back to the future

Fiona Mellor

William Stripp Memorial Lecture

Quantitative Fluoroscopy

Vs

Functional Radiography

of the lumbar spine

http://www.aecc.ac.uk/research/imrci

Learning outcomes

Why measure intervertebral motion?

Sources of errors and variation in

flex/ext (functional) radiographs

A novel adaptation of fluoroscopy

(quantitative fluoroscopy - QF)

Comparison of radiation dose

Uncertainties in intervertebral motion

Diagnostic categories

of back pain (CSAG 1994)

1% Serious pathology

4% Nerve root compression

95% ‘Simple’ (Non-specific) backache

- Chemical

- Central sensitization

- Mechanical (Instability)

Why measure intervertebralmotion?

Diagnosis

Treatment

Disability

Research

Passive

ActiveMotor Control

Motion Subsystems(Panjabi 1992)

In vitro analysis

The Neutral Zone Theory

Neutral

zone

Flexion

Extension

Range of

motion

Failure

Force2Kg

Back……

Wellcome film library. London

…via the present

Intra and inter subject

variation

Intra and inter examiner

error

Positioning

Definition of normal

…. to the future

Passive Quantitative

FluoroscopyAcquisition Image Analysis Output

Image analysis

Vertebral rotation

Inter-vertebral rotation

OutlineHypothesis: There is a higher

prevalence of abnormal mid lumbar

inter-vertebral motion patterns in patients

with mechanical LBP compared to

controls Prospective design

N = 80

Matched cohort for age, gender and BMI

L2-L5

QF passive motion

Coronal and sagittal

Global range 40o

Each direction (Lt Rt, flx,

ext)

Funded by the NIHR

Clinical Academic Training Fellowship

Results

‘Abnormal motion patterns’

Maximum rotation p <0.05

Left L4/5 pts < controls Right L3/4 pts > controls

Reference intervals

Hyper-mobility: p<0.05 Right L3/4 and Flexion L4/5

Hypo-mobility; p<0.05 Left and Right

A definition of ‘abnormal ‘

is those whose rotation

falls beyond that

achieved by 95%of the

healthy population

Mid range motion

In vivo

Neutral Zone

Left L4/5 patients < controls (p<0.05)

Continuous motion patterns:

Reference intervals

Hyper mobility: Left L3/4 and Flexion L3/4

Hypo-mobility; Left L3/4 and L4/5. Right L4/5 and Flexion

Variation is still a problem!

- How to account for the variation

- How to measure the co-dependency of segments

Continuous proportional motion

Proportional range variance

…. The future of inter-vertebral

measurements

Results: Proportional range

varianceVariable Differences (p =) Sensitivity Specificity

PRV left 0.22 0.675

(0.509-0.814)

0.550

(0.385-0.707)

PRV right 0.09 0.775

(0.615-0.892)

0.500

(0.338-0.662)

PRV flexion 0.29 0.850

(0.702-0.943)

0.300

(0.166-0.485)

PRV extension 0.06 0.825

(0.672-0.927)

0.450

(0.293-0.615)

Combined (CPRV) 0.008 0.775

(0.615-0.892)

0.550

(0.385-0.707)

Radiation dose

Radiation dose

Conclusions

QF is more responsive than

functional radiography with a

similar radiation dose

The coronal plane should be

considered

Patient sample = L5/S1 not

included

‘Non Specific’ back pain =

further subgrouping

Implications for clinical practice

Healthy Passive Vs Active

motion

Uncertainties:

Subtle differences detected by QF

Healthy recumbent passive flexionIn

ter-

vert

ebra

l angle

(o)

Time (15 frames = 1 second)

Healthy weight-bearing

flexion

Time (15 frames = 1 second)

Inte

r-vert

ebra

l angle

(o)

QF research at AECC

1. Characteristics of kinematics in healthy

adults and their reproducibility over time

2. Effect of muscle interaction in healthy

adults

3. Effects of manipulation of the cervical

spine and patient reported outcomes

4. Relationship between prosthetic fit and

intervertebral motion

Weight-bearing acquisition

Cervical spine acquisition

Cervical spine rotation

in a patient with whiplash

Flexion

Summary

Functional views could

be replaced with QF

Further sub-grouping

of non specific back

pain

Further analysis of

existing data

Fiona Mellor

E: imrci.fmellor@aecc.ac.uk

Acknowledgements:

National Institute of Health. Clinical Academic Training Fellowship.

Bournemouth University Santander travel award.

Anglo-European College of Chiropractic. Bournemouth . UK

Orthokinematics. Texas USA

Professor Alan Breen and the team at IMRCI. Bournemouth. UK

Professor Nat Ordway and the team at SUNY. Syracuse. USA

William Stripp Memorial Lecture

Bibliography Breen, A., Muggleton, J. and Mellor, F., 2006. An objective spinal motion imaging assessment (OSMIA): reliability,

accuracy and exposure data. BMC Musculoskeletal Disorders, 7 (1), 1-10.

Breen, A. C., Teyhen, D. S., Mellor, F. E., Breen, A. C., Wong, K. and Deitz, A., 2012. Measurement of inter-

vertebral motion using quantitative fluoroscopy: Report of an international forum and proposal for use in the

assessment of degenerative disc disease in the lumbar spine. Advances in Orthopaedics, 1-10.

Deitz, A. K., Mellor, F.E., Teyhan, D.S., Panjabi, M.M., Wong, K.W.M., 2010. Kinematics of the Aging Spine: A

Review of Past Knowledge and Survey of Recent Developments, with a Focus on Patient-Management

Implications for the Clinical Practitioner. Yue, Guyer, Johnson, Khoo & Hochschuler (eds) In: Yue, J. L., Guyer, R.

D., Johnson, P. J., Khoo, L. T., and Hochschuler, S. H., eds. The Comprehensive Treatment of the Aging Spine:

Minimally Invasive and Advanced Techniques. Elsevier.

Mellor, F., Breen, A., 2009. Objective assessment of spinal motion: the future? Imaging and Oncology, 3, 34-41.

Mellor, F. E. and Breen, A. C., 2014. Discrimination of biomechanical back pain patient subgroups from continous

inter-vertebral motion data: a protocol. Bone & Joint Journal Orthopaedic Proceedings Supplement, 96-B (SUPP

4), 5.

Mellor, F. E., Muggleton, J. M., Bagust, J., Mason, W. M. A., Thomas, P. W. and Breen, A. C., 2009. Midlumbar

lateral flexion stability measured in healthy volunteers by in-vivo fluoroscopy. Spine, 34 (22), E811-E817.

Mellor, F. E., Thomas, P. and Breen, A., . 2014a. Moving Back: the radiation dose received from lumbar spine

quantitative fluoroscopy compared to lumbar spine radiographs with suggestions for further dose reduction.

Radiography, In print.

Mellor, F. E., Thomas, P., Thompson, P. and Breen, A., 2014b. Proportional lumbar spine inter-vertebral motion

patterns: a comparison of patients with chronic, non-specific low back pain and healthy controls European Spine

Journal, epub ahead of print (March).

Panjabi, M., Abumi, K., Duranceau, J. and Oxland, T., 1989. Spinal Stability and Intersegmental Muscle Forces: A

Biomechanical Model. Spine, 14 (2), 194-200.

Panjabi, M. M., 1992. The stabilising system of the spine - Part 2: Neutral zone and instability hypothesis. Journal

of Spinal Disorders, 5 (4), 390-397.