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Chiropractic Research / Video Fluoroscopy: Its Necessity and Use
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by Dr. Gregory R. Daniels, BA, DC
This outline is based upon the opinions of the author, his experience with video fluoroscopy and his needs and the requirements of his practice. It is not intended for publication. The sources and references quoted and utilized are readily obtainable from the available literature on the subject of video fluoroscopy.
Musculoskeletal imaging has been profoundly affected by the development of video fluoroscopy. This is a motion x-ray, which is performed while the patient goes through extension and flexion movements. Video fluoroscopy allows us to evaluate subtle variations of motion throughout the entire arc of motion dynamically. I believe this to be the most reliable source of evidence available of soft tissue injury and/or ligamentous damage.
Selected Related Studies:
In a review of 107 cases of cervical spine trauma, with 57 resulting from exceleration/deceleration injury, Buonocore et al. found that 39 cases or approximately 68 % of the whiplash injuries studied by the video fluoroscopy were interpreted as abnormal. The other 18 were interpreted as normal. In 18 of the 39 cases that were found to be abnormal, routine radiographs were interpreted as completely normal.
Woesner and Mitts compared plain radiography and video fluoroscopy in 40 cases and found that in 23 cases, no abnormalities that were not seen on plain films were detected by the video fluoroscopy. However, in 14 out of the 40 cases, videofluoroscopy did detect abnormal motion not appreciated on the plainfilms.
Regarding evaluation and subjective interpretation of the video fluoroscopy, Croft et al. conducted the largest study, which was blinded, controlled and randomized. This study showed that radiologists with a diverse training in video fluoroscopy showed a "moderate" to "good" concordance with each other.
Fielding, Jones, Howe and others, have all reported in their studies successful identification of ligamentous damage by the utilization of video fluoroscopy.
Guidelines for My Use of Video Fluoroscopy:
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A patient history compatible with events known to result in soft tissue/ligamentous instability such as trauma or disease.
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Spinal or joint pain which is persistent and unresponsive to conservative care and management.
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Evaluation of spinal fusion.
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In cases of trauma where initial studies reveal significant instability.
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In cases of clinical instability in which follow-up films are unremarkable.
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In cases which radiographic and clinical instability are present, and the patient remains refractory to treatment beyond 4 months.
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In specific cases, where soft tissue damage is documented by plain film, however validity is questioned by an adjuster, jury, judge, etc.
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In specific motion studies, to show the differences or asynunetrical movement of joints such as a right shoulder vs. left shoulder movement when one of the joints is "normal".
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For use in evaluating permanent impairment.
It has been my experience, in dealing with personal injury and workers compensation cases, that the patients who engage the services of an attorney, that attorney will request a copy of the video tape made of the video fluoroscopy. However, I have learned through experience that it is vitally important for the attorney to receive proper instruction and interpretation of the video. It has occurred in the past, where an attorney simply showed a tape of the video fluoroscopy to a judge and jury without representation of a qualified person, (either a trained radiologist, chiropractor or medical doctor), who could interpret the video for judge and jury. Needless to say, an appropriate picture of soft tissue damage was not represented to those concerned and the irrefutable evidence was not given the proper importance.
Properly presented and explained, as previously stated, a video fluoroscopy can provide irrefutable evidence of soft tissue/ligamentous damage.
It has been my experience that patients are very accepting of the procedures of the video fluoroscopy. The procedure does not involve the claustrophobic worries of a closed Magnetic Resource Imaging Scan or Computed Tomography. In addition, patients are not required to submit to painful stimuli. They are not required to be injected with anything, nor are they required to swallow medications or preparations of any sort. I have found that prior to undergoing video fluoroscopy, explanation of the need for the study and the viewing of a previously completed study are often enough to satisfy the patient's questions and concerns. Of course, it is of utmost importance that a proper report of findings be given to the patient once the report of the video fluoroscopy is received.
It has been my experience that video fluoroscopy has proven to be very beneficial in documenting the existence of soft tissue/ligamentous damage is a patient. It has been very helpful in the management of a patient's future care. I have utilized it to document soft tissue damage on a patient that was involved in a low speed, minor vehicle damage, motor vehicle accident. It has been helpful in documenting shoulder and knee damage on a patient's injured side as opposed to the uninjured side in a workers compensation case. It has supplied me with the necessary evidence of injury in a patient with a pre-existing Degenerative Joint Disease. On the opposite side of the coin, it has provided me with evidence of the lack of a soft tissue injury on a patient that presented with multiple subjective complaints who was very adept at manufacturing abnormal results of orthopedic tests.
It has been brought to my attention, that some clinicians use video fluoroscopy on the majority of their patients, regardless of the nature of these patients' complaints. Others use it exclusively for and in all cases of flexion/extension injury. I have discussed at seminars, the use of video fluoroscopy to record flexion and extension along with a four-view cervical series (AP open mouth, AP lateral cervical, and oblique). There does not appear to be any universally accepted protocol for use of video fluoroscopy at this time, although guidelines have been developed by the American College of Chiropractic Roentgenology.
It is my professional opinion that video fluoroscopy is extremely beneficial in the documentation and illustration of soft tissue/ligamentous damage. It provides an actual "movie" view of an area in motion. It should be left to the individual practitioner to evaluate and determine the need for video fluoroscopy in each individual patient, and in the case of a hearing or trial, adequate preparation and interpretation to judge and jury of utmost importance.
Lastly, I feel there is a great need for further research into the definitions and descriptions of "normal" and "abnormal" kinematics of the spine utilizing video fluoroscopy.
Dr. Gregory R. Daniels, BA,DC
Certified in Impairment Evaluation
Qualified in Second Opinion in the State of Wisconsin
Certified Disability Analyst - American Board of Disability Analysts
Member Chiropractic Clinical Advisory Committee
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