Re: Can Alar Ligament Injury Be Dectected By MRI?

April 24, 2012

"High signal intensity (Grade 2-3) were found in...33% of the chronic neck pain group" That's good enough for me... Just because they found increased signal intensity in 40% of the control group does not mean Alar lig could not be causing pain in 60% of the rest of the population (i.e. just because disc bulges are routinely found in asymptomatic patients doesn't mean disc bulges are asymptomatic in all patients).

Because as we know... There are lies, damn lies and statistics--Mark Twain (:-)

M. s, D.C.

Can Alar Ligament Injury Be Dectected By MRI?

The excellent diagnostic skills of Dr. Wei notwithstanding, the imaging of ligament injuries in the upper cervical spine is controversial. The weight of the evidence indicates that injured tissue often cannot be distinguished from normal, thus calling into question the reasonableness and medical necessity of this procedure.The Bone and Joint Decade Task Force (Spine Volume 33, Number 4S, pp S101–S122) stated:The possible presence of demonstrable ligamentous injury to the upper cervical spine after whiplash exposure has been investigated with special sequence MRI. A phase I study (n = 30) showed that bright signals in the alar, transverse ligaments, and other structures have been observed more frequently in subjects with whiplash trauma exposure after 6 years (range, 2–9 years) than control subjects. However, the reliability of different observers in classifying the presence or degree of ligamentous injury, as shown by the MRI signal change, showed high variability. Validation of this finding as diagnosing bona fide, and clinically relevant ligamentous injury has not been demonstrated in these patients with WAD (grades I–III).They cited three articles by Krakenes, Kaale et al. Curiously, these researchers are about the only ones to purport validity for these imaging studies. The majority of studies indicate otherwise. Muhle et al (Rofo. 2002 Apr;174(4):416-22) discussed radiological aspects of the diagnosis of whiplash injuries. Although asymmetric dens position and widening of the atlantodental distance to > 12 mm are indirect signs of alar ligament rupture, best visualized on MRI, they state, "… changes of the alar ligaments on MRI must be differentiated from normal variants in healthy individuals."Bitterling et al (Rofo. 2007 Nov;179(11):1127-36), reviewed studies on biomechanics, anatomical and clinical MR imaging. They found that "biomechanical experiments can not induce according injuries of alar ligaments. Although MRI provides excellent visualization of alar ligaments, the range of normal variants is high." Furthermore, "… signal alterations of alar ligaments can hardly be differentiated from common normal variants," and "functional MRI provides no diagnostic yield." Myran et al (Spine. 2008 Aug 15;33(18):2012-6) performed a case-control study using MRI to assess signal intensity areas in the alar ligaments. 59 patients with persistent whiplash associated disorder Grade I-II after a car accident, 57 with chronic nontraumatic neck pain, and 57 without neck pain or previous neck trauma were compared. The alar ligaments were evaluated according to a 4-point grading scale. Alar ligament grades 0 to 3 were seen in all 3 diagnostic groups. Areas of high signal intensity (Grade 2-3) were found in at least one alar ligament in 49% of patients in the WAD Grade I-II group, in 33% of the chronic neck pain group, and in 40% of the controls. They concluded, "The previously reported assumption that these changes are due to a trauma itself is not supported by this study. The diagnostic value and the clinical relevance of magnetic resonance detectable areas of high intensity in the alar ligaments are questionable."Respectfully,J. Burke, D.C.

April 24, 2012

All, ... and whether it is found or not, for the right case, having that cya MRI might be one of the best calls you ever make. Sunny ;'-))Sunny Kierstyn, RN DC Fibromyalgia Care Center of Oregon 2677 Willakenzie Road, 7CEugene, Oregon, 97401541- 654-0850; Fx; 541- 654-0834www.drsunnykierstyn.com To: oregondcs From: drbobdc83@...Date: Tue, 24 Apr 2012 16:33:05 -0700Subject: Re: Can Alar Ligament Injury Be Dectected By MRI?

"High signal intensity (Grade 2-3) were found in...33% of the chronic neck pain group" That's good enough for me... Just because they found increased signal intensity in 40% of the control group does not mean Alar lig could not be causing pain in 60% of the rest of the population (i.e. just because disc bulges are routinely found in asymptomatic patients doesn't mean disc bulges are asymptomatic in all patients).

Because as we know... There are lies, damn lies and statistics--Mark Twain (:-)

M. s, D.C.

Can Alar Ligament Injury Be Dectected By MRI?

The excellent diagnostic skills of Dr. Wei notwithstanding, the imaging of ligament injuries in the upper cervical spine is controversial. The weight of the evidence indicates that injured tissue often cannot be distinguished from normal, thus calling into question the reasonableness and medical necessity of this procedure.The Bone and Joint Decade Task Force (Spine Volume 33, Number 4S, pp S101–S122) stated:The possible presence of demonstrable ligamentous injury to the upper cervical spine after whiplash exposure has been investigated with special sequence MRI. A phase I study (n = 30) showed that bright signals in the alar, transverse ligaments, and other structures have been observed more frequently in subjects with whiplash trauma exposure after 6 years (range, 2–9 years) than control subjects. However, the reliability of different observers in classifying the presence or degree of ligamentous injury, as shown by the MRI signal change, showed high variability. Validation of this finding as diagnosing bona fide, and clinically relevant ligamentous injury has not been demonstrated in these patients with WAD (grades I–III).They cited three articles by Krakenes, Kaale et al. Curiously, these researchers are about the only ones to purport validity for these imaging studies. The majority of studies indicate otherwise. Muhle et al (Rofo. 2002 Apr;174(4):416-22) discussed radiological aspects of the diagnosis of whiplash injuries. Although asymmetric dens position and widening of the atlantodental distance to > 12 mm are indirect signs of alar ligament rupture, best visualized on MRI, they state, "… changes of the alar ligaments on MRI must be differentiated from normal variants in healthy individuals."Bitterling et al (Rofo. 2007 Nov;179(11):1127-36), reviewed studies on biomechanics, anatomical and clinical MR imaging. They found that "biomechanical experiments can not induce according injuries of alar ligaments. Although MRI provides excellent visualization of alar ligaments, the range of normal variants is high." Furthermore, "… signal alterations of alar ligaments can hardly be differentiated from common normal variants," and "functional MRI provides no diagnostic yield." Myran et al (Spine. 2008 Aug 15;33(18):2012-6) performed a case-control study using MRI to assess signal intensity areas in the alar ligaments. 59 patients with persistent whiplash associated disorder Grade I-II after a car accident, 57 with chronic nontraumatic neck pain, and 57 without neck pain or previous neck trauma were compared. The alar ligaments were evaluated according to a 4-point grading scale. Alar ligament grades 0 to 3 were seen in all 3 diagnostic groups. Areas of high signal intensity (Grade 2-3) were found in at least one alar ligament in 49% of patients in the WAD Grade I-II group, in 33% of the chronic neck pain group, and in 40% of the controls. They concluded, "The previously reported assumption that these changes are due to a trauma itself is not supported by this study. The diagnostic value and the clinical relevance of magnetic resonance detectable areas of high intensity in the alar ligaments are questionable."Respectfully,J. Burke, D.C.

April 25, 2012

If chiropractors want to be seen as cost-effective providers, we need to move

away from this " cya " kind of thinking. Many diagnostic procedures, including

MRI, have guidelines or clinical decision rules to determine when the procedure

is necessary and when it is not. Adherence to these rules reduces overall costs,

but more importantly they keep patients from undergoing unnecessary procedures

that may lead to adverse consequences, either from the procedure itself (not so

risky in the case of MRI) or from additional unnecessary diagnostic and

treatment procedures when there are false positives. The haphazard ordering of

unnecessary procedures just to keep our butts from hanging out there neither

benefits patients nor enhances our image as authoritative players in the system.

In the case of potential upper cervical ligament injury, why are so many

chiropractors manipulating first and only sending patients for imaging later if

" cya " is a big concern?

J. Burke, D.C.

>

> All, ... and whether it is found or not, for the right case, having that cya

MRI might be one of the best calls you ever make. Sunny ;'-))

>

> Sunny Kierstyn, RN DC

> Fibromyalgia Care Center of Oregon

> 2677 Willakenzie Road, 7C

> Eugene, Oregon, 97401

> 541- 654-0850; Fx; 541- 654-0834

> www.drsunnykierstyn.com

> To: oregondcs

> From: drbobdc83@...

> Date: Tue, 24 Apr 2012 16:33:05 -0700

> Subject: Re: Can Alar Ligament Injury Be Dectected By MRI?

>

> " High signal intensity (Grade 2-3) were found in...33%

> of the chronic neck pain group " That's good enough for me...

> Just because they found increased signal intensity in 40% of the control group

> does not mean Alar lig could not be causing pain in 60% of the

> rest of the population (i.e. just because disc bulges are

> routinely found in asymptomatic patients doesn't

> mean disc bulges are asymptomatic in all patients).

>

> Because as we know... There are lies, damn lies and statistics--Mark

> Twain (:-)

>

> M. s, D.C.

>

> Can Alar

> Ligament Injury Be Dectected By MRI?

>

> The excellent diagnostic skills of Dr. Wei notwithstanding, the imaging of

> ligament injuries in the upper cervical spine is controversial. The weight

of

> the evidence indicates that injured tissue often cannot be distinguished

from

> normal, thus calling into question the reasonableness and medical necessity

of

> this procedure.

>

> The Bone and Joint Decade Task Force (Spine Volume 33,

> Number 4S, pp S101–S122) stated:

>

> The possible presence of demonstrable

> ligamentous injury to the upper cervical spine after whiplash exposure has

> been investigated with special sequence MRI. A phase I study (n = 30) showed

> that bright signals in the alar, transverse ligaments, and other structures

> have been observed more frequently in subjects with whiplash trauma exposure

> after 6 years (range, 2–9 years) than control subjects. However, the

> reliability of different observers in classifying the presence or degree of

> ligamentous injury, as shown by the MRI signal change, showed high

> variability. Validation of this finding as diagnosing bona fide, and

> clinically relevant ligamentous injury has not been demonstrated in these

> patients with WAD (grades I–III).

>

> They cited three articles by

> Krakenes, Kaale et al. Curiously, these researchers are about the only ones

to

> purport validity for these imaging studies. The majority of studies indicate

> otherwise.

>

> Muhle et al (Rofo. 2002 Apr;174(4):416-22) discussed

> radiological aspects of the diagnosis of whiplash injuries. Although

> asymmetric dens position and widening of the atlantodental distance to > 12

> mm are indirect signs of alar ligament rupture, best visualized on MRI, they

> state, " … changes of the alar ligaments on MRI must be differentiated from

> normal variants in healthy individuals. "

>

> Bitterling et al (Rofo. 2007

> Nov;179(11):1127-36), reviewed studies on biomechanics, anatomical and

> clinical MR imaging. They found that " biomechanical experiments can not

induce

> according injuries of alar ligaments. Although MRI provides excellent

> visualization of alar ligaments, the range of normal variants is high. "

> Furthermore, " … signal alterations of alar ligaments can hardly be

> differentiated from common normal variants, " and " functional MRI provides no

> diagnostic yield. "

> Myran et al (Spine. 2008 Aug 15;33(18):2012-6)

> performed a case-control study using MRI to assess signal intensity areas in

> the alar ligaments. 59 patients with persistent whiplash associated disorder

> Grade I-II after a car accident, 57 with chronic nontraumatic neck pain, and

> 57 without neck pain or previous neck trauma were compared. The alar

ligaments

> were evaluated according to a 4-point grading scale. Alar ligament grades 0

to

> 3 were seen in all 3 diagnostic groups. Areas of high signal intensity

(Grade

> 2-3) were found in at least one alar ligament in 49% of patients in the WAD

> Grade I-II group, in 33% of the chronic neck pain group, and in 40% of the

> controls. They concluded, " The previously reported assumption that these

> changes are due to a trauma itself is not supported by this study. The

> diagnostic value and the clinical relevance of magnetic resonance detectable

> areas of high intensity in the alar ligaments are

> questionable. "

>

> Respectfully,

>

> J. Burke, D.C.

>

April 25, 2012

MIchael. I send for this if a patient hasn't responded to U & C care, or if I do flexion/extension or lateral flexion motion xrays and see significant translation. It's not to just "cya". Most of these people have already been adjusted, and some of them have had previous work ups where the question of instability is not even asked. So......I guess there are times to do the tests, and maybe times to not do the tests. In my opinion and experience, the discretionary ordering of these tests IS appropriate. Knee jerk ordering of the test on every CAD isn't.

Don White, RN, DC

If chiropractors want to be seen as cost-effective providers, we need to move away from this "cya" kind of thinking. Many diagnostic procedures, including MRI, have guidelines or clinical decision rules to determine when the procedure is necessary and when it is not. Adherence to these rules reduces overall costs, but more importantly they keep patients from undergoing unnecessary procedures that may lead to adverse consequences, either from the procedure itself (not so risky in the case of MRI) or from additional unnecessary diagnostic and treatment procedures when there are false positives. The haphazard ordering of unnecessary procedures just to keep our butts from hanging out there neither benefits patients nor enhances our image as authoritative players in the system. In the case of potential upper cervical ligament injury, why are so many chiropractors manipulating first and only sending patients for imaging later if "cya" is a big concern?J. Burke, D.C. >> > All, ... and whether it is found or not, for the right case, having that cya MRI might be one of the best calls you ever make. Sunny ;'-))> > Sunny Kierstyn, RN DC > Fibromyalgia Care Center of Oregon > 2677 Willakenzie Road, 7C> Eugene, Oregon, 97401> 541- 654-0850; Fx; 541- 654-0834> www.drsunnykierstyn.com> To: oregondcs > Date: Tue, 24 Apr 2012 16:33:05 -0700> Subject: Re: Can Alar Ligament Injury Be Dectected By MRI?> > > > > > > > > > > > > > > > > > > > > > > > > > > > > > "High signal intensity (Grade 2-3) were found in...33% > of the chronic neck pain group" That's good enough for me... > Just because they found increased signal intensity in 40% of the control group > does not mean Alar lig could not be causing pain in 60% of the > rest of the population (i.e. just because disc bulges are > routinely found in asymptomatic patients doesn't > mean disc bulges are asymptomatic in all patients). > > > Because as we know... There are lies, damn lies and statistics--Mark > Twain (:-)> > M. s, D.C. > > > > Can Alar > Ligament Injury Be Dectected By MRI?> > > > The excellent diagnostic skills of Dr. Wei notwithstanding, the imaging of > ligament injuries in the upper cervical spine is controversial. The weight of > the evidence indicates that injured tissue often cannot be distinguished from > normal, thus calling into question the reasonableness and medical necessity of > this procedure.> > The Bone and Joint Decade Task Force (Spine Volume 33, > Number 4S, pp S101â€“S122) stated:> > The possible presence of demonstrable > ligamentous injury to the upper cervical spine after whiplash exposure has > been investigated with special sequence MRI. A phase I study (n = 30) showed > that bright signals in the alar, transverse ligaments, and other structures > have been observed more frequently in subjects with whiplash trauma exposure > after 6 years (range, 2â€“9 years) than control subjects. However, the > reliability of different observers in classifying the presence or degree of > ligamentous injury, as shown by the MRI signal change, showed high > variability. Validation of this finding as diagnosing bona fide, and > clinically relevant ligamentous injury has not been demonstrated in these > patients with WAD (grades Iâ€“III).> > They cited three articles by > Krakenes, Kaale et al. Curiously, these researchers are about the only ones to > purport validity for these imaging studies. The majority of studies indicate > otherwise. > > Muhle et al (Rofo. 2002 Apr;174(4):416-22) discussed > radiological aspects of the diagnosis of whiplash injuries. Although > asymmetric dens position and widening of the atlantodental distance to > 12 > mm are indirect signs of alar ligament rupture, best visualized on MRI, they > state, "â€¦ changes of the alar ligaments on MRI must be differentiated from > normal variants in healthy individuals."> > Bitterling et al (Rofo. 2007 > Nov;179(11):1127-36), reviewed studies on biomechanics, anatomical and > clinical MR imaging. They found that "biomechanical experiments can not induce > according injuries of alar ligaments. Although MRI provides excellent > visualization of alar ligaments, the range of normal variants is high." > Furthermore, "â€¦ signal alterations of alar ligaments can hardly be > differentiated from common normal variants," and "functional MRI provides no > diagnostic yield." > Myran et al (Spine. 2008 Aug 15;33(18):2012-6) > performed a case-control study using MRI to assess signal intensity areas in > the alar ligaments. 59 patients with persistent whiplash associated disorder > Grade I-II after a car accident, 57 with chronic nontraumatic neck pain, and > 57 without neck pain or previous neck trauma were compared. The alar ligaments > were evaluated according to a 4-point grading scale. Alar ligament grades 0 to > 3 were seen in all 3 diagnostic groups. Areas of high signal intensity (Grade > 2-3) were found in at least one alar ligament in 49% of patients in the WAD > Grade I-II group, in 33% of the chronic neck pain group, and in 40% of the > controls. They concluded, "The previously reported assumption that these > changes are due to a trauma itself is not supported by this study. The > diagnostic value and the clinical relevance of magnetic resonance detectable > areas of high intensity in the alar ligaments are > questionable."> > Respectfully,> > J. Burke, D.C.>

April 25, 2012

I agree, Don. It should not be a knee-jerk kind of thing. There are clinical

tests that can be performed. I'm not up on the validity and reliability of these

tests, but I will check into it and report back to the listserv if anyone's

interested.

One test is Sharp-Purser which has a positive likelihood ratio (OK, I looked it

up) of 17.25. That is outrageously good! Its specificity is .96, sensitivity is

..69. These figures are based on a study of 123 consecutive outpatients with RA.

Maybe there are other studies because one study isn't enough, and this was not a

population of trauma patients, so you can't just apply the results across the

board.

> >

> > All, ... and whether it is found or not, for the right case, having that

> cya MRI might be one of the best calls you ever make. Sunny ;'-))

> >

> > Sunny Kierstyn, RN DC

> > Fibromyalgia Care Center of Oregon

> > 2677 Willakenzie Road, 7C

> > Eugene, Oregon, 97401

> > 541- 654-0850; Fx; 541- 654-0834

> > www.drsunnykierstyn.com

> > To: _oregondcs _ (mailto:oregondcs )

> > From: drbobdc83@

> > Date: Tue, 24 Apr 2012 16:33:05 -0700

> > Subject: Re: Can Alar Ligament Injury Be Dectected By

> MRI?

> >

> > " High signal intensity (Grade 2-3) were found in...33%

> > of the chronic neck pain group " That's good enough for me...

> > Just because they found increased signal intensity in 40% of the control

> group

> > does not mean Alar lig could not be causing pain in 60% of the

> > rest of the population (i.e. just because disc bulges are

> > routinely found in asymptomatic patients doesn't

> > mean disc bulges are asymptomatic in all patients).

> >

> > Because as we know... There are lies, damn lies and statistics--Mark

> > Twain (:-)

> >

> > M. s, D.C.

> >

> > [From OregonDCs] Can Alar

> > Ligament Injury Be Dectected By MRI?

> >

> > The excellent diagnostic skills of Dr. Wei notwithstanding, the imaging

> of

> > ligament injuries in the upper cervical spine is controversial. The

> weight of

> > the evidence indicates that injured tissue often cannot be distinguished

> from

> > normal, thus calling into question the reasonableness and medical

> necessity of

> > this procedure.

> >

> > The Bone and Joint Decade Task Force (Spine Volume 33,

> > Number 4S, pp S101â€ " S122) stated:

> >

> > The possible presence of demonstrable

> > ligamentous injury to the upper cervical spine after whiplash exposure

> has

> > been investigated with special sequence MRI. A phase I study (n = 30)

> showed

> > that bright signals in the alar, transverse ligaments, and other

> structures

> > have been observed more frequently in subjects with whiplash trauma

> exposure

> > after 6 years (range, 2â€ " 9 years) than control subjects. However, the

> > reliability of different observers in classifying the presence or degree

> of

> > ligamentous injury, as shown by the MRI signal change, showed high

> > variability. Validation of this finding as diagnosing bona fide, and

> > clinically relevant ligamentous injury has not been demonstrated in

> these

> > patients with WAD (grades Iâ€ " III).

> >

> > They cited three articles by

> > Krakenes, Kaale et al. Curiously, these researchers are about the only

> ones to

> > purport validity for these imaging studies. The majority of studies

> indicate

> > otherwise.

> >

> > Muhle et al (Rofo. 2002 Apr;174(4):416-22) discussed

> > radiological aspects of the diagnosis of whiplash injuries. Although

> > asymmetric dens position and widening of the atlantodental distance to >

> 12

> > mm are indirect signs of alar ligament rupture, best visualized on MRI,

> they

> > state, " â€¦ changes of the alar ligaments on MRI must be differentiated

> from

> > normal variants in healthy individuals. "

> >

> > Bitterling et al (Rofo. 2007

> > Nov;179(11):1127-36), reviewed studies on biomechanics, anatomical and

> > clinical MR imaging. They found that " biomechanical experiments can not

> induce

> > according injuries of alar ligaments. Although MRI provides excellent

> > visualization of alar ligaments, the range of normal variants is high. "

> > Furthermore, " â€¦ signal alterations of alar ligaments can hardly be

> > differentiated from common normal variants, " and " functional MRI

> provides no

> > diagnostic yield. "

> > Myran et al (Spine. 2008 Aug 15;33(18):2012-6)

> > performed a case-control study using MRI to assess signal intensity

> areas in

> > the alar ligaments. 59 patients with persistent whiplash associated

> disorder

> > Grade I-II after a car accident, 57 with chronic nontraumatic neck pain,

> and

> > 57 without neck pain or previous neck trauma were compared. The alar

> ligaments

> > were evaluated according to a 4-point grading scale. Alar ligament

> grades 0 to

> > 3 were seen in all 3 diagnostic groups. Areas of high signal intensity

> (Grade

> > 2-3) were found in at least one alar ligament in 49% of patients in the

> WAD

> > Grade I-II group, in 33% of the chronic neck pain group, and in 40% of

> the

> > controls. They concluded, " The previously reported assumption that these

> > changes are due to a trauma itself is not supported by this study. The

> > diagnostic value and the clinical relevance of magnetic resonance

> detectable

> > areas of high intensity in the alar ligaments are

> > questionable. "

> >

> > Respectfully,

> >

> > J. Burke, D.C.

> >

>

April 25, 2012

Ditto for my clinic Dan . There is a place for the MRI in assessing possible tears or ruptures of Alar ligament. A high quality MRI read by a competent doc is invaluable in a trauma case.

Schneider DC

MIchael. I send for this if a patient hasn't responded to U & C care, or if I do flexion/extension or lateral flexion motion xrays and see significant translation. It's not to just " cya " . Most of these people have already been adjusted, and some of them have had previous work ups where the question of instability is not even asked. So......I guess there are times to do the tests, and maybe times to not do the tests. In my opinion and experience, the discretionary ordering of these tests IS appropriate. Knee jerk ordering of the test on every CAD isn't.

Don White, RN, DC

If chiropractors want to be seen as cost-effective providers, we need to move away from this " cya " kind of thinking. Many diagnostic procedures, including MRI, have guidelines or clinical decision rules to determine when the procedure is necessary and when it is not. Adherence to these rules reduces overall costs, but more importantly they keep patients from undergoing unnecessary procedures that may lead to adverse consequences, either from the procedure itself (not so risky in the case of MRI) or from additional unnecessary diagnostic and treatment procedures when there are false positives. The haphazard ordering of unnecessary procedures just to keep our butts from hanging out there neither benefits patients nor enhances our image as authoritative players in the system. In the case of potential upper cervical ligament injury, why are so many chiropractors manipulating first and only sending patients for imaging later if " cya " is a big concern?J. Burke, D.C. >> > All, ... and whether it is found or not, for the right case, having that cya MRI might be one of the best calls you ever make. Sunny ;'-))> > Sunny Kierstyn, RN DC > Fibromyalgia Care Center of Oregon > 2677 Willakenzie Road, 7C> Eugene, Oregon, 97401> 541- 654-0850; Fx; 541- 654-0834> www.drsunnykierstyn.com> To: oregondcs

> Date: Tue, 24 Apr 2012 16:33:05 -0700> Subject: Re: Can Alar Ligament Injury Be Dectected By MRI?> > > > > > > > > > > > > > > > > > > > > > > > > > > > > > " High signal intensity (Grade 2-3) were found in...33% > of the chronic neck pain group " That's good enough for me... > Just because they found increased signal intensity in 40% of the control group > does not mean Alar lig could not be causing pain in 60% of the > rest of the population (i.e. just because disc bulges are > routinely found in asymptomatic patients doesn't > mean disc bulges are asymptomatic in all patients). > > > Because as we know... There are lies, damn lies and statistics--Mark > Twain (:-)> > M. s, D.C. > > > > Can Alar > Ligament Injury Be Dectected By MRI?> > > > The excellent diagnostic skills of Dr. Wei notwithstanding, the imaging of > ligament injuries in the upper cervical spine is controversial. The weight of > the evidence indicates that injured tissue often cannot be distinguished from > normal, thus calling into question the reasonableness and medical necessity of > this procedure.> > The Bone and Joint Decade Task Force (Spine Volume 33, > Number 4S, pp S101–S122) stated:> > The possible presence of demonstrable > ligamentous injury to the upper cervical spine after whiplash exposure has > been investigated with special sequence MRI. A phase I study (n = 30) showed > that bright signals in the alar, transverse ligaments, and other structures > have been observed more frequently in subjects with whiplash trauma exposure > after 6 years (range, 2–9 years) than control subjects. However, the > reliability of different observers in classifying the presence or degree of > ligamentous injury, as shown by the MRI signal change, showed high > variability. Validation of this finding as diagnosing bona fide, and > clinically relevant ligamentous injury has not been demonstrated in these > patients with WAD (grades I–III).> > They cited three articles by > Krakenes, Kaale et al. Curiously, these researchers are about the only ones to > purport validity for these imaging studies. The majority of studies indicate > otherwise. > > Muhle et al (Rofo. 2002 Apr;174(4):416-22) discussed > radiological aspects of the diagnosis of whiplash injuries. Although > asymmetric dens position and widening of the atlantodental distance to > 12 > mm are indirect signs of alar ligament rupture, best visualized on MRI, they > state, " … changes of the alar ligaments on MRI must be differentiated from > normal variants in healthy individuals. " > > Bitterling et al (Rofo. 2007 > Nov;179(11):1127-36), reviewed studies on biomechanics, anatomical and > clinical MR imaging. They found that " biomechanical experiments can not induce > according injuries of alar ligaments. Although MRI provides excellent > visualization of alar ligaments, the range of normal variants is high. " > Furthermore, " … signal alterations of alar ligaments can hardly be > differentiated from common normal variants, " and " functional MRI provides no > diagnostic yield. " > Myran et al (Spine. 2008 Aug 15;33(18):2012-6) > performed a case-control study using MRI to assess signal intensity areas in > the alar ligaments. 59 patients with persistent whiplash associated disorder > Grade I-II after a car accident, 57 with chronic nontraumatic neck pain, and > 57 without neck pain or previous neck trauma were compared. The alar ligaments > were evaluated according to a 4-point grading scale. Alar ligament grades 0 to > 3 were seen in all 3 diagnostic groups. Areas of high signal intensity (Grade > 2-3) were found in at least one alar ligament in 49% of patients in the WAD > Grade I-II group, in 33% of the chronic neck pain group, and in 40% of the > controls. They concluded, " The previously reported assumption that these > changes are due to a trauma itself is not supported by this study. The > diagnostic value and the clinical relevance of magnetic resonance detectable > areas of high intensity in the alar ligaments are > questionable. " > > Respectfully,> > J. Burke, D.C.>

-- Schneider DC PDX

April 25, 2012

Well said ….history as in mechanisms of injury, symptoms and a few functional upper cervical tests and if indicated by these AP open-mouth odontoid lateral bending stress views……if there is a contralateral alar lig injury you will see the atlas slide off the axis …not rocket science….Vern SAboe From: oregondcs [mailto:oregondcs ] On Behalf Of mjqpdcSent: Wednesday, April 25, 2012 11:30 AMTo: oregondcs Subject: Re: Can Alar Ligament Injury Be Dectected By MRI? If chiropractors want to be seen as cost-effective providers, we need to move away from this " cya " kind of thinking. Many diagnostic procedures, including MRI, have guidelines or clinical decision rules to determine when the procedure is necessary and when it is not. Adherence to these rules reduces overall costs, but more importantly they keep patients from undergoing unnecessary procedures that may lead to adverse consequences, either from the procedure itself (not so risky in the case of MRI) or from additional unnecessary diagnostic and treatment procedures when there are false positives. The haphazard ordering of unnecessary procedures just to keep our butts from hanging out there neither benefits patients nor enhances our image as authoritative players in the system. In the case of potential upper cervical ligament injury, why are so many chiropractors manipulating first and only sending patients for imaging later if " cya " is a big concern?J. Burke, D.C. >> > All, ... and whether it is found or not, for the right case, having that cya MRI might be one of the best calls you ever make. Sunny ;'-))> > Sunny Kierstyn, RN DC > Fibromyalgia Care Center of Oregon > 2677 Willakenzie Road, 7C> Eugene, Oregon, 97401> 541- 654-0850; Fx; 541- 654-0834> www.drsunnykierstyn.com> To: oregondcs > Date: Tue, 24 Apr 2012 16:33:05 -0700> Subject: Re: Can Alar Ligament Injury Be Dectected By MRI?> > > > > > > > > > > > > > > > > > > > > > > > > > > > > > " High signal intensity (Grade 2-3) were found in...33% > of the chronic neck pain group " That's good enough for me... > Just because they found increased signal intensity in 40% of the control group > does not mean Alar lig could not be causing pain in 60% of the > rest of the population (i.e. just because disc bulges are > routinely found in asymptomatic patients doesn't > mean disc bulges are asymptomatic in all patients). > > > Because as we know... There are lies, damn lies and statistics--Mark > Twain (:-)> > M. s, D.C. > > > > Can Alar > Ligament Injury Be Dectected By MRI?> > > > The excellent diagnostic skills of Dr. Wei notwithstanding, the imaging of > ligament injuries in the upper cervical spine is controversial. The weight of > the evidence indicates that injured tissue often cannot be distinguished from > normal, thus calling into question the reasonableness and medical necessity of > this procedure.> > The Bone and Joint Decade Task Force (Spine Volume 33, > Number 4S, pp S101–S122) stated:> > The possible presence of demonstrable > ligamentous injury to the upper cervical spine after whiplash exposure has > been investigated with special sequence MRI. A phase I study (n = 30) showed > that bright signals in the alar, transverse ligaments, and other structures > have been observed more frequently in subjects with whiplash trauma exposure > after 6 years (range, 2–9 years) than control subjects. However, the > reliability of different observers in classifying the presence or degree of > ligamentous injury, as shown by the MRI signal change, showed high > variability. Validation of this finding as diagnosing bona fide, and > clinically relevant ligamentous injury has not been demonstrated in these > patients with WAD (grades I–III).> > They cited three articles by > Krakenes, Kaale et al. Curiously, these researchers are about the only ones to > purport validity for these imaging studies. The majority of studies indicate > otherwise. > > Muhle et al (Rofo. 2002 Apr;174(4):416-22) discussed > radiological aspects of the diagnosis of whiplash injuries. Although > asymmetric dens position and widening of the atlantodental distance to > 12 > mm are indirect signs of alar ligament rupture, best visualized on MRI, they > state, " … changes of the alar ligaments on MRI must be differentiated from > normal variants in healthy individuals. " > > Bitterling et al (Rofo. 2007 > Nov;179(11):1127-36), reviewed studies on biomechanics, anatomical and > clinical MR imaging. They found that " biomechanical experiments can not induce > according injuries of alar ligaments. Although MRI provides excellent > visualization of alar ligaments, the range of normal variants is high. " > Furthermore, " … signal alterations of alar ligaments can hardly be > differentiated from common normal variants, " and " functional MRI provides no > diagnostic yield. " > Myran et al (Spine. 2008 Aug 15;33(18):2012-6) > performed a case-control study using MRI to assess signal intensity areas in > the alar ligaments. 59 patients with persistent whiplash associated disorder > Grade I-II after a car accident, 57 with chronic nontraumatic neck pain, and > 57 without neck pain or previous neck trauma were compared. The alar ligaments > were evaluated according to a 4-point grading scale. Alar ligament grades 0 to > 3 were seen in all 3 diagnostic groups. Areas of high signal intensity (Grade > 2-3) were found in at least one alar ligament in 49% of patients in the WAD > Grade I-II group, in 33% of the chronic neck pain group, and in 40% of the > controls. They concluded, " The previously reported assumption that these > changes are due to a trauma itself is not supported by this study. The > diagnostic value and the clinical relevance of magnetic resonance detectable > areas of high intensity in the alar ligaments are > questionable. " > > Respectfully,> > J. Burke, D.C.>

April 25, 2012

All,

I've been following this discussion with interest and would ask that Tyrone Wei, Tim Sellers, or Burke might develop a power point presentation with CEU potential to educate us further on this subject covering Indications for ordering the exam, potential conflicts with diagnostic imaging reads, etc. From my perspective, if you have a patient with neck pain, dizziness with specific motion , intense sharp pain with the same motions, order a motion; stress plain film first. Look for the translation motion. If you see that, order a MRI of C-spine to check alar lig. If you have UE radiating symptoms you may also check for this. My personal professional preference with these symptoms, is to avoid HVLA in the cervical spine until there is confirmation of NO disc protrusions, herniations and/or alar lig tears before proceeding with high vel adjusting. I also use a risk consent form and highly recommend everyone do the same with HVLA. In my opinion, if the patient has concurrent symptoms combined with cervical anterior translation, edema and alar lig findings, you have a good case for the diagnostic read being very accurate. I will agree with Dr. Burke that some alar lig tears are less symptomatic. Perhaps due to patient health, no edema present, good muscular strength may substitute for ligament damage. Patient mental health and support systems, ability to rest and avoid manual labor, there are many factors that lower the cost recovery. However, I feel alar tears are significantly problematic in most of the patients I see with combined symptomatology.