A presentation given at the South West UK radiographers study day in 2014. The overview was in vivo measurement of spinal biomechanics using quantitative fluoroscopy. The take home message is that flexion extension radiographs of the lumbar spine are unreliable due to measurement error and intra subject variability.

1. Quantitative Fluoroscopy
Vs
Functional Radiography
of the lumbar spine
Fiona Mellor
Research Radiographer
T: 01202 436280
E; imrci.fmellor@aecc.ac.uk

2. Learning outcomes
Why measure intervertebral motion?
 Sources of errors and variation in
flex/ext (functional) radiographs
A new adaptation of fluoroscopy
(quantitative fluoroscopy - QF)
Comparison of radiation dose
 Novel uses for QF/other studies

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

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

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

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

7. In vitro analysis

8. Back……
Wellcome film library. London

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

11. …. to the future

12. Passive Quantitative
Fluoroscopy
Acquisition Image Analysis Output

13. Image analysis

14. Vertebral rotation

15. Inter-vertebral rotation

16. PhD
Hypothesis: There is a higher
prevalence of abnormal mid lumbar
inter-vertebral motion patterns in patients
with mechanical LBP compared to
controls
 QF passive motion
 40 Patients (mechanical CNSLBP) & 40 healthy
volunteers
 Coronal and sagittal
 Global range 40o Each direction (Lt Rt, flx, ext)
Funded by the NIHR Clinical Academic Training Fellowship

17. Results

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

19. 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

20. 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

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

22. Continuous proportional motion

23. Proportional range variance

24. …. The future of inter-vertebral
measurements

25. Radiation dose

26. Radiation dose

27. Conclusions
 QF is more responsive than
functional radiography with a
similar radiation dose
 The coronal plane should be
considered
 ‘Non Specific’ back pain =
further subgrouping

28. Implications for clinical practice

29. QF research at AECC
i. Characteristics of kinematics in healthy
adults and their reproducibility over time
ii. Effect of muscle interaction in healthy
adults (surface electromyography)
iii. Effects of manipulation of the cervical
spine and patient reported outcomes
iv. Relationship between prosthetic fit and
intervertebral motion

30. Weight-bearing acquisition

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

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

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

34. Cervical spine acquisition

35. Cervical spine rotation
in a patient with whiplash
Flexion

36. Muscle activity:
weight bearing flexion (sEMG)

37. Prosthetic fit and
inter-vertebral motion

38. Summary
 Functional views of
cervical and lumbar
spine could be replaced
with QF
 Further sub-grouping of
non specific neck and
back pain
 Further analysis of
existing data and
economic analysis

39. 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

40. 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.

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