The United Kingdom Radiological Conference William Stripp Memorial Lecture 2014. The webcast can be viewed here: http://www.ukrc.org.uk/presentation-webcasts

1. William Stripp Memorial Lecture
Quantitative Fluoroscopy
Vs
Functional Radiography
of the lumbar spine
Fiona Mellor

4. http://www.aecc.ac.uk/research/imrci

5. 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

6. Diagnostic categories
of back pain (CSAG 1994)
1% Serious pathology
4% Nerve root compression
95% ‘Simple’ (Non-specific) backache
- Chemical
- Central sensitization
- Mechanical (Instability)

7. Why measure intervertebral
motion?
 Diagnosis
Treatment
 Disability
Research

8. Motion Subsystems
(Panjabi 1992)
Passive
Active
Motor
Control

9. In vitro analysis

10. The Neutral Zone Theory
Neutral
zone
Flexion
Extension
Range of
motion
Failure
Force
2Kg

11. Back……
Wellcome film library. London

12. …via the present
Intra and inter subject
variation
Intra and inter examiner
error
Positioning
Definition of normal

14. …. to the future

15. Passive Quantitative
Fluoroscopy
Acquisition Image Analysis Output

16. Image analysis

17. Vertebral rotation

18. Inter-vertebral rotation

19. Outline
Hypothesis: 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

20. Results

21. ‘Abnormal motion patterns’
Maximum rotation p <0.05
Left L4/5 pts < controls Right L3/4 pts > controls

22. Reference intervals
A definition of ‘abnormal ‘
is those whose rotation
falls beyond that
achieved by 95%of the
healthy population
Hyper-mobility: p<0.05 Right L3/4 and Flexion L4/5
Hypo-mobility; p<0.05 Left and Right

23. Mid range motion
In vivo
Neutral Zone
Left L4/5 patients < controls (p<0.05)

24. 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

25. Variation is still a problem!
- How to account for the variation
- How to measure the co-dependency of segments

26. Continuous proportional motion

27. Proportional range variance

28. …. The future of inter-vertebral
measurements

29. Results: Proportional range
variance
Variable 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)

30. Radiation dose

31. Radiation dose

32. 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

33. Implications for clinical practice

34. Uncertainties:
Healthy Passive Vs Active
motion
Subtle differences detected by QF

35. Healthy recumbent passive flexion
Inter-vertebral angle (o)
Time (15 frames = 1 second)

36. Healthy weight-bearing
flexion
Time (15 frames = 1 second)
Inter-vertebral angle (o)

37. 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

38. Weight-bearing acquisition

39. Cervical spine acquisition

40. Cervical spine rotation
in a patient with whiplash
Flexion

41. Summary
 Functional views could
be replaced with QF
 Further sub-grouping
of non specific back
pain
 Further analysis of
existing data

42. William Stripp Memorial Lecture
Fiona Mellor
E: imrci.fmellor@aecc.ac.uk
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

43. 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.
 Mellor, F. E. and Breen, A. C., 2014. Discrimination of biomechanical back pain patient subgroups from continous
inter-vertebral motion data: a protocol. Bone & Joint Journal Orthopaedic Proceedings Supplement, 96-B (SUPP
4), 5.
 Mellor, F. E., Muggleton, J. M., Bagust, J., Mason, W. M. A., Thomas, P. W. and Breen, A. C., 2009. Midlumbar
lateral flexion stability measured in healthy volunteers by in-vivo fluoroscopy. Spine, 34 (22), E811-E817.
 Mellor, F. E., Thomas, P. and Breen, A., . 2014a. Moving Back: the radiation dose received from lumbar spine
quantitative fluoroscopy compared to lumbar spine radiographs with suggestions for further dose reduction.
Radiography, In print.
 Mellor, F. E., Thomas, P., Thompson, P. and Breen, A., 2014b. Proportional lumbar spine inter-vertebral motion
patterns: a comparison of patients with chronic, non-specific low back pain and healthy controls European Spine
Journal, epub ahead of print (March).
 Panjabi, M., Abumi, K., Duranceau, J. and Oxland, T., 1989. Spinal Stability and Intersegmental Muscle Forces: A
Biomechanical Model. Spine, 14 (2), 194-200.
 Panjabi, M. M., 1992. The stabilising system of the spine - Part 2: Neutral zone and instability hypothesis. Journal
of Spinal Disorders, 5 (4), 390-397.