Monthly Archives: September 2015

Open-MRI and quantitative fluoroscopy: the future in diagnosing persistent spinal pain?

British Chiropractic Association Autumn Conference 2015, Bournemouth

I was delighted to have been invited to speak at the British Chiropractic Association’s Autumn Conference 2015, at the Marriot hotel, Bournemouth, perfectly situated to watch the sun glistening on the Channel. The beautiful weather was fitting for a particularly celebratory occasion with chiropractors travelling from all over the world to gather and celebrate 90 years of the BCA and 50 years of AECC. To be included as a speaker alongside some of the top researchers in the musculoskeletal field, and sharing the stage with no less than Professor Alan Breen, was slightly nerve-racking but also a very great honour.

Look Inside: MRI and quantitative fluoroscopy in the future

Photo taken by Stephen Perle DC

Photo taken by Stephen Perle DC

Alan and I were tasked with discussing what the future might look like as regards imaging in (but not limited to) chiropractic practice. I began by delving a little into the historical background. It is pretty well known that in the same year that D.D. Palmer founded chiropractic, 1895, Roentgen discovered x-rays. It is perhaps less well known that the world’s first hospital-based x-ray department opened no less than one year later – at Glasgow Royal Infirmary. Having previously worked in that hospital (and since Alan is originally from Glasgow) this seemed a neat starting point for the presentation. The department was started by Dr John MacIntyre who is credited with being the first person to observe in situ a kidney stone and a foreign body (a ha’penny swallowed by a child – no Scotsman is going to let a ha’penny get lost like that). Most fascinating for me is that he is credited with taking the first cineradiogram (an early precursor to fluoroscopy) showing the movement of a frog’s legs. So as far back as 1896 did interest begin in using imaging techniques to look inside the body, not just for signs of pathology, but to observe motion.

Imaging in the early-mid 20th century, particularly the use of x-rays, soon became an important part of chiropractic practice. However, taking measurement from static radiographs, as was popular in chiropractic around 50 years ago in North America, have not been shown to be reliable in the assessment and diagnosis of spinal function. In Europe around the same time there was a growing interest not in the identification of putative misalignment of vertebra but of motion abnormalities between the vertebrae, thus motion palpation (particularly under the influence of Henri Gillet) and the use of cineradiography (influenced by Fred Illi). However, while measurements from static films were proving to be much less useful than previously hoped, measurements from cineradiography were not possible at all. This was, however, to change.

Alan Breen first started experimenting with what is now known as quantitative fluoroscopy (QF), taking measurements from motion x-rays, in the 1980s but it was not until the 2000s that computing power was sufficient to make this a reality. QF has since been found to be accurate and reliable in the measurement of inter-vertebral motion in both the cervical and lumbar spines, and has been commercialised in the United States. It should start appearing in European hospitals within the next few years – watch this space. What will be possible with QF is a more accurate measurement of spinal stability to better inform surgical decisions and also the potential to better guide conservative treatment. The examples given from a case series during the presentation included showing that suspected lumbar instability is often not confirmed (therefore the potential to avoid unnecessary fusion surgery) and where it is present there is perhaps an increased chance of good surgical outcomes. Also, manipulation/mobilisation might be better targeted at identified segmental restrictions, and exercise therapy better directed where hypermobile or lax joint motion is present.

Alan’s part of the presentation included discussing what was possible with an open-MRI. Aside it being preferable for claustrophobic patients,  the ability to image patients weight-bearing has meant the identification of disc hernia in some patients that would have been missed if imaged lying-down, therefore open-MRI is likely to play an important role in improving the diagnosis of persistent radicular pain. He also touched on diagnostic ultrasound which is showing value particularly in the diagnosis of soft-tissue injury of the extremities.

We are only at the beginning of finding out if the potential of QF (and other imaging techniques) will be fully realised, that of improved outcomes for patients with neck and back pain. Its use, like that of MRI, is likely to be restricted to those patients with particularly problematic spinal pain, but it (and open-MRI/diagnostic ultrasound) is a welcome addition to the diagnostic armamentarium of the chiropractor and other musculoskeletal professionals. And it was developed, not by a massive multinational corporation, but by a member of the BCA at AECC. Now that is worth celebrating.