Gonstead X-RAY Flashcards
Recite Gonstead quote on intern wall.
First, spend all the time necessary to carefully and precisely find and correct a patient’s problem. Do not be in a hurry. Check and re-check your x-ray, your palpation, instrumentation, and visualization. Second, remember that Chiropractic ALWAYS works. When it does not seem to, examine your application, but do not question the principle. Third, be prepared when demand for Chiropractic care increases. Study the spinal column and the nervous system every chance you get. Our future will be our results.
What are the 5 components of the Gonstead system?
1) Symptomatology
2) Visualization
3) Instrumentation
4) Palpation- motion and static
5) Spinography
What is the film size of full spine x-rays?
14” x 36”
What is the tube distance of the x-rays?
72” (FFD)
How should patient placement look for taking a full spine x-ray?
Should include ischia to occiput and the patient should have NO rotation
What are 4 reasons why we use full spine films?
1) Less radiation than sectionals
2) Provide accurate vertebral count
3) Provide full spinal contour representation for posture analysis with axial weight-bearing
4) Shows problems other than chief complaint
What are the 4 components of the Gonstead approach?
1) Patient Symptoms
2) Diagnostic References
3) Pinpoint and Establish
4) Decide Priority of Adjustment
What are the diagnostic references used in the Gonstead approach?
1) X-Rays
2) Motion and Static Palpation
3) Nervo-Scope
4) Lab Tests if indicated
5) Nerve Tracking Chart
How can you pinpoint and establish subluxations according to the Gonstead approach?
1) Nervous systems
2) Specific vertebrae involved
3) Areas of spinal cord pressure
4) Vertebral listings for nerve root pressure
List the 8 differences between a spinal adjustment and spinal manipulation.
See page 10 in notes.
What are the 20 indications to x-ray?
1) Pathology
2) Anomoly
3) Fracture
4) Dislocation
5) Malformation
6) Accurate Count
7) Segmental Relationship
8) Spinal Contour
9) Exact Relationship of Adjacent Segments
10) Specific Listings
11) Disc Condition
12) Disc Spatial Relationship to Level
13) Surrounding Tissues
14) Motion studies for Biomechanics of Disc Under Stress
15) Prosthesis
16) Posture Analysis
17) Progress Changes
18) Patient Education
19) Court Cases (Legally must have)
20) Because every spine is different!
What are the 2 contradictions to x-ray?
1) Pregnancy
2) Radiation Exposure
What is the allowable yearly dose for radiation workers?
5 rem
How much radiation does one get from full spine x-rays, A-P and Lateral?
2 mrem
What are the 14 reasons to take a full spine x-ray over a sectional x-ray?
1) 2 Films
2) 3 Exposures
3) Less radiation
4) Less film cost
5) Time
6) Full spinal contour
7) Exact relation of adjacent segments
8) Posture Analysis
9) Accurate Count of Segments
10) Good for patient who cannot stand for long periods
11) Much easier to read
12) Much easier to analyze
13) Less chance for mistakes
14) Better for patient education
What are the 3 considerations when the ilia are not equal on x-ray?
1) Pathological or congenital condition
2) Poor positioning on the x-ray
3) Misalignment of the pelvis
What does misalignment of the ilium cause?
A weight-bearing change which is compensated for by the sacrum and lumbar spine
What is the normal sacral angle?
40 degrees
Why does the lumbar curve change when the sacrum changes?
The sacrum is the base of the spine and the lumbars follow the movement of the sacrum
The ilium misaligns in relation to the sacrum at the ______________________.
Sacro-iliac Joint
What misalignments can occur at the SI joint?
1) AS
2) PI
3) IN
4) EX
What are the married listings?
ASIN and PIEX
Why do we call ASIN and PIEX married listings?
Because they have the same mechanical effects on the spine
When the ilium subluxates, what causes the ilium to stay in that direction?
Edema, the rest of the spine compensates
Will edema of the SI joint be in the same spot for each listing?
No, it will be in a different area of the joint for each listing
Is edema that occurs due to a ilium misalignment usually palpable?
Yes, in most cases but not all
What 3 structural changes are caused by a misaligned ilium? These can be seen in a postural assessment.
- Change in gluteals and folds
- Change in leg length while weight-bearing and prone
- Foot flare and heel wear
Why is it important to remember that the ilium misaligns in a gliding motion and not by pivoting?
This helps us keep in mind where the edema is located and what line of correction needs to be used to adjust the bone properly.
What does the obturator look like in a AS ilium?
Dimension is decreased vertically
What does the obturator look like in a PI ilium?
Dimension is increased vertically
What do we suspect when the dimension of the obturators are equal?
There is no AS or PI component to the listing.
What does the obturator look like in an IN ilium?
Dimension is decreased diagonally
What does the obturator look like in an EX ilium?
Dimension is increased diagonally
Do we determine the problem by our findings on the x-ray or the patient?
Patient
Which type of ilium appears shorter on x-ray?
AS
Which type of ilium decreases obturator height?
AS
Which type of ilium causes hypolordosis in the lumbar spine?
AS, IN
Which type of ilium causes a higher femur head height on x-ray?
AS, IN
Which type of ilium accumulates edema at the posterior inferior aspect of the joint?
AS
Explain what happens to the sacrum and lumbar spine when the ilium misaligns AS.
Because the edema/fluid is located in the posterior inferior aspect of the joint, the ilium and weight-bearing shift anteriorward. This causes the sacrum to compensate by standing up straighter which then causes the lumbars to compensate and causes hypolordosis
Is edema palpable in an AS ilium?
Yes, it is in the posterior inferior aspect of the joint.
What type of ilium causes the gluteal fold to be higher?
AS
What type of ilium looks taller on x-ray?
PI
What type of ilium increases obturator height?
PI
What type of ilium causes hyperlordosis of the lumbar spine?
PI, EX
What type of ilium causes the femur head to appear lower on x-ray?
PI, EX
What type of ilium accumulates edema at the posterior and superior aspect of the joint?
PI
Explain what happens to sacrum and the lumbar spine when the ilium misaligns PI.
Because the edema is in the posterior and superior aspect of the joint, the ilium and weight-bearing move posteriorward. This causes the sacrum to compensate by tilting forward. The lumbar spine then compensates by causing a hyperlordosis.
Is edema palpable in a PI ilium?
Yes, it is on the posterior and superior aspect of the joint.
What type of ilium causes a lower gluteal fold on the patient?
PI
What type of ilium appears wider on x-ray?
IN
What type of ilium decreases obturator measurement diagonally?
IN
What type of ilium accumulates edema on the anterior portion along the entire length of the joint?
IN
What type of ilium causes the foot to flare out?
IN
Is edema palpable in an IN ilium?
No, because it is on the anterior of the joint.
Which ilium causes a patients toes to flare outward?
IN
How will the heel of a shoe be worn in an IN ilium?
The outside of the heel will be worn out.
What type of ilium appears narrower on x-ray?
EX
What type of ilium increases the obturator measurement diagonally?
EX
What type of ilium causes edema to accumulate on the posterior portion along the entire length of the joint?
EX
What type of ilium causes the foot to flare in?
EX
What type of ilium causes the gluteal fold to be narrow and peaked?
EX
Is edema palpable in an EX ilium?
Yes, because it is along the posterior aspect of the joint.
How will the heel of a shoe be worn in an EX ilium?
The heel will be worn on the inside
What do we have to remember when we talk about foot flare?
It’s not definitive… there can be a problem at the knee or ankle joint so it’s very important to do a through analysis.
How do we measure the magnitude of an ilium misalignment?
We measure the differences in millimeters on the A-P x-ray and write subscripts
Which side of the sacrum becomes wider on x-ray?
The posteriorly rotated side
Name the 4 sacral misalignments.
- P-R
- P-L
- PI-R
- PI-L
How do you determine a base posterior sacrum?
By looking at the lateral x-ray. Compare the sacrum to L5. It will be posterior to L5
What does the disc look like on a base posterior sacrum?
The disc is wider at the posterior
What condition causes the sacrum to move posterior?
Spondylolisthesis of the L5
How much rotation of the sacrum needs to be present in order to list it?
Greater or equal to 7 mm
How much rotation of the sacrum is significant when there is no ilium misalignment?
4-6 mm
How must the bodies of L5-C2 be rotated when the sacrum has gone posterior?
They need to be rotated to the side of the posterior rotated sacrum
When do you adjust sacrum to ilium?
When the ilium listing is ASIN, PIIN, or ASEX
When do you adjust ilium to sacrum?
When the ilium listing is PIEX, PIIN, or ASEX
Name 3 coccyx listings.
- A
- A-R
- A-L
For every 5mm of ______ misalignment, the femur head will be 2mm higher.
AS, IN
For every 5mm of ______ misalignment, the femur head will be 2mm lower.
PI, EX
For every 5mm of ______ correction, the femur head will be raised 2mm.
PI, EX
For every 5mm of _______ correction, the femur head will be lowered 2mm.
AS, IN
When should a heel lift be added?
A heel lift should only be added if the leg imbalance is causing a subluxation.
How do you tell if a heel lift is necessary?
The way to tell this is if your correction on the vertebrae is not holding.
How many mm of deficiency is the body able to adapt to?
less than 6mm… more than 6mm causes subluxations
When should a heel lift NOT be used?
- If there is a scoliosis to the side of the high femur head
- If the body rotation of the lumbar vertebrae is to the side of the high femur head
- Should not be used until any existing SI subluxations are corrected
What term is used to describe the difference in height of the two femur heads as they appear on the A-P film?
Measured Deficiency
What term is used to describe the actual difference in length of the patients leg?
Actual or Anatomical Deficiency
Would you ever add a heel lift to make the legs appear even?
NO!
What are the 2 main functions of the spine?
Protection and support
How is flexibility of the spine accomplished?
Through the segmentation into 24 vertebral segments
How is stability of the spine accomplished?
Through the use of strong restraining ligaments
What is the most important ligament in the spine?
Intervertebral disc
What are the 4 sagittal curves of the spine?
- Cervical
- Thoracic
- Lumbar
- Sacrococcygeal
Why so we have 4 curves in the spine?
The curves exist so that our bodies or spines can resist compression (absorb shock)
How much stronger is a spine with curves than a spine with no curves?
A spine with curves is 16x stronger
What two structures make up the intervertebral disc?
- Nucleus pulposus
2. Annulus fibrosis
How much water does the nucleus pulposus hold at birth?
88%
What is the most hydrophilic tissue in the human body?
The nucleus pulposus
When does vascular supply to the disc diminish?
The 2nd decade of life
At about what time is the vascular supply to the disc completely gone?
The 3rd decade of life
What kind of joint does the nucleus act as with a vertebra on top?
A pivot ball-bearing joint
What is the main function of the nucleus?
Holds the vertebrae apart by resisting compressive loads and allows normal ROM when situated properly
What is the main function of the annulus?
Keeps the vertebrae together, limiting extreme ROM and keeping the nucleus intact
Where does subluxation occur in the vertebra?
At the disc
Explain the origination of subluxation.
- Trauma misaligns the vertebra, shifting it into a sustained position.
- The shifting vertebral body compresses the disc and exerts pressure on the nucleus. Since the nucleus has a high water content, and is non-compressible, it is forced against the annulus.
- The annular fibers are stretched beyond their elastic limit by the bulging nucleus, resulting in damaged or deranged fibers
- Tissue damage induces an inflammatory reaction. Intracellular edematous fluid infuses the disc, causing it to expand and protrude.
- Protrusion of the disc produces compression upon neural structures within the neural canal, or in the intervertebral foramen
- The nerve pressure thereby produces results in nerve dysfunction.
What two portions is the vertebra divided into?
Anterior (vertebral body) and posterior (lamina, spinous, tvp, and articular pillars)
What is the anterior portion of the vertebra responsible for?
It is the supporting structure
What is the posterior portion of the vertebra responsible for?
Directs motion of the vertebrae
Where does subluxation take place on the vertebra?
The anterior motion unit- at the disc
What component plays a major role in the impingement of the spinal nerve?
Swelling of the disc
What component plays a minor role in the impingement of the spinal nerve?
The narrowing of the IVF
What is the nucleus pulposus made up of?
Semi-fluid gel consistency
What is the weight-bearing part of the disc?
The nucleus pulposus
What part of the disc is the fulcrum?
The nucleus pulposus
When is the optimal relationship between two vertebra found?
When the perimeters of the bodies are in line and the vertical distance between opposing surfaces of the bodies are the same at all points (parallel disc)
What is the purpose of the four curvatures of the spine?
Increase its resistance to axial compression forces
What three components must be present to have a TRUE subluxation?
- Fixation
- Edema
- Nerve impingement
What is the status of the nerve in an acute subluxation?
The impingement causes the nerve to fire more often than normal, causing an increase in metabolism
What is the status of the nerve in a chronic subluxation?
With time the nerve is able to adapt to this extra stimulus and raise the threshold to cause an action potential, now the nerve fires less than normal, causing a decrease in metabolism.
Where does the nucleus tend to protrude?
Posterolateral due to poor blood supply in the area and location of surrounding ligaments
Each subluxation results in __________.
Compensation (For every action there is an equal and opposite reaction)
If there is a wedged disc above a level vertebra, is it most likely a subluxation or compensation?
A subluxation
If there is a wedged disc below a level vertebra, is it most likely a subluxation or compensation?
A compensation
What are the three classes of migration of the nucleus?
- Protrusion
- Herniation
- Prolapse
Explain protrusion of the nucleus.
The nucleus shifts
Annular ring bulges outward
Is the annulus still intact in protrusion of the nucleus?
Yes
Explain herniation of the nucleus.
Nucleus has broken through the annular ring
Is the annulus still intact in protrusion of the nucleus?
Yes
Explain prolapse of the nucleus.
Nucleus has broken through the annular ring and through the annular material. Part of the nucleus may actually break free into the spinal canal
What type of nucleus migration will we see most often?
Protrusion
Explain why the disc moves posterior and lateral when subluxated.
The matrix is not as dense posteriorly and anteriorly and the nucleus already sits slightly posterior. The ALL is broad and strong whereas the PLL is narrower and weaker. The vascular system of the structures in the posterior leave a gap which is in the postero-lateral direction. It is where the nerve root is situated.
Explain D1 disc degeneration.
Swollen disc; entire disc is thickened from acute injury
How long does is take for D1 disc degeneration to begin?
Up to 6 months
Explain D2 disc degeneration.
Disc thin at posterior; diminishes disc space at posterior with noticeably posterior and inferior misalignment. Beyond acute stage
How long does it take for D2 disc degeneration to begin?
2-5 years
Explain D3 disc degeneration.
Disc very thin at posterior; disc is extremely wedged at posterior. Chronic state
How long does it take for D3 disc degeneration to begin?
8-10 years
Explain D4 disc degeneration.
Total disc is thin; disc is 2/3 of original height. Minimal damage to vertebral body. Posterior and inferior wedging still seen with arthritis and exostosis present.
How long does it take for D4 disc degeneration to begin?
10-15 years
