Incorporating weight-bearing MRI with biomechanical assessments can enhance patient confidence and compliance

Since the first x-ray images were obtained in 1895, doctors have used various radiographic measurements to evaluate skeletal and soft tissue structures. In the radiographic analysis of the spine and pelvis in particular, specific measurements have often determined the chiropractor’s choice of technique. Radiographic measurements have given doctors indications about the possible presence of tumors, fractures, or other mechanical or musculoskeletal problems; the instability of ligaments or joints due to injury; altered body mechanics and joint function due to changes in posture or skeletal alignment; disc or joint degeneration; and narrowing of the spinal column or other joint spaces.

In current clinical practice, chiropractors routinely use magnetic resonance imaging (MRI) scans as the gold standard for visualizing complex soft tissue and skeletal structures. Additionally, open MRI scanners also provide patients with a nonclaustrophobic alternative to the more confining tubes found in conventional closed MRI or computed tomography (CT) scanners, while maintaining and often improving the examination’s diagnostic accuracy.

By referring my patients to an open MRI facility in my community that provides both weight-bearing scans of the spine and biomechanical assessments that include radiographic measurements specific to the MRI scan written by a chiropractic radiologist, I have dramatically enhanced my practice’s diagnostic capability and treatment protocols and my patient’s confidence and compliance.

“The biomechanical assessment is designed to benefit the doctor and the patient,” says Timothy J. Greenan, MD, medical director of Open MRI of Yorktown, Yorktown Heights, NY. “The biomechanical assessment serves as an objective analysis of both structural and functional abnormalities, stressing standard chiropractic measurements. The measurements comply with the requirements set forth in the American Medical Association’s Guideline Measurement Standard. Utilizing the patient’s MRI films, we prepare a report for the referring chiropractor correlating biomechanical and structural information with the standard medical pathology report.”

“Additionally, sometimes the MRI report comes back negative for medical pathology; but when we do the biomechanical assessment, we may find definite biomechanical abnormalities or structural changes that are not necessarily pathological, but that are structurally important,” says Jonathan B. Davis, DC, a board-certified chiropractic radiologist with a diplomate in chiropractic rehabilitation who performs the biomechanical studies at Open MRI of Yorktown.

“Ninety-nine percent of low back pain problems are mechanical in nature, so when we do a biomechanical assessment that considers the relationship, integrity, and symmetry of bone structures relative to their associated soft-tissue structures, such as the postural muscles of the low back or the neck, we can better identify the true causes of the patient’s pain,” Davis says. “From that point of view, the biomechanical report is a great tool for both the doctors and their patients because it gives the doctor a more complete picture of the cause of the patient’s problem measured precisely in millimeters and degrees, and the doctor can use that information as a guide to devise the best treatment protocol for the patient. The biomechanical and structural assessments provide a union of the best information that medical radiology and the chiropractic profession have to offer.”

For my lumbar spine patients, I typically request a specialized weight-bearing assessment MRI scan using an apparatus that simulates the effects of gravity on the lumbar spine. “When subject to the stresses of standing or sitting, gravity causes a normal degree of compression to the discs of the spine, and that compression typically worsens the stress of a bulging or herniated disc by increasing the inflammatory response or the actual degree of nerve root compression or spinal cord pressure,” says Steven W. Winter, MD, chief of radiology and director of body imaging at Open MRI of Yorktown.

“During a standard MRI scan, because the patient is lying on their back, weight-bearing forces are reduced and the MRI scan might not show the true degree of disc compression that is actually present in the spine,” Winter says. “The weight-bearing technology compensates for this distortion, and provides radiologists with a more detailed image of exactly how the discs deform under the influence of gravitational stress. Often, a weight-bearing scan will show an increase in disc bulging by as much as several millimeters, or it can elicit a malalignment of the spine that was not present without weight-bearing. These findings are of clinical importance to the treating doctor.”

I use the additional information that the weight-bearing and biomechanical assessments offer to substantiate the need for my patients’ care—particularly when they suffer from chronic spinal conditions—to insurance companies. When follow-up studies are performed, the structural assessments also assist me in demonstrating objective improvements during or after a course of care. In a surprising number of cases, the weight-bearing MRI revealed a spondylolisthesis that conventional x-rays, MRI, or CT scans failed to detect.

When referring patients for an MRI scan, it is important to prescreen them for potential red flags. My pre-MRI screening questionnaire asks patients if they ever had a reaction to gadolinium contrast; use any medical implants or devices, such as a pacemaker/defibrillator, aneurysm clips, stents or artificial heart valves, penile implants, or internal birth control devices; have any type of transdermal patches; work with metal; have body piercings (other than earrings); have tattoos or “permanent makeup”; are pregnant or breast-feeding; and have a history of kidney disease, asthma, hypertension, sickle cell disease, or cancer. A “yes” to any of these questions warrants an additional investigation to determine if the patient is a candidate for an MRI scan. Pacemakers, aneurysm clips, and stents are almost always absolute contraindications to an MRI scan.

Reviewing the patients’ MRI films with them after they have their scans also expands my report of findings into a more comprehensive patient encounter. A surprising number of medical practitioners never even show their patients their films. Although this process may take a little more time than the average report of findings, the additional information enhances my patients’ confidence in my clinical decision-making, their subsequent compliance to my treatment recommendations, and my certainty in the care protocols I decide on after reviewing their films. CP

Gerald A. Anzalone, DC, of Hudson Valley Neck and Back Care, Peekskill, NY, has been in practice for 8 years. He is a writer and lecturer about health care issues and conducts CE classes. Anzalone can be reached via email: janzalonedc@hotmail.com.