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Cervical Spine Radiography in Alert and Stable Patients

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Cervical Spine Radiography in Alert and Stable Patients What is the purpose of this course! • Big changes in profession and in State of Wisconsin! Imaging in Clinical Practice • Provide clinical guidelines for need of imaging as part of the SCREENING PROCESS • If images are ORDERED, what are the routine Paul Reuteman PT, DPT, MHS, OCS series of images 2017 WPTA Spring Conference • If images are already taken, how do we educate April 20, 2017 patients on RELEVANT FINDINGS [email protected] Big Changes!!! State of Wisconsin Practice Act • Already an established model of use of imaging in practice • Definition of PT – Military, IHS 448.50(4)(b) – UK, Canada, Australia, Norway and others “Physical Therapy” does not include using • Development of DPT brought imaging into the classroom roentgen rays or radium for any purpose, using – 2015 - Development of “Imaging Education Manual for DPT electricity for surgical purposes, including Professional Degree Programs” Imaging SIG of the Ortho cauterization, or prescribing drugs or devices Section – Provides guidelines for DPT curriculum • 2016 - White Paper published by Ortho section, APTA on • This language prohibits PTs from actually “Diagnostic and Procedural Imaging in PT Practice” “taking” x-rays (flipping the switch) • 2016 - Changes in the State of Wisconsin Practice Act • What can we do? Notice any parallels to other legislation in PT Practice It’s Law! Recent advances in WI in 2016 Bill AB549 was passed • Allows for PTs who satisfy certain criteria to ORDER x-rays! • PT must satisfy one of following: – DPT – Completed a specialty certification program (OCS) – Completed a residency or fellowship program – PT completed formal x-ray ordering training program with MD involvement – Coordination is completed with primary MD or other health care coordinater Full Disclosure Tools for Clinical Decision Making • Not teaching “IMAGING”…why? • American College of Radiology Criteria • Instead, teaching the following: • Clinical Decision Rules – Clinical reasoning for the need of imaging • Diagnostic Imaging Pathways – Basic foundational images in routine series – Patient education regarding imaging • “Don’t you need an x-ray to know what’s wrong” These will be covered by body region • “Have you looked at my MRI?” and summarized for you!!! • “What is PT going to do for me when my knee is ‘bone This article is included in your readings posted on on bone’”? D2L Variables for Imaging Decision Making Red Flag Screening We Already Use In the ACR Appropriateness Criteria • Age • Trauma • Trauma presence/absence • Unexplained weight loss • Mechanism of injury • Age older than 50 years old (esp in • Prior surgery females/males with osteoporosis) • Risk factors • Hx of CA • Appearance • IV drug use • Pain provocation and physical functional tests • Prolonged use of corticosteroids • Weight bearing ability • Tenderness to palpation. • PROGRESSIVE neuro deficit These are already WELL ESTABLISHED in PT • UMN finding educational curricula and in clinical practice • Prior surgery Great Resources What are the different types of • Imaging Education Manual for DPT programs by imaging? Imaging SIG – https://www.orthopt.org/uploads/content_files/ISIG/IMAGI • Plain film radiography NG_EDUCATION_MANUAL_FINAL_4.15.15..pdf • Digital radiography • McKinnis L. Fundamentals of Musculoskeletal • Computed tomography (CT) Imaging, 4th Edition • Arthrogram • McKinnis L. Musculoskeletal Imaging Handbook: A • Ultrasound Guide for Primary Practitioners. • Bone scan • Malone T. Imaging in Rehabilitation. • MRI • JOSPT – Musculoskeletal Imaging Series and Clinical Practic Guidelines • OTHER HEALTH CARE COLLEAGUES What is a Radiograph? How it works • An x-ray film or digital image containing an • X-rays are form of radiant energy with shorter image of an anatomic part of a patient wavelength of visible light • Requires: • Materials absorb the x-ray at different rates – X-ray source depending on: – The patient – Atomic number (density of tissue) – An image receptor (film or digital technology) – Tissue thickness • Terminology • The greater x-rays absorbed, the whiter the – Radiograph or plain films (preferable term) structure (radiodensity) – X-ray – Less radiodense (aka: radiolucent): objects appear • Advantages?? darker – More radiodense (aka: Radiopaque) objects appear • Disadvantages?? lighter) 50 shades of Gray AP views of the Pelvis Radiodensity of structures Air/lungs Increasing Decreasing Fat/multiple layers of tissue Radiodensity Radiodensity Thin bone/Water/Muscle Decreasing Increasing Cancellous Bone/Tendon/Thick muscle Radiolucency Radiolucency Thick Cortical bone/Metal/Contrast Medium (Darker) (Whiter) Rationale for multiple views Plain Film Radiography • Most effective way of demonstrating a bone or joint abnormality • 1st order of diagnostic study • 2 dimensional view – All radiographs are 2 dimensional – To get 3 dimensional must have a view 90° to the other (Minimum of 2 views is the rule) Varying 2 dimensional views Most common projections • View same object from different angles • Most common projections – AP: Anterior-posterior – PA: Posterior-anterior – Lateral (R or L) – Oblique (R or L / Post or anterior) Reading a radiograph: Common views of the C-Spine BASIC “Search Patterns” • View the image as if you are the radiograph machine (image source) • ABCs – Alignment – Bone Density – Cartilage space – Soft tissue Digital Imaging: Variations of radiographs Image Quality Factors • Stress views: Stress the joint to determine if • Radiographic density: Can be regulated by the structure changes machine or by the digital image viewer • Fluoroscopy: Radiograph in real time. Able to • Radiographic contrast: High contrast increases move joints to see what is happening. Also anatomic detail used to perform epidural and other injections. • Detail (sharpness, definition, resolution): Increased amount of exposure to radiation. Sharpness of the structural lines • Distortion: difference in the size and shape of the actual image and the recorded image The Radiographic Examination • Each joint typically has a routine order of films • May either rule in OR rule out a specific diagnosis • Must first perform a THOROUGH history and examination – May have a “working diagnosis” that may be confirmed with plain films • More often than not, radiographs are not required and may be avoided when establishing a diagnosis TWO Critical Points “Advanced” Imaging • For the radiologist and MD to perform their • Advanced imaging interpretation requires job, they must be provided with sufficient foundations in: patient history, signs and symptoms and results – Imaging technology of other special tests • More complex physics • Technology is not infallible: False negatives – Dimensional anatomy and positives will occur. It is the clinicians • Sectional anatomy responsibility to recognize that if results of any • Orthogonal planes or relative to the anatomy imaging study do not fit, further evaluation and – A methodical search pattern diagnostic investigation is warranted • Develop a sequence to search images – Characteristics of pathology • Soft tissue is more complex than bone In Reality…. Magnetic Resonance Imaging • Body is imaged within a • Indications: powerful magnetic field – Imaging soft tissue. Advanced imaging interpretation cannot be with use of nonionizing Examples: learned as easily as radiographic interpretation radio waves • Muscle or ligament tears • NO radiation • Disc herniation HOWEVER…. • Meniscus or labral tears • MRI is based on the an achievable goal is to gain an understanding – Changes in bone marrow process by which nuclei (bone bruises, AVN, bone of what advanced imaging modality would aligned in a magnetic field tumors, etc) best define the pathologies you commonly see absorb and release energy – Staging neoplasm in bone • MRI is based on signals and/or soft tissue in your PT population • Does not give as high resolution of from hydrogen nuclei in cortical bone than CT does but still water molecules can be used to diagnose bony pathologies Disadvantages/Contraindications MRI of MRI • Weighted images • Disadvantages – High cost – T1: Anatomic detail is better – Claustrophobia of the patient • Fat and bone marrow have high signal intensity (bright) – Length of time to complete (do not get images right away) • Water has low signal intensity (dark) – Pt needs to sit still to get adequate image (difficult if they are in – T2: Detects swelling and water better pain) • Opposite as above – Cannot do with ferrous metal in the body • Water shows up bright – Findings do not always correlate to symptoms • Muscle is slightly darker • T2 → H2O • Contraindications – Muscle has moderate signal intensity on both – Magnetic field may lift heavy metal objects and displace them – Ortho hardware is not ferromagnetic BUT will distort image – Tendons and ligaments have low signal intensity on – Pacemakers may malfunction both (dark) – Cochlear implants https://mrimaster.com/characterise%20physics.html Viewing MR or CT Images CT Scan • Frontal (Coronal): Images are viewed from the front, as if facing the patient • Merges radiograph with • Indications • Sagittal: Images on either side of the body are computed imagery viewed from side to side – Images of the brain • Computer mathematically – Subtle or complex • Axial (transverse): Images are viewed from below, reconstructs the image fractures in a caudo-cephalad direction (similar to a CT) • Creates a series of axial – Degenerative changes (cross-sectional) slices – Intra-articular • Much more sensitive than abnormalities (loose radiographs
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