Dynamic MRI - Effective Imaging and Implications for the DC

Canadian Chiropractor Magazine
http://www.canadianchiropractor.ca/index.php?option=com_content&task=view&id=1672&Itemid=136

Written by Richard Brownlee, MD, a neurosurgeon.
Dr. Brownlee has an active cranial and spinal practice in Kamloops, British Columbia, and is president of the new Welcome Back MRI and Pain Management Centre in Kamloops, British Columbia, which is the site of the only upright MRI unit in Canada. (www.welcomebackclinic.com).

Within the article

IMPROVED DIAGNOSIS WITH DYNAMIC MRI
MRIs performed with patients sitting with flexion and extension views have uncovered “hidden” abnormalities such as disc herniations, spinal stenosis and spondylolisthesis in patients who had a “normal” recumbent MRI. One study of 510 patients reported an 18 per cent incidence of spondylolisthesis of greater than three millimetres that were missed in neutral MRIs, but that were found on flexion and extension MRIs.

DYNAMIC MRI – IMPLICATIONS FOR CHIROPRACTIC
Spinal adjustments have been practised for thousands of years and are the basic foundation for chiropractic care. The idea of the “spinal subluxation complex” has been used by chiropractors, but can be difficult for physicians to envision or accept. Dynamic MRI could become integral to chiropractic practice, particularly with respect to enhancing diagnostic acumen, as well as in chiropractic education and research. Performing positional MRIs before and after spinal adjustments could identify the anatomic or pathological correlation between spinal dysfunction and pain. This
technology could also validate current treatment protocols and aid in the development of new chiropractic procedures.

Upright positional MRI of the lumbar spine

Published: Clinical Radiology (2008) 63, 1035-1048

F. Alyas (a,b), D. Connell (a,b), A. Saifuddin (a,b), * (a) London Upright MRI Centre, London, UK, and (b) Department of Radiology, The Royal National Orthopaedic Hospital NHS Trust, Stanmore, Middlesex, UK

Supine magnetic resonance imaging (MRI) is routinely used in the assessment of low back pain and radiculopathy. However, imaging findings often correlate poorly with clinical findings. This is partly related to the positional dependence of spinal stenosis, which reflects dynamic changes in soft-tissue structures (ligaments, disc, dural sac, epidural fat, and nerve roots). Upright MRI in the flexed, extended, rotated, standing, and bending positions, allows patients to reproduce the positions that bring about their symptoms and may uncover MRI findings that were not visible with routine supine imaging. Assessment of the degree of spinal stability in the degenerate and postoperative lumbar spine is also possible. The aim of this review was to present the current literature concerning both the normal and symptomatic spine as imaged using upright MRI and to illustrate the above findings using clinical examples.

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The Effects of the Degenerative Changes in the Functional Spinal Unit on the Kinematics of the Cervical Spine

Published: Spine. 33(6):E178-E182, March 15, 2008

Morishita, Yuichiro MD, PhD *; Hida, Shinichi MD, PhD +; Miyazaki, Masashi MD *; Hong, Soon-Woo MD, PhD *; Zou, Jun MD *; Wei, Feng MD, PhD *; Naito, Masatoshi MD, PhD +; Wang, Jeffrey C. MD *

From the *Department of Orthopaedic Surgery, University of California at Los Angeles, Los Angeles, CA; and †Department of Orthopaedic Surgery, Fukuoka University, Fukuoka, Japan. Acknowledgment date: September 10, 2007. Revision date: November 15, 2007. Acceptance date: November 19, 2007. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

http://www.spinejournal.com/pt/re/spine/abstract.00007632-200803150-
00023.htm;jsessionid=L8sR1ST4NNPc0PJLhW8NvRxDT5DlF1t5R3SfGvS4QDRCQphpBZxw!-
93356440!181195629!8091!-1

Key Points:

• A total of 289 consecutive symptomatic patients underwent dynamic cervical MRI in flexion, neutral, and extension postures.

Conclusion:
Our results suggest that cervical cord compression may cause deterioration of cervical cord function and kinematic changes in the cervical spine. We hypothesize that the spinal cord may potentially protect its functions from dynamic mechanical cord compression by restricting segmental motion, and these mechanisms may be closely related to the interveterbral discs.

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Missed Lumbar Disc Herniations Diagnosed With Kinetic Magnetic Resonance Imaging

Published: Spine. 33(5):E140-E144, March 1, 2008

Zou, Jun MD *; Yang, Huilin MD, PhD *; Miyazaki, Masashi MD +; Wei, Feng MD, PhD +; Hong, Soon W. MD +; Yoon, Seung H. MD +; Morishita, Yuichiro MD +; Wang, Jeffrey C. MD +

From the *Department of Orthopedic Surgery, The First AffiliatedHospital of Soochow University, Suzhou, China; and †Department of Orthopedic Surgery, UCLA, Los Angeles, CA. Acknowledgment date: August 30, 2007. Revision date: October 20, 2007. Acceptance date: November 1, 2007. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

http://www.spinejournal.com/pt/re/spine/abstract.00007632-200803010-
00026.htm;jsessionid=L8YKz749ZWDcvWPc9Xp451rnPqDLp7NM2PsyQs8h6sG5MKQLWgPQ!-1539859368!181195628!8091!-1

Methods:
Five Hundred fifty-three patients underwent kMRI with assessment of the degree of disc bulge iin neutral and flexion and extension.

Discussion and Key Points

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Kinematic Analysis of the Relationship Between the Grade of Disc Degeneration and Motion Unit of the Cervical Spine

Published January 2008 SPINE Volume 33, Number 2, pp 187–193

Masashi Miyazaki, MD,* Soon Woo Hong, MD, PhD,* Seung Hwan Yoon, MD, PhD,*Jun Zou, MD,* Benjamin Tow, MD,* Ahmet Alanay, MD,† Jean-Jacques Abitbol, MD,‡ and Jeffrey C. Wang, MD*

From the *Department of Orthopaedic Surgery, University of California at Los Angeles, Los Angeles, CA; †Department of Orthopaedics and Traumatology, Faculty of Medicine, Hacettepe University, Sihhiye, Ankara 06100, Turkey; and ‡Department of Orthopaedics, University of California at San Diego, San Diego, CA. Acknowledgment date: May 8, 2007. Revision date: July 18, 2007. Acceptance date: July 19, 2007. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

www.spinejournal.com/pt/re/spine/abstract.00007632-200801150-00012.htm;jsessionid=L2npLdyHrdgysLRPCvJxtJbVQcxmpwRdv
KLdljlrYCLdp7JgdChv!1975103396!181195629!8091!-1

Methods:
164 patients with symptomatic neck pain were studied.

Discussion and Key Points

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Syndrome of occipitoatlantoaxial hypermobility, cranial settling, and Chiari malformation Type I in patients with hereditary disorders of connective tissue

Published December 2007 in the Journal of Neurology: Spine, Volume 7, Number 6

Thomas H. Milhorat, M.D., Paolo A. Bolognese, M.D., Misao Nishikawa, M.D., Nazli B. McDonnell, M.D., Ph.D., and Clair A. Francomano, M.D.

Department of Neurosurgery, The Chiari Institute, North Shore-Long Island Jewish Health System, Manhasset, New York; Medical Genetics, NIH National Institute on Aging; and Harvey Institute for Medical Genetics, Greater Baltimore Medical Center, Baltimore, Maryland

Abstract: http://thejns.org/doi/abs/10.3171/SPI-07/12/601

Full text (pdf) http://www.northshorelij.com/workfiles/chiari/J%20Neurosurg%20Spine%20article%20Dec%2007.pdf

The primary diagnostic tools utilized in the study were 2D reconstructed CT and upright X-ray radiography. The final stage of the study included examinations of patients in the FONAR UPRIGHT® MRI for comparison.

FIG. 6. Results of vertical MR imaging in a 27-year-old woman with HDCT/CM-I. Midsagittal image in supine position (left) showing normal basion–dens interval (7.7 mm), normal basion– atlas interval (3.5 mm), normal clivus–axis angle (141°), large retroodontoid pannus, and low-lying cerebellar tonsils. On assumption of the upright position (right), there is evidence of cranial settling (2.6 mm decrease of basion–dens interval), posterior gliding of occipital condyles (4.3 mm increase of basion–atlas interval), anterior flexion of the occipitoatlantal joint (8° decrease of clivus–axis angle), increased basilar impression, and cerebellar ptosis with downward displacement of cerebellar tonsils to C-1 (white arrow). Note the greatly increased impaction of the foramen magnum anteriorly and posteriorly. Line C, superior plane of the clivus; Line D, plane of the posterior surface of the dens. Asterisk indicates the retroodontoid pannus. )

Upright MRI of glenohumeral dysplasia following obstetric brachial plexus injury

Published 23 April 2007 in Magn Reson Imaging.

Nath RK, Paizi M, Melcher SE, Farina KL
Texas Nerve and Paralysis Institute, Houston, TX 77030, USA.

The purpose of this study was to evaluate the role of upright magnetic resonance imaging (MRI) shoulder scanning in the diagnosis of glenohumeral deformity following obstetric brachial plexus injury (OBPI). Eighty-nine children (ages 0.4 to 17.9 years) with OBPI who have medial rotation contracture and reduced passive and active lateral rotation of the shoulder were evaluated via upright MRI of the affected glenohumeral joint. Qualitative impressions of glenoid form were recorded, and quantitative measurements were made of glenoid version and posterior subluxation. Glenoid version of the affected shoulder averaged -16.8+/-11.0 degrees (range, -55 degrees to 1 degrees ), and percentage of the humeral head anterior to the glenoid fossa (PHHA) averaged 32.6+/-16.5% (range, -17.8% to 52.4%). The glenoid form was normal in 43 children, convex in 19 children and biconcave in 27 children. Standard MRI protocols were used to obtain bilateral images from 14 of these patients. Among the patients with bilateral MR images, glenoid version and PHHA were significantly different between the involved and uninvolved shoulders (P<.000). Glenoid version in the involved shoulder averaged -19.0+/-13.1 degrees (range, -52 degrees to -3 degrees ), and PHHA averaged 29.7+/-18.4% (range, -16.2% to 48.7%). In the uninvolved shoulder, the average glenoid version and PHHA were -5.2+/-3.7 degrees (range, -12 degrees to -1 degrees ) and 47.7+/-3.0% (range, 43% to 54%), respectively. The relative beneficial aspects of upright MRI include lack of need for sedation, low claustrophobic potential and, most important, natural, gravity-influenced position, enabling the surgeon to visualize the true preoperative picture of the shoulder. It is an effective tool for demonstrating glenohumeral abnormalities resulting from brachial plexus injury worthy of surgical exploration.

http://www.superconductorweek.com/pr/0507rmd/fonar2.htm

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The Response of the Nucleus Pulposus of the Lumbar Intervertebral Discs to Functionally Loaded Positions

Biomechanics

Spine. 32(14):1508-1512, June 15, 2007.

Alexander, Lyndsay A. BSc *; Hancock, Elizabeth MSc *; Agouris, Ioannis PhD *; Smith, Francis W. MD +; MacSween, Alasdair PhD *

Abstract:
Study Design. Asymptomatic volunteers underwent magnetic resonance imaging to investigate how different positions affect lumbar intervertebral discs.

Objective:
To quantify sagittal migration of the lumbar nucleus pulposus in 6 functional positions.

Summary of Background Data. Previous studies of the intervertebral disc response in the sagittal plane were limited to imaging of recumbent positions. Developments of upright magnetic resonance imaging permit investigation of functional weight-bearing positions.

Methods:
T2-weighted sagittal scans of the L1-L2 to L5-S1 discs were taken of 11 volunteers in standing, sitting (upright, flexed, and in extension), supine, and prone extension. Sagittal migration of the nucleus pulposus was measured (mm) as distance from anterior disc boundary to peak pixel intensity. Lumbar lordosis (Cobb angle) was measured in each position.

Results:
Fifteen comparisons between positions showed significant positional effects (14 at L4-L5, L5-S1, the most mobile segments). Prone extension and supine lying induced significantly less posterior migration than sitting. Flexed and upright sitting, significantly more than standing at L4-L5, as did flexed sitting compared with extended.

Conclusion:
These results support for the first time the validity of clinical assumptions about disc behavior in functional positions: sitting postures may increase risk of posterior derangement, and prone and supine may be therapeutic for symptoms caused by posterior disc displacement.

(C) 2007 Lippincott Williams & Wilkins, Inc.

http://www.spinejournal.com/pt/re/spine/abstract.00007632-200706150-00009.htm;jsessionid=
GLsJD2c2ys3MgCGyJYTVLS8ynBWJJmJMgLTQ6TC51G1t4RTSFW12!-9948752!181195628!8091!-1

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Upright weight-bearing cervical flexion/extension dynamic magnetic resonance imaging: Case report and review of the literature

European Journal of Radiology Extra 60 (2006) 121-124
John W. Gilbert, Greg R. Wheeler, Richard A. Lingreen, Robert K. Johnson, Steven J. Scheiner and Richard D. Gibbs

Abstract:
Conventional recumbent magnetic resonance imaging (MRI) of the cervical spine may underestimate disease because the imaging is performed in a non-dynamic, non-weight bearing position. The cervical myelogram may provide additional information but requires an invasive procedure and a post-myelogram computed tomography (CT) scan. We present a patient with cervical symptomatology imaged in an upright weight-bearing sitting position in the flexion, neutral, and extension positions. Measurements of the anterior to posterior midsagittal plane were obtained at several disc space levels. The T2 sagittal images are presented and compared. This case clearly shows a reduction in the anterior–posterior distance in the midsagittal plane progressively from flexion to neutral to extension with the extension position showing the greatest reduction in cervical central canal diameter. Images show a decrease in anterior and posterior subarachnoid space in the extension position. Upright weight bearing cervical flexion/extension dynamic magnetic resonance imaging provides an innovative noninvasive technique to see changes in midsagittal cervical spinal canal diameter and may provide for imaging of the dynamic nature of spinal cord compression.

last paragraph of article:
Our case report adds to the extensive literature in this area (Upright MRI). A patient with progressive neck pain with a previously negative MRI now has a diagnosis and is able to continue to function at a higher level at work using a conservative treatment regimen without any surgical intervention. The patient's diagnosis, prognosis, and therapeutic options may be enhanced with upright weight bearing dynamic flexion/extension cervical MRI.

For a reprint email librarian@uprightmripublications.com and ask for this article and include your postal address. This article has 4 pages and 6 MRI images.

Effects of X-Stop Device on Sagittal Lumbar Spine Kinematics in Spinal Stenosis

Journal of Spinal Disorders & Techniques. 19(5):328-333, July 2006.
Siddiqui, Manal FRCS *; Karadimas, Efthimios MD *; Nicol, Malcolm MRCS *; Smith, Francis W. FRCR +; Wardlaw, Douglas FRCS ChM *

Abstract:
The X-Stop device is designed to distract the posterior elements of the stenotic segment and place it in flexion to treat neurogenic claudication. Previous biomechanical studies on X Stop have been done in vitro on cadavers looking at disc pressures and segmental range of movements. The objective of this study is to understand the sagittal kinematics in vivo of the lumbar spine at the instrumented and adjacent levels. Twenty-six patients with lumbar spine stenosis underwent 1 or 2 level X-Stop procedure. All had pre- and postoperative positional magnetic resonance imaging (MRI) in standing, supine, and sitting in flexion and extension. Measurements of disc heights, endplate angles, segmental and lumbar range of movement were performed after placement of X Stop at the stenosed level in patients with lumbar spinal stenosis. No significant changes were seen in disc heights, segmental and total lumbar spine movements postoperatively. The X-Stop device does not affect the sagittal kinematics of the lumbar spine in vivo.

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Postural Changes of the Dural Sac in the Lumbar Spines of Asymptomatic Individuals Using Positional Stand-Up Magnetic Resonance Imaging

Spine. 32(4):E136-E140, February 15, 2007.
Hirasawa, Yoichiro MD *+; Bashir, Waseem A. FRCR +; Smith, Francis W. MD +; Magnusson, Marianne L. DrMedSc +; Pope, Malcolm H. PhD, DSc, DrMedSc +; Takahashi, Keisuke MD *

Subjects:
Thirtw-two male volunteers, with no symptoms of low back pain, were recruited for the study. The mean age was 32 years

Objectives:
To determine dimensional changes in the lumbar dural sac as a function of posture, and to establish changes between the supine, erect and seated positions.

Conclusions:
A significant posture-dependent difference of the dural sac cross-sectional area at the level of intervertebral disc in asymptomatic volunteers has been demonstrated. When the posture changed from supine to standing position, lumbar dural sac volume expanded by the increased pressure of cerebrospinal fluid, and the dural sac cross-sectional area increased. The smallest values were found in the supine position.
Abstract:
http://www.spinejournal.com/pt/re/spine/abstract.00007632-200702150-00020.htm;jsessionid= G7Qc8V0QxLgcQ2BsJpdpWL8cBtyvNGgn673K62JpBMbp2765C7yh!-1804036389!-949856145!8091!-1

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Sagittal plane moment arms of the female lumbar region rectus abdominis in an upright neutral torso posture

Michael J. Jorgensen a,*, William S. Marras b, Francis W. Smith c, Malcolm H. Pope d
a Department of Industrial and Manufacturing Engineering, Wichita State University, 120 Engineering Building, Wichita, KS 67260-0035, USA
b Biodynamics Laboratory, Ohio State University, Columbus, OH, USA
c Department of Radiology, Aberdeen Royal Infirmary, UK
d Department of Environmental and Occupational Medicine, University of Aberdeen,

Clinical Biomechanics 20 (2005) 242-246

Abstract:
Background. Prior imaging studies of torso muscle moment arms for use as inputs into biomechanical models have been derived from subjects lying supine. Recent research suggests moment arms of the rectus abdominis are larger when standing versus lying supine.

Methods:
Axial MRI images, through and parallel to the intervertebral discs were obtained from five females in a standing upright neutral posture. Digitizing software was utilized to quantify the distance in the sagittal plane between the centroids of the intervertebral disc and the rectus abdominis muscle, and converted to the transverse plane to allow comparisons with studies with subjects in a supine posture.

Findings:
The mean sagittal plane moment arms in the transverse plane were 9.7, 9.1, 8.5, 8.5 and 9.8 cm at the L1/L2, L2/L3, L3/L4, L4/L5 and L5/S1 intervertebral levels, respectively. Compared with a study on females of a similar age group, the moment arms from this study were larger at each level, increasing from 7.3% larger at L1/L2 to 43.7% larger at L5/S1.

Interpretation:
Accurate anatomical geometrical representation in biomechanical models is necessary for valid estimates of internal loading. Sagittal plane rectus abdominis moment arms were larger from the upright neutral torso posture in this study compared to studies with subjects lying supine. This suggests the torso internal moment generating capability would be represented differently in biomechanical models that use data from studies where subjects were upright, which is more reflective of the postures biomechanical
models are utilized for, than when using anatomical geometry derived from supine postures.

Conclusions:
The sagittal plane moment arms of the rectus abdominis were observed to be larger when subjects were in an upright neutral torso posture as compared to those found when subjects were lying supine, by as much as 43.7% at the lower lumbar level. These findings suggest that biomechanical models of the torso utilizing moment arms from imaging studies on supine subjects may under represent the rectus abdominis moment arms, which would result in prediction error of the true moment generating capability of the rectus abdominis muscle.

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Influence of X Stop on Neural Foramina and Spinal Canal Area in Spinal Stenosis

Spine. 31(25):2958-2962, December 1, 2006.
Siddiqui, Manal FRCS *; Karadimas, Efthimios MD *; Nicol, Malcolm MRCS *; Smith, Francis W. FRCR +; Wardlaw, Douglas FRCS ChM *

Abstract:
Study Design. Measurements of cross sections of exit foramen and spinal canal were performed before and after placement of X Stop in physiologic postures using positional MR scanner at the stenosed level in patients with lumbar spinal stenosis.

Objective:
To quantify the effect of the implant in vivo on the lumbar spine at the instrumented levels in various postures.

Summary of Background Data:
Dimensions of the spinal canal and neural foramen decrease from flexion to extension. Symptoms of spinal stenosis occur typically in standing or extension. The X Stop device is designed to distract the posterior elements of the stenotic segment and place it in flexion to treat neurogenic claudication. We think that the device will improve the dimension of the canal in standing and extension.

Methods:
Twenty-six patients with lumbar spine stenosis underwent a one- or two-level X Stop procedure. All had preoperative and postoperative positional MRI in standing, supine, and sitting flexion and extension. Measurements were carried out on the images acquired.

Results:
Significant increase in the dimensions of the neural foramen and canal area were demonstrated after surgery.

Conclusions:
The X Stop device improves the degree of central and foraminal stenosis in vivo.

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SMIT 18th International Conference, Pebble Beach, CA, USA, 11-14 May 2006

Jean Pierre J. Elsig, FMRI Zentrum & Denis L. Kaech, Kantonsspital Chur, Suisse

Background:
Imaging of the spine during axial loading and during kinetic maneuvers is now possible with a top-front open MRI unit. The first imaging studies obtained at the fmri center in Zurich confirms the positive statements made by the pioneers, as published by Jinkins.

Material & Methods:
Patients with a history of recurrent positional or motion-dependent pain and/or neurological dysfunction of the cervical and lumbar spine were investigated in the upright-seated or standing position, including flexion-extension and/or rotation imaging.

Results:
A position-dependent appearance or increase of posterior disc protrusions, a varying degree of central canal and foraminal stenosis, and of mobile spinal instability was demonstrated in cases with preceding less remarkable or even negative recumbent MRI examinations. Illustrative cases include, cervical and lumbar unilateral and bilateral spinal instability, lateral, rotational instability, dynamic spinal cervical and lumbar stenosis and position-dependent disc herniations.

Conclusion:
By visualizing position-related alterations in the bony structures and the underlying soft tissues in the upright weight-bearing position, fmri enables the physician to make more accurate decisions regarding treatment options and alternatives, as compared to recumbent MRI. In the near future it could become the imaging modality required before performing complex spinal surgery.

Keywords:
MRI, UprightMRI, Instability, FBSS

http://www.smit2006.com/downloads/abstracts.pdf

Biomechanical aspects of the cervical cord: effects of postural changes in healthy volunteers using positional magnetic resonance imaging.

J Spinal Disord Tech. 2006 Jul;19(5):348-52.

Kuwazawa Y, Bashir W, Pope MH, Takahashi K, Smith FW.
Department of Environmental and Occupational Medicine, Liberty Safe Work Research Centre, University of Aberdeen, Scotland, UK.

Study Design:
The area in cross-sectional view of the cervical cord (ACSCC) at each disc levels was measured in supine and erect positions using positional magnetic resonance imaging (pMRI).

Conclusions:
We found posture-dependent differences of ACSCC in the recumbent and erect series. These results may be valuable for identifying a dynamic factor in patients with cervical spondylotic myelopathy.

Abstract: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&
dopt=AbstractPlus&list_uids=16826007&query_hl=30&itool=pubmed_docsum

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The Length of the Cervical Cord: Effects of Postural Changes in Healthy Volunteers Using Positional Magnetic Resonance Imaging.

Spine. 31(17):E579-E583, August 1, 2006.

Kuwazawa, Yasuyuki MD *+; Pope, Malcolm H. PhD *; Bashir, Waseem MD ++; Takahashi, Keisuke MD +; Smith, Francis W. MD, FRCP, FRCR ++

Conclusions:
We found posture-dependent differences of the length of the cervical cord in the recumbent and erect series. These results may be important when assessing the dynamic factor in cervical spondylotic myelopathy.

Abstract:
http://www.spinejournal.com/pt/re/spine/abstract.00007632-200608010-00030.htm;
jsessionid=GkDhD0hcxvPBRthTv2X60kf6BJkglvHlJvNLX

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Textbook: The Failed Spine
by Marek Szpalski & Robert Gunzburg; Lippincott Williams & Wilkins, 2005.

Chapter 14: Imaging of the FailedSpine by J.W.M. Van Goethem et al.

Excerpt:
Despite the relative loose application of criteria for judging operative success, lumbosacral spinal surgery has been so often unsuccessful in the past (range: 10% to 40%) that failed back surgery is now labeled as a clinical syndrome: the failed back surgery syndrome (FBSS). FBSS is characterized by intractable pain and various degrees of functional incapacitations following spinal surgery. The major identifiable causes of FBSS include recurrent/residual disc herniation, arachnoiditis, radiculitis, spinal or spinal neural foraminal stenosis, and the failure to identify the structural sources(s) of pain correctly.

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Textbook: Spondylolysis, Spondylolisthesis and Degenerative Spondylolisthesis
by Robert Gunzburg & Marek Szpalski; Lippincott Williams & Wilkins, 2006.

Chapter 8: Dynamic MRI Using the Upright or Positional MRI Scanner
by F.W. Smith et al.

Results:
(58 patients in the total study.) Thirty-eight (65.5%) patients with posterior prolapsed disc showed an increase in the degree of prolapse when seated. In 30 (52% of the 38 , the amount of prolapse decreased on flexion and increased on extension. In 67% with lateral disc prolapse, the prolapse was more prominent when seated and decreased on flexion and increased on extension.

Discussion:
The ability to image the spine in different postures adds significantly to the diagnostic accuracy of the MRI examination. For more than 50% of the patients examined in our study, a better understanding of the condition of the spine was obtained, resulting in improved management.

http://www.fmri.ch/download/spondylolysis_spondylolisthesis_2005.pdf

Acquired degenerative changes of the intervertebral segments at and suprajacent to the lumbosacral junction. A radioanatomic analysis of the nondiscal structures of the spinal column and perispinal soft tissues

European Journal of Radiology 50 (2004) 134–158
J. Randy Jinkins, M.D.

THE POSITIONAL MRI CHANGES IN THE LUMBAR SPINE FOLLOWING INSERTION OF A NOVEL INTER-SPINOUS PROCESS DISTRACTION DEVICE
British Association of Spine Surgeons
Aberdeen, Scotland – 2–4 February, 2005

Manal Siddiqui; Malcolm Nicol; Efthimios Karadimas; Kay Mutch; Frank Smith; Malcolm Pope; and Douglas Wardlaw
Woodend Hospital, Aberdeen AB156XS, Scotland

Introduction:
Symptoms of neurogenic intermittent claudication in spinal stenosis are explained by the narrowing of the spinal canal in the extended (upright) position and widening in the sitting (flexed) position. The XStop inter-spinous process distraction device is a new product that is designed to hold the affected segments in a flexed posture. This prospective study looks at the changes in the lumbar spine in a variety of postures from pre- to post insertion.

Methods:
Using a positional magnetic resonance imaging (pMRI) scanner, patients were scanned before and six months after the insertion of the device. Images were taken in sitting flexed and extended, and standing positions. The change in the total range of movement of the lumbar spine and in the individual operated segments was measured along with changes in the surface areas of the exit foramen, the dural sac, and the disc height.

Results:
12 patients with 17 levels distracted have been scanned and measured. The cross sectional area of the dural sac at the level of the stenosis has increased from a mean of 77.8 mm2 to 93.4 mm2 in the standing position (p=0.006) and from 84.56mm2 to 107.35mm2 on extension (p=0.008). There were no statistically significant changes in the range of movement of the whole lumbar spine, or at levels adjacent to the device.

Discussion:
This study demonstrates that the X Stop device increases the cross sectional surface area of the spinal canal at the stenosed level, without causing extensive changes in the posture of the lumbar spine.

http://proceedings.jbjs.org.uk/cgi/content/abstract/88-B/SUPP_II/219

Please send correspondance to BASS at the Royal College of Surgeons, 35 - 43 Lincoln’s Inn Fields, London WC2A 3PE, UK.

SPINE Volume 30, Number 23, pp 2677-2682, 2005

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Positional MR Imaging of the Lumbar Spine: Does It Demonstrate Nerve Root Compromise Not Visible at Conventional MR Imaging?(1)
Dominik Weishaupt, MD, Marius R. Schmid, MD, Marco Zanetti, MD, Norbert Boos, MD, Ben Romanowski, RT, Ruedi O. Kissling, MD, Jiri Dvorak, MD and Juerg Hodler, MD

(1) From the Institute of Diagnostic Radiology, University Hospital, Zurich, Switzerland; the Departments of Radiology, Orthopedic Surgery and Rheumatology, Orthopedic University, Zurich, Switzerland; and the Spine Unit, Schulthess Hospital, Zurich, accepted August 25, 1999.

To evaluate whether positional magnetic resonance (MR) images of the lumbar spine demonstrate nerve root compromise not visible on MR images obtained with the patient in a supine position (conventional MR images).

Abstract:  http://radiology.rsnajnls.org/cgi/content/abstract/215/1/247
Full Text:  http://radiology.rsnajnls.org/cgi/content/full/215/1/247
PDF Text: http://radiology.rsnajnls.org/cgi/reprint/215/1/247

Dynamic Weight-bearing Cervical Magnetic Resonance Imaging: Technical Review and Preliminary Results.
Southern Medical Journal. 97(5):456-461, May 2004.
Vitaz, Todd W. MD; Shields, Christopher B. MD; Raque, George H. MD; Hushek, Stephen G. PHD; Moser, Robert RT(R); Hoerter, Neil RT(R); Moriarty, Thomas M. MD, PHD

Conventional magnetic resonance imaging (MRI) of complex cervical spine disorders may underestimate
the magnitude of structural disease because imaging is performed in a nondynamic non-weight-bearing
manner. Myelography provides additional information but requires an invasive procedure.

Abstract: http://www.smajournalonline.com/pt/re/smj/abstract.00007611-200405000-
00008.htm;jsessionid=DLNdyJBqxVi2hnFxF991HEbwMgbVWi1AGI23TINhsVssHf5XF
dir!586698740!-949856144!9001!-

Upright, Weight-Bearing, Dynamic-Kinetic MRI of The Spine: PMRI/KMRI

J.R. Jinkins MD.
J. Dworkin, PhD.

A chapter in the textbook SPINAL RESTABILIZATION PROCEDURES (PDF) (Edited by D.L. Kaech and J.R. Jinkins)
Publisher: Elsevier Science B.V. (2002)(Chapter 6:pp.73-82)

Changes in cross-sectional measurements of the spinal canal and intervertebral foramina as a function of body position: in vivo studies on an open-configuration MR system

American Journal of Roentgenology, Vol 172, 1095-1102
MR Schmid, G Stucki, S Duewell, S Wildermuth, B Romanowski and J Hodler
Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland.

The purpose of this study was to evaluate physiologic changes of the cross-sectional area of the spinal canal and neural foramina in young asymptomatic volunteers. In asymptomatic volunteers, MR imaging is able to show position-dependent changes in the cross-sectional areas of the spinal canal and the intervertebral foramina. The extended positions best reveal important findings.

Abstract: http://www.ajronline.org/cgi/content/abstract/172/4/1095

Functional MRI of the spine: different patterns of positions of the forward flexed lumbar spine in healthy subjects

European Spine Journal (2001) 10:437-442
A Konig, HE Vitzhum

The purpose of this study was to determine the relation between facet joint orientation and flexion patterns in the lower lumbar spine in a vertical open scanner.

Abstract: http://highwire.stanford.edu/cgi/gca?allch=&gca=pmid;11718199&