Download - Back to the future
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Fiona Mellor
William Stripp Memorial Lecture
Quantitative Fluoroscopy
Vs
Functional Radiography
of the lumbar spine
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http://www.aecc.ac.uk/research/imrci
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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
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Diagnostic categories
of back pain (CSAG 1994)
1% Serious pathology
4% Nerve root compression
95% ‘Simple’ (Non-specific) backache
- Chemical
- Central sensitization
- Mechanical (Instability)
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Why measure intervertebralmotion?
Diagnosis
Treatment
Disability
Research
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Passive
ActiveMotor Control
Motion Subsystems(Panjabi 1992)
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In vitro analysis
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The Neutral Zone Theory
Neutral
zone
Flexion
Extension
Range of
motion
Failure
Force2Kg
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Back……
Wellcome film library. London
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…via the present
Intra and inter subject
variation
Intra and inter examiner
error
Positioning
Definition of normal
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…. to the future
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Passive Quantitative
FluoroscopyAcquisition Image Analysis Output
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Image analysis
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Vertebral rotation
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Inter-vertebral rotation
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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
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Results
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‘Abnormal motion patterns’
Maximum rotation p <0.05
Left L4/5 pts < controls Right L3/4 pts > controls
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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
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Mid range motion
In vivo
Neutral Zone
Left L4/5 patients < controls (p<0.05)
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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
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Variation is still a problem!
- How to account for the variation
- How to measure the co-dependency of segments
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Continuous proportional motion
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Proportional range variance
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…. The future of inter-vertebral
measurements
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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)
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Radiation dose
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Radiation dose
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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
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Implications for clinical practice
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Healthy Passive Vs Active
motion
Uncertainties:
Subtle differences detected by QF
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Healthy recumbent passive flexionIn
ter-
vert
ebra
l angle
(o)
Time (15 frames = 1 second)
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Healthy weight-bearing
flexion
Time (15 frames = 1 second)
Inte
r-vert
ebra
l angle
(o)
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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
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Weight-bearing acquisition
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Cervical spine acquisition
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Cervical spine rotation
in a patient with whiplash
Flexion
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Summary
Functional views could
be replaced with QF
Further sub-grouping
of non specific back
pain
Further analysis of
existing data
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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
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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.
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Radiography, In print.
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Panjabi, M. M., 1992. The stabilising system of the spine - Part 2: Neutral zone and instability hypothesis. Journal
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