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by Dr. Christopher Kent
Videofluoroscopy has a distinguished track record in clinical research
and practice. Its judicious use in chiropractic practice may be valuable
in detecting and characterizing spinal kinesiopathology associated with
the vertebral subluxation complex.
first known fluoroscopic image was produced by Roentgen in 1895.
Roentgen placed his hand between an x-ray source and a fluorescent
screen, and was astonished to see an image of the bones of his hand on
the screen. One year later fluoroscopic screens became available, and
the technique was employed for "real time" observation of human
videofluoroscopic system consists of an x-ray generator capable of
operating at low (1/4 to 5) milliamperage settings, an x-ray tube
assembly, an image intensifier tube, a television camera, a VCR, and a
monitor. The heart of the system is the image intensifier tube. This
tube permits imaging at very low radiation levels. It is used instead of
intensifying screens and film as an image receptor.
of videofluoroscopy in the evaluation of abnormalities of spinal motion
has been discussed in textbooks, medical journals, and chiropractic
publications. Observational and case cases have appeared in the
literature comparing the diagnostic yield of fluoroscopic studies vs.
plain films. In addition, studies have been published reporting
abnormalities detected by fluoroscopy which could not be assessed using
described cases where instability of the upper cervical spine was
appreciated on videofluoroscopic studies. It was observed that all cases
of upper cervical instability are not revealed by static
flexion-extension studies. The role of videofluoroscopy in assessing the
upper cervical spine in Down's syndrome patients competing in Special
Olympics events was discussed.
Wagner reviewed the use of radiographic methods for the analysis of
cervical sagittal motion. They reported that videofluoroscopic studies
may reveal kinematic irregularities not detectable by examining the
extremes of range of motion alone.
et al studied the reliability of certain methods of fluoroscopic
measurements, reporting that independent examiners could replicate the
Mameren et al used fluoroscopy to determine the variability of
instantaneous centers of rotation in the cervical spine. These
investigators concluded that their procedure "shows variability of such
low extent that it seems feasible to use it to diagnose abnormal
mobility or in assessing therapy in the neck region."
states, "Clearly, cineradiography is the best method for the study of
biomechanics and dynamics of motion in the cervical spine...The
determination of normal motion, sites of greatest and least motion,
contribution by joints, discs, ligaments, tendons, and muscles to motion
(and their limitations), and the biomechanics of normal motion of the
occiput-atlas-axis complex all have been studied very successfully
According to Ochs, "Cineradiography, using film or videotape, is shown
in a study of 34 painful or injured necks to be a valuable diagnostic
tool. It is useful in fracture management, diagnosis of instability and
demonstration of solid healing. A video tape system featuring instant
replay, clear image and low radiation exposure was found to be ideal for
Buonocare, Hartman, and Nelson examined the cervical spines of 107
patients using cineradiography, including 57 who sustained
flexion-extension injuries. They concluded, "The ability to demonstrate
localized abnormal motion in the cervical spine allows one to predict
soft-tissue injuries and the quality of spinal fusions, spinal
stability, and early subluxation of the cervical spine--conditions that
may not be identified on static roentgenograms nor at physical
studied abnormalities of the upper cervical spine using cineradiography,
and concluded, "Cineradiography has been used to detect instability not
ascertainable by routine roentgenograms obtained in flexion and
case study of abnormal atlanto-axial motion, Tasharski noted,
"Interpretation by means of standard static radiographs failed to
disclose the nature of the functional post-traumatic disorder.
Cinefluorographic visualization of the articulation in motion
demonstrated abnormal mobility."
and Mitts also concluded that fluoroscopic studies often revealed
abnormalities undetected on plain films. They stated, "There were,
however, a significant number of instances in which cineroentgenography
demonstrated abnormal motion not detected on conventional
Cineroentgenography is, therefore, a valuable adjunctive technique and
its continued utilization in the analysis of cervical spine motion is
applications for spinal fluoroscopy have been reported in the medical
literature. These include recording the effects of cervical spine
traction, evaluating cervical spine laminectomies, examining athletes
presenting with pain, to assist in surgical planning, evaluating atlanto-axial
rotatory fixation, examining the effects of cervical collars,
characterizing joint disorders in the cervical spine, studying
degenerative disease of the cervical spine, and determining the effects
of occipitalization and odontoid hypoplasia on spinal motion.[12-20]
addition to the studies cited, applications for fluoroscopy in
chiropractic have been reported in chiropractic trade publications,
indexed peer reviewed literature, and presented at chiropractic
Henderson and Dorman, and Howe used fluoroscopy to study cervical spine
kinetics.[21-24] Shippel and Robinson described a case where fluoroscopy
and magnetic resonance imaging were used to evaluate cervical spine
instability. Leung used fluoroscopy to evaluate the cervical spine
and concluded, "Cineradiography has been found to be the method of
examination that conveys most functional abnormalities. The diagnostic
value of cineradiography is substantiated...The effect of chiropractic
adjustment in removal of cervical fixations was proven with
Chiropractors Foreman and Croft in their textbook, "Whiplash Injuries,"
state, "This motion study of the spine may be quite useful in detecting
abnormal biomechanics secondary to ligamentous damage that may be
unappreciated with plain film radiography... Cineradiography or
fluorovideo radiography plays an important role in the diagnosis of
aberrant spinal biomechanics that may be secondary to chronic muscle
contracture, scar tissue formation, or ligamentous instability."
Robinson, Keating and Jacobs presented the results of an interexaminer
reliability study of cinefluoroscopic detection of fixation in the
mid-cervical spine. Two examiners reviewed 50 videotapes of fluoroscopic
examinations of the cervical spine. The examiners achieved 84% agreement
for the presence of fixation, 96% agreement for the absence of fixation,
and 93% total agreement. The Kappa value was .80 (p<.0001). Only the
C4/C5 level was examined. The authors concluded, "The current data
indicate that VF determination of fixation in the cervical spine is a
chiropractic authors have described applications for fluoroscopy.
and Skippings used the procedure to study paradoxical motion of the
atlas in flexion. Betge described applications for fluoroscopy in
the diagnosis of dysfunctions of the cervical spine. Masters, and
Mertz both used fluoroscopy to evaluate spinal motion.[31,32] Robinson,
and Sweat have also published articles concerning chiropractic
applications for fluoroscopy.[33,34]
addition to diagnostic studies, fluoroscopy has been used to study
normal motion in the spine.
and Jochumsen used cineradiography to evaluate intermediate stages and
extremes of intervertebral motion in the lumbar spine. Fielding, and
Howe described normal motion of the cervical spine based on
technologies in chiropractic enjoy the literature support of
videofluoroscopy. Unfortunately, it is currently under-utilized. Doctors
of chiropractic should consider exploring the potential of this
technology in the assessment of subluxation induced pathomechanics.
Glasser O: "Dr. W.C. Roentgen." Springfield, IL, Charles C. Thomas,
AM: "Video fluoroscopy as a method of detecting occipitoatlantal
instability in Down's syndrome for Special Olympics."
Chiropractic Sports Medicine
J, Wagner N: "A review of methods for radiographic analysis of cervical
sagittal motion." Chiropractic
Technique 4(3):83, 1992.
Wallace H, Wagnon R, Pierce W: "Inter-examiner reliability using
videofluoroscope to measure cervical spine kinematics: a sagittal plane
(lateral view)." Proceedings of the International Conference on Spinal
Manipulation May 1992, pages 7-8.
Mameren H, Sanches H, Beursgens J, Drukker J: "Cervical spine motion in
the sagittal plane II." Spine
JH: "Disorders of the Cervical Spine." Philadelphia, PA, W.B. Saunders
Co. 1987. P. 144.
CW: "Radiographic examination of the cervical spine in motion."
US Navy Med 64:21, 1974.
Buonocare E, Hartman JT, Nelson CL: "Cineradiograms of cervical spine in
diagnosis of soft-tissue injuries."
JAMA 198(1):143, 1966.
MD: "Cineradiographic studies of abnormalities of high cervical spine."
AMA Arch Surg 94:206, 1967.
Tasharski CC: "Dynamic atlanto-axial aberration: a case study and
cinefluorographic approach to diagnosis."
JMPT 4(2):65, 1981.
Woesner ME, Mitts MG: "The evaluation of cervical spine motion below
C-2: a comparison of cineroentgenographic methods."
Am J Roent Rad Ther & Nuc Med
G, Jones MD: "Cineradiographic recording of traction of the cervical
spine." Arch Phys Med 45:403, 1964.
G, Jones MD: "Cineradiographic analysis of laminectomy in cervical
spine." AMA Arch Surg 97:672, 1968.
Becker E Griffiths HJ: "Radiologic diagnosis of pain in the athlete."
Clin in Sports Med 6(4):699, 1987.
Brunton FJ, Wilkerson JA, Wise KS, Simonis RB: "Cine radiography in
cervical spondylosis as a means of determining the level for anterior
fusion." J Bone and Joint Surg
Fielding JW, Hawkins RJ: "Atlanto-axial rotatory fixation."
J Bone and Joint Surg
Jones MD: "Cineradiographic studies of collar immobilized cervical
spine." J Neurosurg
Jones MD: "Cineradiographic studies of various joint diseases in the
cervical spine." Arthritis &
Rheumatism 4:422, 1961.
Jones MD: "Cineradiographic studies of degenerative disease of the
cervical spine." J Canad Assoc
Radiol 12:52, 1961.
Jones MD, Stone BS, Bard G: "Occipitalization of atlas with hypoplastic
odontoid process, a cineroentgenographic study." Calif Med 104:309,
Gillet H: "A cineradiographic study of the kinetic relationship between
the cervical vertebrae." Bull Eur Chiro Union 28(3):44, 1980.
Henderson DJ, Dormon TM: "Functional roentgenometric evaluation spine in
the saggital plane." JMPT
Henderson DJ: "Kinetic roentgenographic analysis of the cervical spine
in the saggital plane: a preliminary study."
Int Review of Chiro 35:2,
JW: "Observations from cineroentgenological studies of the spinal
column." ACA J of Chiro
Shippel AH, Robinson GK: "Radiological and magnetic resonance imaging of
cervical spine instability: A case report."
JMPT 10(6):316, 1987.
Leung ST: "The value of cineradiographic motion studies in diagnosis of
dysfunctions of the cervical spine." Bull Eur Chiro Union 25(2):28,
Foreman SM, Croft AC: "Whiplash Injuries: The Cervical
Acceleration/Deceleration Syndrome." Baltimore, MD, Williams and
Wilkins, 1988. P. 114, 133.
Antos J, Robinson GK, Keating JC, Jacobs GE: "Interexaminer reliability
of cinefluoroscopic detection of fixation in the mid-cervical spine."
Proceedings of the Scientific Symposium on Spinal Biomechanics,
International Chiropractors Association, 1989. P. 41.
Taylor M, Skippings R: "Paradoxical motion of atlas in flexion: a
fluoroscopic study of chiropractic patients."
Euro J Chiro 35:116, 1987.
Betge G: "The value of cineradiographic motion studies in the diagnosis
of dysfunction of the cervical spine."
J Clin Chiro 2(6):40, 1979.
Masters B: "A cineradiographic study of the kinetic relationship between
the cervical vertebrae." Bull Eur Chiro Union 28(1):11, 1980.
Mertz JA: "Videofluoroscopy of the cervical and lumbar spine."
ACA J of Chiro 18(8):74,
Robinson GK: "Interpretation of videofluoroscopic joint motion studies
in the cervical spine C-2 to C-7." The Verdict February 1988.
Sweat RW: "C-Arm Cinefluorography."
Today's Chiropractic 13(4):31, 1984.
Bronfort G, Jochumson OH: "The functional radiographic examination of
patients with low back pain." JMPT
Fielding JW: "Normal and selected abnormal motion of cervical spine from
second cervical vertebra based on cineroentgenography."
J Bone and Joint Surg
JW: "Cineradiographic evaluation of normal and abnormal cervical spinal
function." J of Clinical Chiro
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