back to the future
TRANSCRIPT
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
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.