Using DMX to Diagnose Injuries
Digital Motion X-ray of the Spine
Recently, a Defense Medical Examination was performed on a patient on whom I had done a cervical spine digital motion x-ray study. The examiner, Zoran Maric, MD, went out of his way to trash my report, complete with his biased opinions and cherry picking from National Enquirer level articles he found on the Internet to support his suppositions. I could probably write an article about each one of them, but the one which really caught my eye was a Medical Policy position paper written by unknown authors for Anthem Blue Cross/Blue Shield about the use of “Dynamic Spinal Visualization (including Digital Motion X-Ray and Cineradiography/Videofluoroscopy,” dated 10/4/2016, which he used to establish his contention that any dynamic visualization technology was worthless.
The position of the authors was that “dynamic spinal visualization, including, but not limited to, digital motion x-ray of the spine, with or without digitization of spinal x-rays and computerized analysis of the back or spine, is considered investigational and not medically necessary for all indications (emphasis theirs).” Their rationale? They stated that the current literature on the subject was “limited to a few studies involving very small numbers of participants,” so “further evidence from large controlled trials is needed to demonstrate that the results have significant impact on clinical care and are superior to currently available alternatives.” They went on to state that, “the data is insufficient to support the use of digital motion x-rays, or cineradiography/videofluoroscopy of the spine for any indication (emphasis mine).” This is simply not true.
Fluoroscopy was invented by Thomas Edison in 1896, one year after the invention of the first x-ray machine, and by the mid-1920’s, researchers were trying to record fluoroscopic images of the spine on 16 mm film. As the years went by, more and more evidence was piled up, and I have 600+ pages of medical archival literature from the early days to prove it, along with close to two hundred more recent articles which I have collected over the past 5 years while I have been learning about dynamic imaging. And I don’t have everything. In fact, the Anthem BC/BS position paper cited six sources from the literature to support their rejection of the technology, and I was only familiar with one of them. But I was really surprised to see it there, as I was very familiar with it, and I knew it was very pro- motion x-ray. So, naturally, I requested the other five from the librarian at Cleveland Chiropractic College- Kansas City (my alma mater), and proceeded to read them to see if they supported the thesis of Anthem BC/BS. The short answer is…. they didn’t even come close to supporting it.
One of the basic tenets in writing research papers is for the authors to list any biases, any conflicts of interest, and any perceived weaknesses in the finished product, for the purpose of getting “out in front” of any criticisms from the rest of the professional community, so as to appear as objective as possible in reporting the facts discovered by the research project. If you will notice, this is done in every research paper routinely, and the same is true about the six research papers which I reviewed. Each of the papers has in common a statement concerning any shortcomings in the research design, as they should, and unfortunately, this is what the unknown authors (I picture these guys as sitting at a conference table with paper bags over their heads, with eye holes cut out) chose to highlight as the focus of the literature. No direct footnoting is done, but the implication of listing the articles is that they somehow support the supposition of the Medical Policy paper, which is that digital motion x-ray is useless. But if you really want to see what a research paper is all about, the place you go to is the end of the paper, where you will find the “Discussion” section, followed by the “Conclusions” section. The Anthem BC/BS Medical Policy paper is a sham of a professional publication, just junk science, masquerading as the real thing. Here’s the evidence from the literature they themselves cited:
Harvey S, Hukins D, Smith F, et al. Measurement of Lumbar Spine Intervertebral Motion in the Sagittal Plane Using Videofluoroscopy. J Back Musculoskelet Rehabil. 2015 Sep 25. [Epub ahead of print]
What’s funny about this one is that the first statement in the paper is this: “Static radiographic techniques are unable to capture the wealth of kinematic information available from lumbar spine sagittal plane motion.” Geez, where have I heard that before? I’m tempted to stop right there, but this is a study which has a very small patient sample size, and they came to no conclusions- because they intended this study to be a mere pilot study, contemplating a much bigger and better study in the future. Note that it is extremely recent (2015).
Hino H, Abumi K, Kanayama M, Kaneda K. Dynamic Motion Analysis of Normal and Unstable Cervical Spines Using Cineradiography. An In Vivo Study. Spine (Phila Pa 1976). 1999; 24(2):163-168
The authors studied ten healthy subjects and 12 patients with unstable cervical spines by recording and analyzing, under videofluoroscopy, the entire range of motion from full extension to full flexion. The pathological spines exhibited a different order of onset of segmental motion; in other words, the unstable segments moved first! “Cineradiographic motion analysis is a valuable adjunctive technique, especially in the diagnosis of conditions that cannot be identified by conventional radiographic examination.”
Lindgren KA, Leino E, Manninen H. Cervical Rotation Lateral Flexion Test in Brachialgia. Arch Phys Med Rehabil. 1992; 73(8):735-737
In this study, the authors studied 23 patients with brachialgia and thoracic outlet symptoms under videofluoroscopy and with the cervical rotation lateral flexion test (CRLF) in order determine the role of fixation of the first rib in their symptoms. The videofluoroscopy was performed in order to confirm the physical findings of the two examiners, who determined that 25 of the 56 ribs tested (that’s what the article said- shouldn’t that be 46 ribs?) were fixated. The intermethod reliability between the clinical and the radiologic tests was found to be excellent (K score= .84).
Okawa A, Shinomiya K, Komori H, et al. Dynamic Motion Study of the Whole Lumbar Spine by Videofluoroscopy. Spine (Phila Pa 1976). 1998; 23(16):1743-1749
This study observed the act of lumbar flexion from the standing position under videofluoroscopy in a control group (n=13) and a group of 8 patients with degenerative spondylolisthesis and a group of 8 patients with chronic low back pain. A significant number of those with degenerative spondylolisthesis exhibited abnormal biomechanics, while the differences in motion between the normal controls and those with chronic low back pain (without spondylolisthesis) were felt to be insignificant. The authors had some doubts about their data analysis and their methodology, but bottom line, it is a fact that they were analyzing a video and it yielded valuable kinematic information.
Teyhen DS, Flynn TW, Childs JD, et al. Fluoroscopic Video to Identify Aberrant Lumbar Motion. Spine 2007; 32(7):E220-229
This is the one I was already aware of, and I have been using it in my seminar. The authors studied 20 healthy controls and 20 patients with low back pain under videofluoroscopy while moving from standing neutral to full flexion. They used eight kinematic variables to quantify the rate of attainment and magnitude of intersegmental angular and liner displacement, and found that those with low back pain demonstrated aberrant motion during the mid-range of motion as compared with the controls. The statistical analysis proved to be 96% accurate in identifying those with low back pain! “DFV (Dynamic fluoroscopic video) was useful for discriminating between individuals with and without LBP based on kinematic parameters. Disruptions in how the motion occurred during midrange motions were more diagnostic for LBP than range of motion variables.”
Wong KW, Leong JC, Chan MK, et al. The Flexion-Extension Profile of Lumbar Spine in 100 Healthy Volunteers. Spine (Phila Pa 1976). 2004; 29(15):1636-1641
The purpose of this study was to contribute to the already present data base of research on what constituted normal lumbar motion (as cited by the first ten sources in the bibliography, some of which involved large cohorts for study). The subjects were recorded using an electrogoniometer and videofluoroscopy through the full range of motion in flexion and extension. They established differences in range of motion between those who were under 50 years old and those who were over 51 years old. Not exactly earth-shaking information. The fluoroscopy was used to establish a data base which “is useful to assist the diagnosis of spinal instability in the future.”
All of these articles cite the need for more research, which is the prudent thing to do when you are researching. Not doing so would imply that all questions about the subject have been answered, which common sense tells you doesn’t happen in anyone’s research. But the authors of the Medical Policy paper jump the gun and state that all of the research is inconclusive, and that there needs to be more done, so in the meantime, let’s ignore any and all information which can be gleaned from any form of dynamic radiography. Any objective reader of these articles, and all the rest of my personal collection, can see that motion x-ray is essential in the determination of spinal instability. But the insurance company is dead set on being blind to the facts, as demonstrated by the list of exclusions they included in the paper. All the CPT codes for motion x-ray, including the one I use (76496) are included on their list of procedures which are ”Investigational and Not Medically Necessary.” Then, to emphasize that there are no indications for which the technology may be useful, they list every ICD-10 code they can come up with, from M40 to M99, then Q76, and then everything (almost!) from S12- S33.
The American Academy of Professional Coders (AAPC) bills itself as “the nation’s largest medical coding training and certification association for medical coders and medical coding jobs.” I found an interesting opinion piece on their website, dated 10/27/2008, written by attorney Michael D. Miscoe, who at the time was the President-elect of the AAPC National Advisory Board, concerning the use of the correct CPT code for billing for DMX studies. The confusion arose because in 2000, an article appeared in the AMA CPT Assistant that equated videofluoroscopy with videofluorography/cineradiography, when subsequent to that decision, the FDA determined that “videofluorography/cineradiography and videofluoroscopy devices are substantially different, and diagnostic purpose (in terms of anatomic structures evaluated and conditions that can be diagnosed) of each is also substantially different.” Videofluoroscopic devices are classified as “image intensified fluoroscopic x-ray systems” while cineradiographic and videofluorographic devices are classified as “cine or spot fluorographic x-ray cameras.” He concluded that the only code which should be used for a DMX study was the one I use, which is 76496 (unlisted fluoroscopic procedure –eg diagnostic, interventional) because of the use of the descriptor “diagnostic.” There are two other codes, 76120 (cineradiography/videoradiography except where specified), and 76125 (cineradiography/videoradiography to complement routine examination), which describe the recording of the use of fluoroscopic devices when they are used for procedures such as placing cardiac catheters or needles into injection sites. The difference between the two is the use of the device for diagnostic purposes, rather than a procedural purpose. The Anthem Blue Cross/Blue Shield arbitrarily decided to lump all three codes together, and excluded the use of all three. Once again: “Based on what?”
You know why they do this. The sole purpose of Managed Health Care is to save insurance companies money by limiting access for services. And it’s pretty much guaranteed that the diagnoses of greater severity result in more money being spent on health care. That would be a ”reverse ka-ching” for the insurance industry. Digital motion x-ray studies up the ante on the diagnosis severity by identifying ligament injuries which are permanent, progressive, and painful. This is in no way “padding the bill” in order to get greater reimbursement; it is merely reporting the truth.
For the record, before medical machines can be used on the general public, they have to be approved for use by the Food and Drug Administration. The digital motion x-ray machine that I use, the Visualizer 2000, was approved by the FDA in 1994 as a Class B Medical Machine. The definition of a class B medical machine is that it is “non-experimental.” I have the original paperwork in my possession and can make it available to anyone who wants to see it. The National Clearinghouse Guidelines, which you can find on the website for the Department for Health and Human Services, which is a Cabinet level government office, lists videofluoroscopy (a synonym for digital motion x-ray) for the diagnosis of ligament injuries under the section outlining the accepted standard operating procedures for Whiplash Associated Disorders (WAD), including it in the same sentence in which it also approves of plain film x-ray, MRI, CT scans, and diagnostic ultrasound. The National Clearinghouse Guidelines also has a Chiropractic Subluxation Practice section, in which it reiterates the use of diagnostic videofluoroscopy for doctors of chiropractic. Jeff Cronk, DC, JD, of Spinal Kinetics, put on the first two seminars for Bill Gallagher’s Motor Vehicle Injuries course, and one of the many points he made several times during his presentations was that doctors need to know the professional guidelines under which they practice; if they cannot articulate them, they are open to criticism, medicolegally. From a medicolegal standpoint, the use of the machine has passed the Daubert challenge (November 28, 2007) in Federal Appeals Court in a case entitled Graftenreed vs. Seabaugh. The judge accepted the DMX technology into evidence and opined that he was doing so because it was not a new technology, but an improvement on older, previously accepted technology.
In addition, the injuries I regularly diagnose with DMX studies are attested to and described in the AMA Guidelines for Evaluation of Permanent Impairment, 6th ed., in Chapter 17, Table 17-2 (Cervical Spine Regional Grid: Spine Impairments), page 564, under the section which describes Alteration of Motion Segment Integrity (AOMSI). Our profession affirmed the use of the digital motion x-ray technology for the purpose of assessing ligament injury in a position statement written by the American Chiropractic College of Radiologists (ACCR) in 1989, and ratified by the International Chiropractic Association (ICA) soon after. And, more locally, I have been approved by the State of Arizona Board of Chiropractic Examiners to teach a continuing education course in interpretation of digital motion x-ray. I can provide you with all the documentation you need concerning the efficacy of digital motion x-ray studies.
At this point, if someone is still of the opinion that DMX is experimental and investigational, I am ready to argue, “Based on what?” If someone has peer-reviewed literature which categorically states that digital motion x-ray is worthless, I would be glad to look at it. But, remember that no type of x-ray treats anyone or gets anyone well. What this specialized fluoroscopic study does is give the clinician a more accurate diagnosis, and that in itself is instrumental in improving patient outcomes. What the doctor who orders this test does with it is completely in his/her hands, but, if you don’t test, you’re guessing, and if you’re guessing, then the one who suffers for the willful ignorance of the doctor is the patient. Most patients don’t want their doctors guessing about their health. If you would put yourself in their shoes, I’m sure that you would feel the same way.
Using digital motion x-rays and static motion studies are invaluable in determining diagnoses in personal injury cases, and also in just about any case in which instability of the spine is suspected. There is a learning curve, though, for each doctor who orders a study, in learning how to incorporate the information gained from motion studies.