -7.00-5.25-3.50-1.75 AOP 1.75 3.50 5.25 7.00 C6 6.23 6.62 5.38 5.45 4.52 Disc Height Posterior Disc Height Posterior
Page: 5 Spine George's Line /, /, /, /C6 and George's Line C6/C7 George's Line is also known as the posterior vertebral alignment line and the posterior body line. George's line is a measure of spinal ligament integrity of the posterior longitudinal ligament and vertebral body alignment. The key landmark is the alignment and integrity of one vertebra to each superior and inferior vertebra. The normal translation or laxity of each vertebral motor unit is 0.0 to 0.6 mm. Normally, there is a smooth vertical alignment of each posterior body corner. Interruption of a smooth curve is suggestive of ligament instability due to fracture, dislocation, trauma with ligamentous subfailure or degenerative joint disease which can cause or aggravate spinal stenosis with resultant altered spinal biomechanics, and degenerative changes.
Page: 6 Spine Jackson's Angle 12.89 Jackson's Angle 39.91 Ruth Jackson's Angle is also known as Cervical Stress Lines, which is measured by constructing lines of mensuration from the posterior bodies of C-2 and C-7. These lines will form an angle which ordinarily intersect at the - disc interspace in the neutral and extension view and -C6 disc interspace in flexion. The intersection point represents the focus of stress when the cervical spine is placed in the respective position. Muscle spasms, joint fixation, and disc degeneration may alter the stress point. Spine Occiput Angle 23.97 S Occiput Angle 16.06 S The occiput angle is an assessment of skull positioning constructed by comparing a true horizontal to the baseline of the occiput. The occiput s relative position is governed by the vestibular and ocular response to the known horizon. Increase or decrease of this angle can indicate biomechanical instability, ligamentous damage, and/or trauma.
Page: 7 Spine Spondylolisthesis C: Grade 1 at,,,, C6. Spondylolisthesis (None) Spondylolisthesis is an anterior displacement of 1mm or greater of one vertebral body in relation to the segment immediately below. 1-25% slippage is a Grade I, 26-50% slippage is a Grade II, and 51-75% slippage is a Grade III. Greater than 75% slippage is a Grade IV. Usually, anterior head carriage in the cervical and or degenerative disc disease is seen at the level of the Spondylolisthesis. These measurements can also be considered anterior offsets, and if the offset exceeds 1mm this indicates a functional pathology in one or both forms described above. Spine Lateral Neutral [ C7-Skull ] mm -3.00-2.25-1.50-0.75 AOP 0.75 1.50 2.25 3.00 C6-1.91-1.59-2.04-1.19-1.39 Lateral Neutral [ C7-Skull ] mm -1.00-0.75-0.50-0.25 AOP 0.25 0.50 0.75 1.00 C6 0.00 0.00 0.00 0.00 0.00 Vertebra Offset Vertebra Offset Translatory Anterior and Posterior displacement in graphical form is measured from the posterior inferior corner of the body of the superior vertebra to the posterior superior corner of the inferior vertebra. This graph identifies the direction each segment has translated, bringing a clear understanding of which vertebra could be considered treatable. Measurement of 1-3mm is considered to be a subluxation. A displacement of more than 3.5mm in the cervical spine radiographs is considered abnormal and indicates severe ligamentous instability or sub-failure and is a ratable impairment.
Page: 8 Spine Vertebra Offset Image Vertebra Offset Image Spine Lateral Extension [C6-Skull] Spine Lateral Flexion [C6-Skull] Atlas/Skull Angle 11.96 Atlas/Skull Angle 13.76 The Atlas/Skull Angle is an angular comparison of the plane line of C1 to the plane line of the base of the skull at the level of the foramen magnum. During motion studies the normal range of Atlas/Skull motion is 7 degrees in flexion and 7 degrees in extension. In the healthy lateral neutral spine, the angle is divergent to the posterior. A substantial increased angle in extension would suggest an Alar ligament sub-failure. A reversal of the angle with divergence to the anterior of the spine indicates an extension subluxation. Both of these categories indicate failed biomechanics, abnormal stresses on the ligamentous structures and possible neurologic sequlae.
Page: 9 Spine Lateral Extension [C6-Skull] Spine Lateral Flexion [C6-Skull] Base Lines Base Lines The lateral Base Lines are drawn from the inferior epiphyseal plates of each vertebra. This is a qualitative analysis used to assist the physician in determining fixed flexion or fixed extension of vertebra (e). When a base line intersects with the next superior base line during flexion, this indicates the inferior vertebra (e) is fixed in flexion. When a base line intersects with the next inferior vertebra during extension, this indicates the superior vertebra is fixed in extension. If not corrected this may leads to biomechanical dysfunction, which may assist with or lead to premature degenerative changes. (Wolf's Law)
Page: 10 Spine Lateral Extension [C6-Skull] Spine Lateral Flexion [C6-Skull] Established Patient ( ) Established Abnormal ( ) Ratable Threshold ( ) 2.49 I 7-11 11.00 6.18 I 7-11 11.00 9.81 I 7-11 11.00 12.93 I 7-11 11.00 Motion Segment Integrity, Angular Motion Segment Integrity Angular of the spine is defined as a target vertebra and two adjacent vertebrae, an intercalated disk, and the vertebral facet joint. The angular loss of integrity is defined as a difference in the angular motion of one vertebra compared to the two adjacent motion segments in response to flexion only. Measurement of 7 to 11 degrees of Angular Variation is considered to be clinically significant and indicative of spinal subluxation and ligament damage (White and Punjabi). Abnormal measurements over 11 degrees or greater of Angular Variation (Loss of Cervical Spine Motion Segment Integrity) by definition (DRE Model) constitutes ligament sub-failure or tear and the result is instability. DRE Category IV defines whole person Impairment of 25% to 28% if the target vertebra angular motion is greater than 11 degrees or more in comparison to the two adjacent vertebral motor units in the cervical and thoracic spine, greater than 15 degrees at L1/L2, L2/L3, L3/L4 and greater than 20 degrees at L4/L5. This finding qualifies as a ratable impairment. Loss of integrity of the lumbosacral joint is defined as an angular motion between L5/S1 that is greater than 25 degrees greater than motion at L4/L5 level at 20 degrees. (Ref: Guides to the Evaluation of Permanent Impairment, Fifth Edition, Errata.)
Page: 11 Spine Lateral Extension [C6-Skull] Spine Lateral Flexion [C6-Skull] Established Established Extension Established Ratable Flexion Established Ratable Patient Values Abnormal Threshold Patient Values Abnormal Threshold 5.80 P 2.51 A 1-3.5 3.50 5.80 P 3.29 P 1-3.5 3.50 5.91 P 2.76 A 1-3.5 3.50 5.91 P 3.14 P 1-3.5 3.50 5.88 P 1.91 A 1-3.5 3.50 5.88 P 3.96 P 1-3.5 3.50 2.66 P 0.57 P 1-3.5 3.50 2.66 P 3.23 P 1-3.5 3.50 Motion Segment Integrity, Translational Motion Segment Integrity, Translational Translational motion is measured by determining the anteroposterior motion of one vertebra over another. Loss of motion is defined by translational motion that is greater than 3.5 mm in the cervical spine, 2.5 mm in the thoracic spine and 4.5 mm in the lumbar spine. Using DRE Cervical Category IV, loss of motion segment integrity may be assessed as 25%-28% Impairement of the Whole Person.Using DRE Lumbar Category IV, loss of motion segment integrity may be assessed as 20%-23 % Impairment of the Whole Person. Spine Lateral Extension [C6-Skull] Spine Lateral Flexion [C6-Skull] Lateral Extension [ C6-Skull ] mm -3.00-2.25-1.50-0.75 AOP 0.75 1.50 2.25 3.00 2.51 2.76 1.91-0.57 Lateral Flexion [ C6-Skull ] mm -4.00-3.00-2.00-1.00 AOP 1.00 2.00 3.00 4.00-3.29-3.14-3.96-3.23 Vertebra Offset Vertebra Offset Translatory Anterior and Posterior displacement in graphical form is measured from the posterior inferior corner of the body of the superior vertebra to the posterior superior corner of the inferior vertebra. This graph identifies the direction each segment has translated, bringing a clear understanding of which vertebra could be considered treatable. Measurement of 1-3mm is considered to be a subluxation. A displacement of more than 3.5mm in the cervical spine radiographs is considered abnormal and indicates severe ligamentous instability or sub-failure and is a ratable impairment.
Page: 12 Spine Lateral Extension [C6-Skull] Spine Lateral Flexion [C6-Skull] Vertebra Offset Image Vertebra Offset Image
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Page: 14 PATIENT'S NAME: Nechurtz,Mya REFERRED BY: Howard Glans DC DAAMLP DRIT DATE OF FILMS: 12/28/2010 DOB: 5/22/1964 ANALYSIS: 2/9/2011 REPORT: 3/17/2011 DIGITAL RADIOGRAPHIC BIOMECHANICAL, MENSURATION REPORT This report is compiled upon evidence based objective biomechanical analysis and protocols that have been established for Roentgenometric Digitization of the spine. This evaluation will not include a pathological report. The Digital Radiographic Images used were of acceptable quality and in compliance with normal protocols for X-ray digitization. This report follows the AMA Guidelines to The Evaluation of Permanent Impairment, 5th Edition. The Mensuration Analysis is considered 'Established' by the World Health Organization (WHO) and can be found in the US National Guideline Clearinghouse. Lateral Cervical Spine: FINDINGS»There are abnormal Lateral Baselines.»Centre of Gravity=46.30mm A.»Grade 1 at,,,, C6.»There are abnormal anterior Lateral Vertebral Offsets at,,, and C6. Interruptions of the George's Line at /, /, /, /C6 and C6/C7 are indicative of ligamentous instability or sub failure.»occiput Angle=23.97 ( normal = 16.1 )»Atlas Angle=7.24 ( normal = 21.7 )»Atlas/Axis angle=20.12 ( normal = 0.2 )»Atlas/Skull angle=16.73 ( normal = 5.6 )»Jackson's Angle=12.89 ( normal = 39.9 )»The angular motion segment integrity appears to be compromised at.»the translational motion segment integrity appears to be compromised at, and.
Page: 15 CERVICAL IMPRESSIONS : 1.The Centre of Gravity is 46.30mm Anterior. 2.Abnormal straightening of the cervical spine. 3.Lateral Anterior Vertebral Offset (Spondylolisthesis) at, which is a ratable impairment at 6% whole body. Lateral Anterior Vertebral Offset (Spondylolisthesis) at, which is a ratable impairment at 6% whole body. Lateral Anterior Vertebral Offset (Spondylolisthesis) at, which is a ratable impairment at 6% whole body. Lateral Anterior Vertebral Offset (Spondylolisthesis) at, which is a ratable impairment at 6% whole body. Anterior offsets are considered to be extremely unstable motor units. 4.Interruptions of the George's Line at /, /, /, /C6 and C6/C7 are indicative of ligamentous instability or sub failure. 5.Ligamentous instability is suggested in the cervical spine. 6.Cervical motion study (C1-C7) indicates Angular Motion Segment Integrity change at. The impairment of the cervical region is due to ratable Loss of Motion Segment Integrity and is ratable at 25% for cervical spine (AMA Guides, Fifth Edition, Errata). This patient s digital analysis reveals Loss of Motion Integrity at =12.93 Inferior yielding an impairment estimate based on plain film forensics at 25%. 7.Cervical motion study indicates Translational Motion Segment Integrity change at, and. The impairment of the cervical region is due to ratable Loss of Motion Segment Integrity and is ratable at 25% for cervical spine (AMA Guides, Fifth Edition, Errata). This patient s digital analysis reveals Loss of Motion Integrity at =5.80mm Posterior, =5.91mm Posterior and =5.88mm Posterior yielding an impairment estimate based on plain film forensics at 25% whole person. *Measurement of 1mm to 3mm Translation and/or 7 to 11 Angular Variation is considered to be clinically significant and indicative of spinal subluxation and ligamentous damage. (White and Panjabi). *Measurements of 1mm or greater Translation and/or 7 or greater Angular Variation are considered to be clinically significant and in excess of normal flexibility of the cervical spine. (SPINE 2001, February; 26(3):(256-261), Lin, Tsai, Chu and Chang. **Abnormal Measurements over 11 Angular Variation and/or greater than or equal to 3.5mm Translation in Flexion (Loss of Cervical Spine Motion Segment Integrity) by definition (DRE Model) constitutes ligament damage and the resulting instability. DRE Category IV defines a Whole Person Impairment of 25% to 28%, Guides to the Evaluation of Permanent Impairment, Fifth Edition, (Errata) AMA, 2000 Howard Glans D.C. DAAMLP D.R.I.T. Digital Radiographic Imaging Technologist