Editor's note: A 1982 graduate of LACC, Dr. Futoran is a Fellow of the Academy of Chiropractic Orthopedists and first vice president on the executive board of the American College of Chiropractic Orthopedists. He is a member of the Musculoskeletal Ultrasound Society, Society of Diagnostic Medical Sonographers, and the American Institute of Ultrasound Medicine, among others. He serves on the postgraduate faculty of the Univ. of Bridgeport College of Chiropractic, and is a California QME.
The Jan. 27, 1997 article in Dynamic Chiropractic on so-called "spinal imaging" with ultrasound is one of the reasons this technology has met resistance by chiropractic associations, medical associations and now insurance carriers for imaging superficial structures of the back.
The article in question, "Diagnostic Ultrasound: PLL and ALL Fibrosis" (hence referred to as the PLL article), claims that the posterior longitudinal ligament and anterior longitudinal ligament can be imaged with ultrasound, and that pathology could be identified.
Current chiropractic and medical literature does not support diagnostic ultrasound (DUS) imaging in its ability to accurately and reproducibly visualize the PLL, ALL, or other intraspinal canal anatomy. Of all the spine related DUS studies conducted since mid 1980s, none reference the PLL or ALL as normal or in a state of pathology.1,2,3,4,5,6,7,8
Extensive experience in the application of musculoskeletal imaging with ultrasound, teaching the subject and regularly performing Medline and other database searches in this technique, I have concern for this type of misinformation being distributed. I presented a lecture last September at the annual conference for the American College of Chiropractic Radiologist at their request titled, "Facts and Fallacies of Adult Spine imaging with Ultrasound." I have lectured on this subject at the Bowman Gray School of Medicine in Winston Salem and conferred there with Dr. Knappertz and Dr. Tegeler on spinal imaging and their study in this arena.7 The "Paraspinal ultrasonic and anatomical correlation" article by Dr. Knappertz and Tegeler as referenced in the PLL article does not profess to image either, PLL, ALL or other intra-canal contents.7,8
Several recent chiropractic papers referencing the PLL with DUS use the term "soft tissue inflammation" interchangeably with "soft tissue fibrosis" when describing DUS tissue characteristics. This has created confusion for many practitioners learning ultrasound imaging as "inflammation" relates to an acute tissue change while "fibrosis" is referred to in more chronic or healing stages of soft tissue injury. These terms are not interchangeable and do not appear the same on ultrasound.
Categories of fibrotic change to the PLL referenced from work by Stipkovich in the PLL article are theoretical and speculative, and are based on general anatomical regions. There is no current documentation or research to support these findings or any other with regards to imaging a normal PLL or one in a state of pathology.
The following are some of the numerous reasons diagnostic ultrasound imaging of the PLL and ALL should be considered, at minimum, premature and potentially improbable with current DUS technology:
In scanning the back, in order to obtain the density described as PLL fibrosis, the transducer must be significantly angled (as much as 30-40 degrees). This angling of the probe would cause the PLL to be dark, or not visualized at all rather than present as echogenic (white).14
Imaging of the extremities is an important medically accepted application of DUS with references too numerous to list. All areas of musculoskeletal imaging, including forms of spinal imaging with DUS, should continue to be studied and explored. Current literature and research have identified superficial paraspinal soft tissue anatomy with an abundance of clinically correlated information, though it has yet to be widely accepted. This area of DUS imaging continues to grow. As noted in previous articles, diagnosis of these regions are more a question of efficacy then ability of technology.15
I continue to be a strong advocate of DUS imaging for musculoskeletal structures throughout the body. But I am an opponent to its misguided and premature uses. I have reviewed scans and reports referred to me by insurance carriers not uncommonly to find many types of misuse and over interpretation. This is an important imaging modality for the musculoskeletal practitioner and their patients. I am dedicated to moving this technology forward in the private practice in an ethical and appropriate manner.
For those interested, I will be presenting a "Diagnostic Ultrasound of the Adult Spine: Facts & Fallacies" lecture at the conference for the American College of Chiropractic Orthopedists (ACCO) in New Orleans March 30, 1997. I will also give a paraspinal soft tissue lecture for the Neurosonology Research Group of the World Federation of Neurology during August of this year in Winston-Salem, North Carolina.
I welcome questions and information of the subject of musculoskeletal imaging with DUS.
References
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
