THE AMERICAN INSTITUTE OF MUSCULOSKELETAL DIAGNOSTIC ULTRASOUND
Board Certified Consultants in Musculoskeletal Diagnostic Ultrasound
2232 Santa Monica Blvd. Suite 101, Santa Monica, California 90404 | (310) 456-6182 | facsimile (310) 456-9092 | alex@dxus.com | www.dxus.com
Kevin K. Drake, M.D. | Alex Kaliakin, D.C.


Santa Monica Physical Medicine
Adam Silver D.O.
2232 Santa Monica Blvd #101
Santa Monica, CA 90404
Referring Physician: Dr Pain


Patient (first, middle, last)Back Pain
Date of ScanSeptember 19, 2017
Consulting DateSeptember 19, 2017
Number of submitted images18 images submitted
Additional Patient informationLumbar spine(Pelvic Non Obstetric) and Sacroiliac

Dear Doctor(s):

Attached herewith-kindly find an evaluation of the 18 scans submitted by your offices for review. For your convenience, we have placed our diagnostic impressions at the beginning of this report.

Diagnostic Impression

  1. There is facet zygapophyseal joint inflammation demonstrated by increased hyperechoic sonographic signals bilaterally at the joint planes noted consistent with facet inflammation and/or arthropathy. L5

  2. At the lumbar spine, the posterior longitudinal ligament appears to have sonographically increased in the thickness and is intruding into the intrathecal space (within either the subarachnoid or the subdural space) at the noted segments. This PLL swelling is also accompanied by a hyperechoic signal reflected from within the canal at both the main body and the lateral extensions of the ligament. This is consistent with ligament sprain and /or disc protrusion. L5 The PLL measures 5.3mm in thickness/protrusion.

  3. The erector spinae musculature of the lumbar spine bilaterally demonstrates sonographically a slight to moderate degree of effusion with accompanying hyperechoic fibrosis at the noted levels consistent with muscular strain.

  4. There is sonographic evidence demonstrating a form of degenerative joint disease to the lumbar spine that appears to be at a middle stage of evolvement.

  5. Sonagraphic evaluations of the sacroiliac joints are unremarkable for any frank pathology or swelling. Left & Right Side

Findings

    The images are of adequate diagnostic quality with identification of all echogenic structures made. The findings are consistent with the diagnoses indicated below. Other than the scans commented on, the balance of the sonographic scans are unremarkable.

Procedure

    System used:

    Presented images were by an electronic linear scanning ultrasound diagnostic unit. Ultrasonographic image projections appear to have been extracted by an appropriate transducer at full resolution zoom. Scans taken are of regions noted at each study.

    Report documentation:

    A total of 18 images have been scanned and digitized on a high-speed processing computer. The diagnostically significant image has been C weighted through computer software for maximum visualization. There has been no alteration to the physical or diagnostic characteristic features of that selected image(s).

Discussion:

    The patient, Back Pain, has demonstrated a diagnosis as noted above. For your information the sonographic significance of these findings are as follows:

    1. Lumbar Zygopophysis Inflammation
      The superior articulating surface (zygopophysis) arises from the mamillary process of the lumbar vertebra. It has a facet type joint, which forms a double arthrodia and is covered with a thin layer of cartilage. The surrounding capsular ligaments are short thick fibrous structures.

      The fibers of the ligament are arranged at a 90-degree angle to the plane of the facet joint and are firmly bound to the bony prominence above and below the facetThe fibers of the joint capsule of the lumbar spine are very responsive to trauma and become sonographically echogenic when traumatized.

      The brighter and more hyperechoic the area the greater the traumatic response has been. Transverse images are typical and dramatic, and the longitudinal view of the region will confirm the diagnosis.

    2. Increased Signal Intensity At The Post. Longit. Ligament-Lumbar Region
      Clinical manifestations related to the thoracolumbar ligament changes may be more severe than those associated with a cervical involvement. Often, increased signal intensity in the thoracic and lumbar areas is accompanied by changes in the cervical spine, although isolated involvement in thoracic or lumbar region is common.

      In the lumbar spine, changes may be apparent at any level, although changes seem to predominate in the L1 to L2 region. Changes seen by hyperechoic reflections can also involve the ligamenta flava, capsules of the apophyseal joints as well as the dura mater.

      Classification of the PLL:

      The classification in use at the Institute of the sonographic reflection of the posterior longitudinal ligament is for identification of echogenicity location only and is not intended as an index of severity.

        Type I
        Increased echogenicity of the bilateral extensions of the PLL.

        Type II
        Increased echogenicity of the main body of the PLL.

        Type III
        Increased echogenicity of the main body and a single extension.

        Type IV
        Increased echogenicity of the entire ligament.

      (Ref: White et al. The PLL, The DC 1997)



    3. Swelling about the Stabilizing Muscles of the Paraskeletal Regions
      Any accumulation of fluids in an area is associated with the synovitis and tendonitis of the surrounding support structures. When a patient gives a traumatic history, the symptomatology presented will usually be a consistent and objective range of motion loss, slight to moderate gross swelling and a general feeling of boggy tissue. These are usually transient in nature and will subside with the formation of internal fibrotic adhesions about the articular capsular area. (cf Linnen et.al. Radiology 1985; 157:205-209. & Bretzke, et.al., Invest Radiology 1985 20:311-315)



    4. Degenerative Osteoarthritis
      From a sonographic point of view, the overall contrast character is greatly diminished when compared to the sonographic gray scale on the scan. This finding is suggestive of the early form of the process, where the compartment membranes lose their natural hyperechoic reflection. The term "osteoarthrosis" and "degenerative joint disease" have also been used to emphasize the primary cartilaginous breakdown that is consistently observed. This coupled with the patient age and presenting symptoms confirms the sonographic finding.

      Major or minor traumatic episodes appear to be important in producing abnormal stress across a joint, leading to its degeneration. Repetitive trauma is significant in athletic and occupation-induced degenerative joint disease. It is also implicated in the appearance of joint degeneration in association with ligament laxity, loss of protective sensory feedback extraarticular malalignment such as inequality of leg length, malunited fractures, congenital and acquired varus and valgus deformities, and also intraarticular malalignment. Single episodes of trauma can also lead to incongruity of opposing articular surfaces, with resultant degenerative joint disease.

      Although in most cases the disease is clinically benign, degenerative changes can be severe, and serious disability may result. This is especially so if critical joint structures such as the cervical spine, lumbar spine or weight bearing joints are affected. Usually secondary in origin, mild to moderate synovitis is a common component of the pathology of involved joints, hence the designation "osteoarthritis."

    5. Sprain of the Posterior Sacroiliac Ligament
      The posterior sacroiliac ligament is situated in a deep depression between the sacrum and ilium behind; it is strong, and forms the chief bond of union between the bones. The ligament consists of numerous fasciculi, which pass between the bones in various directions. The upper part is nearly horizontal in direction, and passes from the first and second transverse tubercles on the back of the sacrum to the tuberosity of the ilium, the lower part is oblique in direction; it is attached by one extremity to the third transverse tubercle of the back of the sacrum, and by the other to the posterior superior spine of the ilium, where it merges with the upper part of the sacrotuberous ligament.

      Three diagnostic classes exist of sprain of the posterior sacroiliac ligament:- They are: 1- hypomotility dysfunction, 2- nerve root adhesion, and 3- sacroiliac hypermobility.



A careful review of the 18 submitted images strongly suggest that a follow-up study should be performed in 4-6 weeks to contrast and compare progress during the treatment phase of the case.

The above findings suggest the patient is a candidate for conservative therapeutic procedures, including passive and active physical therapy and rehabilitation, interventional physical medicine, and/or Chiropractic, as directed by the patients treating physician.

Please note that these diagnoses indicated above should be correlated to your clinical findings. Should you have any questions regarding this report submission please contact this office. We will respond to your inquiry promptly.

Thank you for allowing us to participate in the care of your patient, Back Pain.


KEVIN K. DRAKE, M.D.
The American Board of Radiology
American College of Radiology


ALEX KALIAKIN, D.C.
Registered Chiropractic Musculoskeletal Ultrasonologist
American Institute of Chiropractic
Musculoskeletal Diagnostic Ultrasound


The patient's history was taken from a presented medical record and a report and analysis was performed. This report is for a consultation only and is not to be construed either directly or by implication as a report on a complete evaluation for medical or chiropractic problems. As the treating group, the medical or chiropractic offices may perform medical or chiropractic procedures to treat the patient's complaint or injury. Only those symptoms that we believe have been reported or involved in the injury or alleged injury have been sonographically evaluated and commented upon. (Report certification id: 1505850922-)