John A.M. Taylor

Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 3: Spinal Disorders

PURPOSE To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for spinal disorders. METHODS A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research were invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by practicing chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. RESULTS Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed. CONCLUSIONS The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Interpretation of abnormal lumbosacral spine radiographs. A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic.

Study Design Controlled comparison of radiographic interpretive performance based on training and experience. Objectives This study compared each of these groups in medicine and chiropractic by testing abilities to interpret abnormal plain film radiographs of the lumbosacral spine and pevis. Summary of Background Data Low back pain is a common and costly problem that is evaluated and treated primarily by medical physicions, orthopedists, and chiropractors. Although radiology is used extensively in patients with low back pain, the radiographic interpretations of students, clinicians, radiology residents, and radiologists have never been compared. Methods Four hundred ninety-six eligible volunteers from nine target groups completed a test of radiographic interpretation consisting of nineteen cases with clinically important radiographic findings. The nine groups included 22 medical students, 183 chiropractic students, 27 medical radiology residents, 13 chiropractic radiology residents, 66 medical clinicians (including 12 general practice physicians, 25 orthopedic surgeons, 21 orthopedic residents, and 8 rheumatologists), 46 chiropractic clinians, 48 general medical radiologists, 55 chiropractic radiologists, and 36 skeletal radiologists and fellows. Results The test established a high level of internal consistency reliability (0.880) and revealed that, in the interpretation of abnormal plain film radiographs of the lumbosacral spine and peivis, significant difference were found among professional groups(p<0.0001).Post hoc tests (P< 0.05) revealed that skeletal radiologists achived significantly higher test result than did all other medical groups; that the test results general medical radiologists and medical radiology residents was significantly higher than those of medical clinicians; that test results of medical students was significantly poorer than that of all other medical groups; that the performance of chiropractic radiologists and chiropractic radiology residents was significantly higher than that of chiropractic clinicians and chiropractic students; that no significant difference was revealed in the mean values of performance of chiropractic clinicians and chiropractic students; that the test results of chiropractic radiologists, chiropractic radiology residents, and chiropractic students was significantly higher than that of the corresponding medical categories (general medical radiologists, medical radiology residents, and medical students. respectively); that no significant difference in test results was identified between chiropractic radiologists and skeletal radiologists or between chiropractic and medical clinicians; and that the length of time in practice for clinicians and radiologists was not a significant factor in the test results. Conclusions These data demonstrate a substantial increase in test results of all radiologists and radiology residents when compared to students and clinicians in both medicine and chiropractic related to the interpretation of abnormal radiographs of the lumbosacral spine and pelvis. Furthermore, the study reinforces the need for radiologic specialists to reduce missed diagnoses, misdiagnoses, and medicolegal complications.

Diagnostic imaging guideline for musculoskeletal complaints in adults-an evidence-based approach-part 2: upper extremity disorders.

PURPOSE To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for upper extremity disorders. METHODS A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research was invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer-reviewed by practicing chiropractors and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. Dissemination and implementation strategies are discussed. RESULTS Recommendations for diagnostic imaging guidelines of adult upper extremity disorders are provided, supported by over 126 primary and secondary citations. The overall quality of available literature is low, however. On average, 44 Delphi panelists completed 1 of 2 rounds, reaching over 88% agreement on all 32 recommendations. Peer review by specialists reflected high levels of agreement and perceived ease of use of guidelines and implementation feasibility. CONCLUSIONS The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Intra-articular Osteoid Osteoma in the Femoral Neck of an 18-year-old Man: A Case Report

OBJECTIVE This case study presents the delayed diagnosis, surgical management, and postsurgical follow-up of an intra-articular osteoid osteoma of the left femoral neck in an 18-year-old male patient with special emphasis on discussing the confusing clinical and imaging characteristics of the lesion often associated with delayed diagnosis and increased morbidity. CLINICAL FEATURES The patient initially complained of left knee and hip pain at which time conventional radiographs were reported as normal. In magnetic resonance imaging studies, the diagnosis of intra-articular osteoid osteoma of the femoral neck was suggested; however, working diagnoses also included old posttraumatic injury, hip infection, juvenile chronic arthritis, and posttraumatic arthritis. The correct diagnosis was made 31 months after presentation based on computed tomography depiction of the lesion. INTERVENTION AND OUTCOME Pain associated with the tumor was alleviated after surgical removal with minimal loss of motion and muscle atrophy 19 months after tumor excision. CONCLUSION Clinicians and radiologists should be aware of the potentially confusing clinical and imaging findings associated with intra-articular osteoid osteoma of the hip. Early correlation between juvenile joint pain and imaging abnormalities as well as the use of thin slice computed tomography imaging could reduce the time to diagnose the lesion and prevent unnecessary morbidity.

Diagnostic imaging for spinal disorders in the elderly: a narrative review

The high prevalence of neck and low back pain in the rapidly aging population is associated with significant increases in health care expenditure. While spinal imaging can be useful to identify less common causes of neck and back pain, overuse and misuse of imaging services has been widely reported. This narrative review aims to provide primary care providers with an overview of available imaging studies with associated potential benefits, adverse effects, and costs for the evaluation of neck and back pain disorders in the elderly population. While the prevalence of arthritis and degenerative disc disease increase with age, fracture, infection, and tumor remain uncommon. Prevalence of other conditions such as spinal stenosis and abdominal aortic aneurysm (AAA) also increase with age and demand special considerations. Radiography of the lumbar spine is not recommended for the early management of non-specific low back pain in adults under the age of 65. Aside from conventional radiography for suspected fracture or arthritis, magnetic resonance imaging (MRI) and computed tomography (CT) offer better characterization of most musculoskeletal diseases. If available, MRI is usually preferred over CT because it involves less radiation exposure and has better soft-tissue visualization. Use of subspecialty radiologists to interpret diagnostic imaging studies is recommended.

Criteria to Screen for Traumatic Cervical Spine Instability: A Consensus of Chiropractic Radiologists

Objective: The purpose of this study was to establish consensus on a radiographic definition for cervical instability for routine use in chiropractic patients who sustain trauma to the cervical spine. Method: We conducted a modified Delphi study with a panel of chiropractic radiologists. Panelists were asked to rate potential screening criteria for traumatic cervical spine instability when assessing cervical spine radiographs. Items rated as important for inclusion by at least 60% of participants in round 1 were submitted for a second round of voting in round 2. Items rated for inclusion by at least 75% of the participants in round 2 were used to create the consensus‐based list of screening criteria. Participants were asked to vote and reach agreement on the final screening criteria list in round 3. Results: Twenty‐nine chiropractic radiologists participated in round 1. After 3 rounds of survey, 85% of participants approved the final consensus‐based list of criteria for traumatic cervical spine instability screening, including 6 clinical signs and symptoms and 5 radiographic criteria. Participants agreed that the presence of 1 or more of these clinical signs and symptoms and/or 1 or more of the 5 radiographic criteria on routine static radiographic studies suggests cervical instability. Conclusion: The consensus‐based radiographic definition of traumatic cervical spine instability includes 6 clinical signs and symptoms and 5 radiographic criteria that doctors of chiropractic should apply to their patients who sustain trauma to the cervical spine.

Calcium Pyrophosphate Dihydrate Crystal Deposition Disease Simulating Osteoarthrosis of the Knee: A Case Report.

OBJECTIVE The purpose of this case report is to describe a case where calcium pyrophosphate dehydrate crystal deposition disease (CPPD) simulated osteoarthritis of the knee. CLINICAL FEATURES A 78-year-old woman had a 2-week history of severe right knee pain accompanied by mild swelling. The onset was sudden and did not involve a history of trauma or previous injury to the right knee. Inspection and palpation revealed pain along the medial joint line and marked difficulty ambulating. Results of Lachmans test, anterior drawer test, and posterior sag sign were negative upon orthopedic assessment. Diagnostic imaging was performed and showed degenerative changes with diffuse calcification of the fibrocartilage and hyaline articular cartilage within the knee joint and the medial collateral ligament consistent with the appearance of CPPD crystal deposition. INTERVENTION AND OUTCOME Low-level laser therapy was performed to the affected medial joint line of the knee, and knee stabilization exercises were given. Lower Extremity Function Scale changed from 34% to 60% after 4 weeks of care. CONCLUSION Although knee osteoarthritis is much more common than knee CPPD, it is important to consider both diagnoses in elderly patients who present with unilateral knee pain. Diagnosis should be based on clinical presentation, history, and radiographic or histological means to ensure accuracy and proper diagnosis.