Examination Of Cervical Spine Research Articles

How does evidence on the diagnostic accuracy of the vertebral artery test influence teaching of the test in a professional physical therapist education program?

The purpose of “Evidence in Practice” is to illustrate the literature search process to obtain evidence that can guide clinical decision making. This article is not a case report. The examination, evaluation, and intervention sections are purposely abbreviated. Although faculty members have always had the obligation to remain current in their teaching,1 they are now being called on to provide evidence to support classroom teaching.2 We believe evidence-based teaching leads to several positive outcomes. First, the importance of using evidence to make decisions is modeled to students. Second, students are shown that, for some topics, the evidence is contradictory or sparse. Addressing this ambiguity in the classroom also models ways to address similarly ambiguous clinical situations. Third, evidence-based teaching provides faculty with one standard for deciding what should or should not be included in a curriculum. When teaching tests and measures to physical therapist students, we believe faculty should teach not only psychomotor competency, but also the appropriate use of test information in the clinical reasoning process. In order to draw confident conclusions from a clinical test, clinicians must understand the diagnostic characteristics of that test. Faculty should present the available evidence on diagnostic accuracy—including sensitivity, specificity, positive and negative predictive values, and likelihood ratios—particularly when the test itself puts the patient at risk. In the case of vertebral artery (VA) testing, the information gained from the test must outweigh the risk to the patient. Vertebral artery testing is a traditional component of cervical spine examination for the assessment of vertebrobasilar insufficiency (VBI),3–7 a syndrome of brainstem ischemia.8 This syndrome can result from pathologies such as atherosclerosis of the subclavian, vertebral, and basilar arteries; postural hypotension; Stokes-Adams attacks; and mechanical compression from cervical spondylosis.9 It also has been attributed to cervical spine examination …

Cervical spine trauma in children under 5 years: productivity of CT.

The aim of the study was to determine the value of CT in the evaluation of cervical spine trauma in children under 5 years in the Emergency Department. A retrospective review of 606 patients undergoing cervical spine examination in the emergency room was undertaken. The age and sex of the patients were documented, and in addition presence or absence of fracture-dislocation was noted on each of the plain film and CT studies. Of the 606 patients studied, 459 (75.7%) were cleared by a combination of clinical and plain film radiographic findings. The other 147 (24.3%) went on to CT imaging for clearing of the cervical spine. Of the 147 patients evaluated with CT, 143 (97.3%) had exams that were negative for fracture, dislocation, and instability. Only four (2.7%) demonstrated positive findings for fracture, dislocation, or instability. All of these patients had positive, diagnostic findings on initial plain film evaluation. Another five patients demonstrated new findings which were unrelated to trauma and of no clinical consequence. The yield of positive, clinically significant findings on CT of cervical spine injuries in children less than 5 years was low and showed significant findings only in patients where the same findings were seen on initial plain radiographs.

Provocative Tests in Cervical Spine Examination: Historical Basis and Scientific Analyses

The majority of the provocative tests described for physical examination of the neck and cervical spine relate to identification of radiculopathy, spinal cord, or brachial plexus pathology. These tests are often performed routinely by many providers with variable methods and interpreted in a variety of ways. Several commonly performed provocative tests include Spurling's Neck Compression Test, Shoulder Abduction (Relief) Test, Neck Distraction Test, L'hermitte's Sign, Hoffmann's Sign and Adson's Test. This review describes some specialized provocative tests with comprehensive literature review. The goal of this review is to develop standardization in the performance and clinical use of these tests. Each of the tests described in this manuscript apparently originated from the anecdotal observations of experienced, well respected clinicians. However, only few studies have been performed addressing the interexaminer reliability or validity of these tests. The existing literature appears to indicate high specificity, low sensitivity, and good to fair interexaminer reliability for Spurling's Neck Compression Test, the Neck Distraction Test, and The Shoulder Abduction (Relief) Test when performed as described. For Hoffman's Sign, the existing literature does not address interexaminer reliability but appears to indicate fair sensitivity and fair to good specificity. For L'hermitte's Sign and Adson's Test, not even tentative statements can be made with regard to interexaminer reliability, sensitivity, and specificity, based on the existing literature. It is concluded that more research is indicated to understand the clinical utility of all the provocative tests employed in the physical examination of the neck and cervical spine.

Lateral cervical spine examinations: an evaluation of dose for grid and non-grid techniques

Purpose: Radiation doses have been monitored for a long time, as we are aware that radiation can produce biological effects. However, there is a limited amount of information available on patient dose from cervical spine examinations. In addition, the techniques used are variable between radiographic departments and even radiographers within one department. The difference in technique of particular concern is the use of radiographic grids. While it reduces scatter and improve image quality, the use of a grid demands increased exposure factors and dose to obtain the same optical density on the film. Method: This study investigated the range of doses for lateral cervical spine examinations in the Hunter and Sydney metropolitan regions of New South Wales, Australia. Radiation doses were calculated from X-ray tube output measurements and patient exposure parameters. Results: Differences in dose for 116 patients (53 non-grid, 63 grid) examined on 13 X-ray units were analysed. The study calculated the mean entrance surface dose for the non-grid system (228 μGy) to be significantly lower at the 95% significance level than the mean entrance surface dose for the grid techniques (505 μGy). However, the use of a grid for computed radiography systems did not produce any differences in dose with the use or non-use of a grid, while there was a three-fold increase for film-screen systems. Conclusion: The increased level of dose and the inherent air-gap nature of the lateral cervical spine examination raises severe doubt on the use of anti-scatter grids and the recommendation is that they should not be used.

Chronic Lateral Epicondylitis: Survey of current practice in the outpatient departments in Scotland

Summary Chronic lateral epicondylitis has been identified as one of the most common lesions of the upper limb ( Thurston, 1999 Thurston AJ ‘Conservative and surgical treatment of tennis elbow: A study of outcome’. Australian and New Zealand Journal of Surgery. 1999; 68: 568-572 Crossref Scopus (22) Google Scholar ). However, a literature search of Medline, Embase (Exerpta Medica) and CINAHL revealed limited published evidence regarding treatment protocols used by physiotherapists in the management of this condition. A survey of opinions of outpatient physiotherapists regarding their current practice of chronic lateral epicondylitis was therefore carried out in a random sample of National Health Service outpatient departments in Scotland. The questionnaire was completed by 120 physiotherapists, giving a response rate of 80%. According to 77.3% of respondents, lateral epicondylitis patients always or frequently present with chronic symptoms. A sizeable proportion of respondents (67.5%) indicated that their chronic lateral epicondylitis patients have a poor understanding of their condition. The importance of joint protection techniques was highlighted with 83.3% of the respondents reporting that they demonstrated protection techniques to patients. Only 1.7%, however, provided written information about these techniques for future reference. Respondents identified pain upon resisted wrist extension (88.3%) and palpation of the wrist extensor origin (63.3%) as diagnostic tests for chronic lateral epicondylitis. Differential diagnosis tests were identified as cervical spine examination and radial nerve tension test by 67.5% and 66.7% of respondents, respectively. Range of motion was the most commonly used outcome measure with 83.3% of respondents using it always or frequently. Only one respondent indicated a defined departmental protocol regarding the management of chronic lateral epicondylitis, although much agreement was found regarding treatment. Progressive stretching (88%) and strengthening exercises (75.8%) were always or frequently used by respondents. This study has provided information regarding current physiotherapeutic approaches to chronic lateral epicondylitis and identified the latest published evidence. However, this condition will continue to be a therapeutic challenge until more evidence regarding best practice is available and physiotherapists acknowledge that it is a multi-factorial condition. Chronic lateral epicondylitis has been identified as one of the most common lesions of the upper limb ( Thurston, 1999 Thurston AJ ‘Conservative and surgical treatment of tennis elbow: A study of outcome’. Australian and New Zealand Journal of Surgery. 1999; 68: 568-572 Crossref Scopus (22) Google Scholar ). However, a literature search of Medline, Embase (Exerpta Medica) and CINAHL revealed limited published evidence regarding treatment protocols used by physiotherapists in the management of this condition. A survey of opinions of outpatient physiotherapists regarding their current practice of chronic lateral epicondylitis was therefore carried out in a random sample of National Health Service outpatient departments in Scotland. The questionnaire was completed by 120 physiotherapists, giving a response rate of 80%. According to 77.3% of respondents, lateral epicondylitis patients always or frequently present with chronic symptoms. A sizeable proportion of respondents (67.5%) indicated that their chronic lateral epicondylitis patients have a poor understanding of their condition. The importance of joint protection techniques was highlighted with 83.3% of the respondents reporting that they demonstrated protection techniques to patients. Only 1.7%, however, provided written information about these techniques for future reference. Respondents identified pain upon resisted wrist extension (88.3%) and palpation of the wrist extensor origin (63.3%) as diagnostic tests for chronic lateral epicondylitis. Differential diagnosis tests were identified as cervical spine examination and radial nerve tension test by 67.5% and 66.7% of respondents, respectively. Range of motion was the most commonly used outcome measure with 83.3% of respondents using it always or frequently. Only one respondent indicated a defined departmental protocol regarding the management of chronic lateral epicondylitis, although much agreement was found regarding treatment. Progressive stretching (88%) and strengthening exercises (75.8%) were always or frequently used by respondents. This study has provided information regarding current physiotherapeutic approaches to chronic lateral epicondylitis and identified the latest published evidence. However, this condition will continue to be a therapeutic challenge until more evidence regarding best practice is available and physiotherapists acknowledge that it is a multi-factorial condition.

Effect of Emergency Department CT on Neuroimaging Case Volume and Positive Scan Rates

Rationale and Objectives The authors performed this study to determine the effect a computed tomographic (CT) scanner in the emergency department (ED) has on neuroimaging case volume and positive scan rates. Materials and Methods The total numbers of ED visits and neuroradiology CT scans requested from the ED were recorded for 1998 and 2000, the years before and after the installation of a CT unit in the ED. For each examination type (brain, face, cervical spine), studies were graded for major findings (those that affected patient care), minor findings, and normal findings. The CT utilization rates and positive study rates were compared for each type of study performed for both years. Results There was a statistically significant increase in the utilization rate after installation of the CT unit ( P < .001). The fractions of studies with major findings, minor findings, and normal findings changed significantly after installation of the CT unit for facial examinations ( P = .002) but not for brain ( P = .12) or cervical spine ( P = .24) examinations. In all types of studies, the percentage of normal examinations increased. In toto, there was a significant decrease in the positive scan rate after installation of the CT scanner ( P = .004). Conclusion After installation of a CT scanner in the ED, there was increased utilization and a decreased rate of positive neuroradiologic examinations, the latter primarily due to lower positive rates for facial CT scans.

SHOULDER INJURY - FOOTBALL

HISTORY: An 18-year-old high school football player was involved in full speed hitting drills when he went shoulder to shoulder with his teammate, striking the superior aspect of his right shoulder against the superior aspect of his teammate's shoulder. The impact was such that both players came to a complete stop and both immediately complained of pain. The presenting player was unable to move his right shoulder in any direction without significant discomfort. He reported no numbness, tingling, or swelling. He had no prior history of shoulder dislocations or injuries. He did not finish practice. Upon office presentation his main complaint was painful, limited motion of the right shoulder. He continued to be free of numbness and tingling. He had no neck pain. PHYSICAL EXAM: The patient's exam revealed no gross deformities. He displayed decreased range of motion of the right shoulder in all planes as well as pronounced pain with any movement. There was mild anterior joint tenderness and early echymotic changes but no swelling. There was pain with humeral palpation. Apprehension and AP glide tests were difficult to assess secondary to pain and limited motion. Sensation was intact. Refelexes were 2/4 and symmetrical. Cervical spine examination was within normal limits. DIFFERENTIAL DIAGNOSIS: Acromioclavicular separation Clavicular fracture Glenoid fracture Shoulder subluxation/dislocation TESTS AND RESULTS: 4 view radiographs: lucency through the glenoid region consistent with fracture MRI: nondisplaced glenoid fracture extending through fossa with apparent tear of articular cartilage FINAL WORKING DIAGNOSIS: Glenoid fracture TREATMENT AND OUTCOMES: Sling for immobilization Gentle home range of motion exercises Ice, NSAIDS Physical therapy initiated at 3 weeks post injury Restricted return to play at 4 weeks post injury Full return to play at 6 weeks post injury

POSTERIOR SHOULDER PAIN ??? BASEBALL

HISTORY: A 20-year-old Division 1 college baseball pitcher presented with posterior right shoulder pain of 6 month's duration. He is 2 years post UCL reconstruction. He returned to 2–3 innings of pitching 1 year post-op without incident in the fall season. He had two good outings the following spring followed by inability to pitch on the third outing. He has falled multiple attempts at rehabilitative strengthening. He was previously diagnosed with RTC tendonitis. PHYSICAL EXAMINATION: Cervical spine and UE neuro vascular examination is WNL bilateral. ROM is WNL for an overhead athlete with reduced ipsilateral IR. Increased LSS on the right. NIS produces end range pain. HIS produces posterior shoulder pain, DIT is positive Relocation is positive. Full can is 5/5, Empty can is 4/5. ER is 5/5. Sulcus is 2 on right 1 on left. Anterior draw is 2+ with click, posterior draw is 1+ on right, Anterior and posterior draws are 1+ on left. LOT is positive on right negative on left. Obrien's Maneuver positive SLAP lesion. Negative anterior slide test. Negative SLAP-rehension test. DIFFERENTIAL DIAGNOSIS: RTC tendonitis right shoulder Secondary impingment right shoulder Internal glenoid impingement right shoulder SLAP tear right shoulder TEST AND RESULTS: Plain film X-rays – Right shoulder:WNL MRI with contrast – Right shoulder: 1st MRI: signal changes consistent with impact lesion on the greater tuberosity Capsular redundancy 2nd MRI: RTC fraying and posterior labral fraying Capsular redundancy FINAL/WORKING DIAGNOSIS: Right shoulder internal glenoid impingement with RTC and labral fraying Right shoulder acquired MDI-AI TREATMENT: Right shoulder arthroscopic debridement Right shoulder thermal capsular shrinkage

Radiation-induced brachial plexopathy in women treated for carcinoma of the breast.

To study the clinical presentation and natural history of radiation-induced brachial plexopathy in 33 women treated for carcinoma of the breast. All of the patients were referred to a single consultant neurologist. Details of surgical procedures, radiotherapy, symptoms at presentation and follow-up and neurological findings were recorded. Patients were reviewed at six or 12 monthly intervals for 2-19 years (median 9.5 years). Investigations included blood tests, chest X-ray, bone scan, neurophysiological studies, computerized tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine and cerebrospinal fluid examination. Symptoms began from six months to 20 years after radiotherapy (median time 1.5 years). Progressive weakness was universal and resulted in loss of any useful hand function in all but three patients. The time taken to loss of useful hand function ranged from six weeks to five years (median 1.25 years). Three patterns of upper limb weakness were identified, distal limb weakness only (13 patients), global limb weakness that was more marked distally (11 patients), and completely flaccid arm (10 patients). Seventeen patients required long-term morphine to palliate pain. A chemical sympathectomy benefited three patients. Most patients developed symptoms within three years, but late presentations 8-20 years later were encountered. Symptoms were progressive in all patients, though the rate did vary. Pain was common and persisted indefinitely in all but one patient. Morphine was effective and should be used early and in adequate doses. Chemical sympathectomy provided sustained relief in three of six patients.

Helical CT of the cervical spine for trauma patients: a time study.

The purpose of the study was to determine the time needed to perform a helical CT examination of the entire cervical spine. Our study population included 156 trauma victims: 100 of these patients underwent CT examination in conjunction with a cranial examination; the remaining 56 patients underwent a primary cervical examination only. Performing a cervical CT examination in conjunction with a cranial CT examination added an average of 12 min to the overall study time. The time for performing a primary cervical examination was 11 min on average. These times are approximately half of those required for a six-view radiographic evaluation. Helical CT has been suggested as a replacement for the more traditional radiographic evaluation of the cervical spine in trauma victims. Evidence now exists to support that recommendation.

Removing the Pediatric Cervical Collar

To identify the current practice patterns of emergency medicine practitioners and the typical criteria used in discontinuing cervical spine immobilization (CSI) in the pediatric patient. Mail-in survey. All physicians on the mailing list of the American Academy of Pediatrics Section of Emergency Medicine and an equal number of randomly chosen members of the American College of Emergency Physicians. The total number of participants was 1360. The survey consisted of a case scenario describing a 3-year-old child brought to the emergency department with CSI. The approach to such a scenario was assessed. Surveys were mailed with self-addressed stamped envelopes; repeat mailings were sent at 4 and 8 weeks after the first mailing. Those not currently in active practice or not involved in the decision to discontinue CSI were excluded from the study. The response rate was 55%. Most respondents were younger than 44 years (71%), in practice less than 10 years (56%), and practiced in an urban setting (68%). Nearly two thirds (62.6%) had completed residency training in pediatrics, 24% in emergency medicine and 36% a pediatric emergency medicine fellowship. Most (63%) would discontinue CSI without obtaining radiographs. Factors associated with removal were residency training in pediatrics and being in practice for less than 10 years. The most common criteria for discontinuing CSI were normal neurological (96%) and cervical spine (98%) examinations, normal mental status (92%), and absence of neck pain (93%). Discontinuing CSI without obtaining radiographs is common, especially among those with residency training in pediatrics and those in practice for less than 10 years. Knowledge of current practice is essential to future development of guidelines for managing pediatric trauma patients for whom cervical spine injury is a consideration.

Operative versus non operative treatment of odontoid non unions. How dangerous is it not to stabilize a non union of the dens?

Injuries precede the vast majority of all odontoid pseudarthroses. Because of specific anatomic conditions type II injuries lead more often than other types to non unions. For its development insufficient internal or external fixation and a persisting fracture gap are crucial. In 71 patients after operative stabilization of odontoid fractures with two anterior lag-screws we detected 8 non unions. In 3 patients the interval between accident and operation amounted to more than 5 weeks, seven times we did not succeed in closing the fracture gap. Technical mistakes like insufficient reduction (n = 1) or screw misplacement (n = 3) were additional reasons. According to the literature and own observations an os odontoideum must be considered in most instances as a pseudarthrosis after a lesion of the subdental synchondrosis in childhood. The most important diagnostic tool in odontoid non unions is a dynamic examination of the upper cervical spine under fluoroscopic control in maximum flexion and extension. We propose a classification of posttraumatic dens non unions into 4 types. Type I corresponds to a stable "non union" in approximate anatomical position of the dens and without signs of instability in the former fracture zone. Type II describes a relatively stable grossly displaced non union that is not to be reduced by simple, closed means. Type III means an unstable non union and Type IV a posttraumatic os odontoideum. Therapeutical recommendations need to be differentiated. Unstable non unions are most often responsible for persistent pain, may result in acute or chronic myelopathy++ and therefore - as well as ossa odontoidea - need operative fixation. In considerably displaced non unions a closed reduction manoeuver with long term traction should be tried. The operative treatment of choice is the posterior transarticular screw fixation C1/C2 desirably in a percutaneous technique. Tight, "stable" pseudarthroses in the sense of a persisting fracture gap in painfree patients should first be controlled radiologically. If the odontoid position remains unchanged, non operative treatment may be continued.

Influence of medicolegal factors in the use of cervical spine and head computed tomographic examinations in an emergency setting

Estimates suggest that defensive medicine, including radiologic studies, costs Americans more than $21 billion annually. As a result of our prior evaluation of 13,228 emergency department patients, we already knew that cervical spine and head computed tomographic examinations were the third and fourth most commonly ordered studies in our emergency department. The emergency medicine, obstetrics/gynecology, surgery, and internal medicine physicians at The Ohio State University agreed to cooperate in a study to determine the factors that influence the decision to order these examinations. Overall, 26 (28%) of the physicians surveyed had personal experience in a medical malpractice lawsuit. Attending physicians in all groups were more concerned about potential medicolegal consequences, compared to residents and fellows (P=0.055) when ordering cervical spine examinations. This coincides with the finding that attending physicians were more likely to have been sued (P<0.001). Emergency medicine physicians were more likely to order one of these examinations if the patient had demanded or requested it (P<0.001) and were more likely to weight physical examination findings more heavily (P=0.007) when compared to other physician groups. Finally, all physician groups combined suggested that approximately 33% of all cervical spine and 39% of all head computed tomographic examinations could be avoided if there were no worries about medicolegal consequences.

Use of magnetization transfer for improved contrast on gradient-echo MR images of the cervical spine.

To evaluate whether magnetization transfer (MT) can improve image contrast on gradient-recalled echo (GRE) magnetic resonance (MR) images of the cervical spine. Sagittal and axial two-dimensional conventional GRE and MT GRE images were obtained in 103 patients with degenerative disk disease or intrinsic cord lesions. The contrast-to-noise ratios (C/Ns) for the cervical spinal cord and cerebrospinal fluid (CSF) were compared for images obtained at various MT power level and section-select flip angle combinations. Axial three-dimensional GRE images were also obtained with application of MT and C/N evaluated in 10 additional patients. Tailored two-dimensional MT GRE images, obtained with a moderate MT power level and a section-select flip angle similar to the Ernst angle for CSF, provided an average of 2.2-2.4-fold improvement in spinal cord-CSF C/N than conventional GRE images (P < .001). The MT GRE images demonstrated superior delineation of disk herniations, foraminal stenosis, and intrinsic cord lesions over conventional GRE and T2-weighted spin-echo images in clinical cervical spine examinations.

Complicance with guidelines for choice of radiographic projections: A multicentre study

A study of compliance with guidelines for choice of radiographic projections was carried out in each of six centres. The study concerned 5851 examinations undertaken by 116 radiographers under the supervision of 29 consultant radiologists. The results showed good compliance between centres for examination of the chest (range 81-93%), abdomen (range 73-100%), thoracic spine (range 82-96%), pelvis/hip (range 78-99%) but not for examination of cervical spine (range 0-85%), paranasal sinus (range 0-100%) and lumbar spine (range 52-84%). The reasons given for these wide variations are discussed and estimates are given for the potential reductions in exposure to the UK population consequent upon national implementation of guidelines such as these.

Computed tomographic evaluation of C1–C2 in Pediatric cervical spine trauma

The supine open-mouth odontoid view required in most cervical spine trauma series often is difficult to obtain, especially in the pediatric or uncooperative patient. This retrospective study compared thin-section computed tomography with multiplanar reconstructions and the standard plain film cervical spine examination for evaluation of C1–C2 in a group of 31 pediatric patients age 6 years and under with combined craniocervical trauma. The plain film examination demonstrated adequate visualization of C1–C2 in only 58% of patients. The average number of anteroposterior odontoid films was 3.5 per examination (range, 1–6 films). Only 9% of anteroposterior open-mouth odontoid views were felt to be of adequate diagnostic quality vs. 60% of the Fuch’s odontoid view. The computed tomographic examination was diagnostic in 91% of examinations and could be acquired more rapidly.

Peripheral findings in MR using surface coil

Incidental peripheral lesions found during neuroradiological MR examinations with surface coils are reviewed. These include intracranial metastases during orbital examinations, cerebellar and thyroid lesions during cervical spine examinations, and dissecting and saccular abdominal aneurysms, as well as renal and intrapelvic abnormalities during lumbar spine examinations. Because of the reduced field-of-view and rapid signal drop-off in deeper portions of the body when examinations are performed with surface coils, peripheral and deep regions also need careful attention during routine evaluation.

Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication.

Trauma constitutes a significant portion of emergency department practice. Such patients often have suspected cervical spine injury necessitating cervical spine radiographs. The importance of detecting cervical spine injury is obvious because failure to do so can lead to tragic consequences for patient and physician alike. Although most cervical spine radiographs are justified, poorly indicated and unnecessary examinations are unfortunately commonplace. Indiscriminate ordering of cervical spine examinations can easily exceed radiology resources assigned to the emergency department. Rational ordering practices are therefore essential for efficient patient management. A risk-tailored approach to performing these examinations, which can improve efficiency, is presented. Once obtained, cervical spine radiographs are presumed to detect injury with consistently high sensitivity. Prevailing conditions of emergency department practice that may lower the "sensitivity" of cervical spine radiographs are reviewed. Overreliance on the initial radiologic examination may lead to inappropriate haste in the evaluation of suspected cervical region injury as exemplified by the commonly voiced mandate to "clear the cervical spine" of injury. This approach is discouraged in patients with significant trauma in favor of a careful, progressive evaluation of the potentially injured cervical spine. Periodic review of these complex issues and close cooperation between clinical services are emphasized.

Radiographic Measurements of Occipito-atlanto-axial Dislocation in Rheumatoid Arthritis

Atlanto-axial dislocation is frequently found in patients with rheumatoid arthritis. Vertical atlanto-axial dislocation with invagination of the dens into the foramen magnum may result in most serious myelopathy. Decompression, removal of the dens and atlanto-axial fixation have given fair results in such cases. It is our aim, however, to prevent myelopathy in our rheumatoid patients. The prerequisite for that is routine, radiographic examination of the cervical spine and prophylactic atlanto-axial fixation. For these routine controls we need a radiographic measuring method which can be used even in cases of greater destruction. Our radiographic measuring method is compared with other methods and seems to be more appropriate and also gives information about the forward or backward tilting of the atlas. In a group of non-rheumatoid patients we have measured normal figures for this method.

Individual and population doses in Manitoba from chiropractic x-ray procedures

Manitoba (population of 1.0 million) has a total of 37 chiropractors who perform X-rays on behalf of the 100 practising chiropractors. In 1987 these specialists performed approximately 33300 spinal X-ray studies. Of the three main types of studies done, cervical spine examinations contribute the lowest patient does (average HE of 26 mu Sv) while thoracic and lumbar spine examinations show a considerably higher patient dose (HE in the range 240-410 mu Sv). The average patient HE was determined to be 220 mu Sv. Lumbar spine examinations account for 45% of all chiropractic X-ray examinations, and contribute 84% of the collective dose. Cervical spine examinations also account for 45% of chiropractic X-ray examinations, but contribute only 5% of the collective dose with thoracic spine examinations contributing the 11% balance of the collective dose. Patients undergoing chiropractic procedures involving exposure to X-rays account for about 3.6% of all diagnostic X-ray procedures in this province. The per caput dose contribution from chiropractic practice was calculated to be 7.3 mu Sv which is estimated to be about 1.2% of the total population dose from diagnostic procedures employing ionising radiation.