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Dynamic Vertical MRI

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analgesic

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Hi everyone,

I was wondering if any pain fellows/programs have started incorporating dynamic vertical MRI? It seems to be somewhat superior to recumbant MRI for early detection of disc herniations. Here is a website if anyone else is interested http://www.fonar.com/standup.htm. I hope it is informative/helpful. :D
 

Aether2000

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I have sent approximately 12 patients to one of these machines over the past year. The bottom line is:
1. For morbidly obese patients, this may be the only possible way to obtain an MRI
2. Patients love them compared to closed or traditional open MRIs
3. Some insurers consider the technology experimental and will not cover the MRI
4. Approximately 25% more pathology is picked up in the standing position, esp. lumbar disc herniations vs. traditional MRI in the same patient. Cervical flexion vs extension MRIs may be very useful in dynamic spinal stenosis
5. The pictures obtained are very very small. When attempting to enlarge the pictures, pixelation occurs obscuring fine details.
 

lobelsteve

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5. The pictures obtained are very very small. When attempting to enlarge the pictures, pixelation occurs obscuring fine details.[/QUOTE]


Limited experience, but agree with above. That and motion artifact was problematic.

Steve
 

f_w

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Be careful with the claims to the superiority of the standup MRI. The guy running the company has a bit of a complex since he was 'passed over' for the nobel as 'inventor' of the MRI. Since he has seemingly given up his quest for recognition, he at least tries to get some $$$ out of the upright thing. I used to work with folks who considered buying one of these contraptions, but after they looked at the image quality (and the very limited use for the scanner otherwise), they bought a regular unit instead.



You can obtain a similar effect in the standard recumbent magnet with a dynamic compession device (a contraption right from you favourite Dominatrix's studio)
http://www.dynawell.biz/
You still have a problem with motion artifact, but you have the superior image quality of a standard clinical magnet.

(did you know that the only way to do an MRI on an awake monkey is in an upright scanner ?)
 

fedor

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f_w said:
(did you know that the only way to do an MRI on an awake monkey is in an upright scanner ?)

God damn those noncompliant monkeys!
 

f_w

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They just won't lay still. But once you turn them upright (including a 7T MRI scanner), they do whatever monkey business you ask of them.

Magn Reson Imaging. 2004 Dec;22(10):1343-59
 

fedor

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Anatomical and functional MR imaging in the macaque monkey using a vertical large-bore 7 Tesla setup

Josef Pfeuffera, Corresponding Author Contact Information, E-mail The Corresponding Author, Hellmut Merkleb, Michael Beyerleina, Thomas Steudela and Nikos K. Logothetisa

aDepartment Physiology of Cognitive Processes, Max-Planck Institute for Biological Cybernetics, 72012 Tübingen, Germany
bLaboratory of Functional and Molecular Imaging, NINDS/NIH, Bethesda, MD 20892-1065, USA

Received 16 August 2004; accepted 8 October 2004. Available online 8 February 2005.


Abstract

Functional magnetic resonance imaging (MRI) in the nonhuman primate promises to provide a much desired link between brain research in humans and the large body of systems neuroscience work in animals. We present here a novel high field, large-bore, vertical MR system (7 T/60 cm, 300 MHz), which was optimized for neuroscientific research in macaque monkeys. A strong magnetic field was applied to increase sensitivity and spatial resolution for both MRI and spectroscopy. Anatomical imaging with voxel sizes as small as 75×150×300 μm3 and with high contrast-to-noise ratios permitted the visualization of the characteristic lamination of some neocortical areas, e.g., Baillarger lines. Relaxation times were determined for different structures: at 7 T, T1 was 2.01/1.84/1.54 s in GM/GM-V1/WM, T2 was 59.1/54.4 ms in GM/WM and T2* was 29 ms. At 4.7 T, T1 was 25% shorter, T2 and T2* 18% longer compared to 7T. Spatiotemporally resolved blood-oxygen-level-dependent (BOLD) signal changes yielded robust activations and deactivations (negative BOLD), with average amplitudes of 4.1% and −2.4%, respectively. Finally, the first high-resolution (500 μm in-plane) images of cerebral blood flow in the anesthetized monkey are presented. On functional activation we observed flow increases of up to 38% (59 to 81 ml/100 g/min) in the primary visual cortex, V1. Compared to BOLD maps, functional CBF maps were found to be localized entirely within the gray matter, providing unequivocal evidence for high spatial specificity. The exquisite sensitivity of the system and the increased specificity of the hemodynamic signals promise further insights into the relationship of the latter to the underlying physiological activity.

Keywords: Functional imaging; Monkey brain; High-field MR system; Cerebral blood flow
 

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beverly

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analgesic said:
Hi everyone,

I was wondering if any pain fellows/programs have started incorporating dynamic vertical MRI? It seems to be somewhat superior to recumbant MRI for early detection of disc herniations. Here is a website if anyone else is interested http://www.fonar.com/standup.htm. I hope it is informative/helpful. :D
More SUPERIOR UPRIGHT MRI INFO not BS its real SIMPLE STUFF the PUBLIC GOES TO THE INTERNET DRS try google on UPRIGHT-MRI..POSTIONAL MRI.. Sit Stand MRI...STAND UP MRI any more ?'s ... http://groups.yahoo.com/group/mriengineeringandservice?yguid=2420 YOU MIGHT HAVE TO JOIN TO GET THE UPRIGHT MRI real info..SURGEONS say 50 % overlooked pathology = rolling wheelchairs BILLBOARDS of FBS 48% because of conventional mri overlooked pathology I can give you mor but your the drs.
 

beverly

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lobelsteve

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J. Randy Jinkins 1, 2 , Jay S. Dworkin 2 and Raymond V. Damadian 2

(1) Department of Radiology, Downstate Medical Center, State University of New York, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
(2) Fonar Corporation, 110 Marcus Drive, Melville, NY 11747, USA

Received: 8 September 2004 Revised: 31 December 2004 Accepted: 31 December 2004 Published online: 20 May 2005

Abstract The potential relative beneficial aspects of upright, weight-bearing (pMRI), dynamic–kinetic (kMRI) spinal imaging over that of recumbent MRI (rMRI) include the revelation of occult spinal disease dependent on true axial loading, the unmasking of kinetic-dependent spinal disease and the ability to scan the patient in the position of clinically relevant signs and symptoms. This imaging unit under study also demonstrated low claustrophobic potential and yielded comparatively high resolution images with little motion/magnetic susceptibility/chemical shift artifact. Overall, it was found that rMRI underestimated the presence and maximum degree of gravity-dependent spinal pathology and missed altogether pathology of a dynamic nature, factors that are optimally revealed with p/kMRI. Furthermore, p/kMRI enabled optimal linkage of the patients clinical syndrome with the medical imaging abnormality responsible for the clinical presentation, thereby allowing for the first time an improvement at once in both imaging sensitivity and specificity.

One of the authors works for the company, need full text to assess Methods, Materials.
 

lobelsteve

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This looks more promising, but still a case series...

South Med J. 2004 May;97(5):456-61. Related Articles, Links


Dynamic weight-bearing cervical magnetic resonance imaging: technical review and preliminary results.

Vitaz TW, Shields CB, Raque GH, Hushek SG, Moser R, Hoerter N, Moriarty TM.

Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY 40202, USA. [email protected]

BACKGROUND: Conventional magnetic resonance imaging (MRI) of complex cervical spine disorders may underestimate the magnitude of structural disease because imaging is performed in a nondynamic non-weight-bearing manner. Myelography provides additional information but requires an invasive procedure. METHODS: This was a prospective review of the first 20 upright weight-bearing cervical MRI procedures with patients in the flexed, neutral, and extended positions conducted in an open-configuration MRI unit. RESULTS: This technique clearly illustrated the changes in spinal cord compression, angulation, and spinal column alignment that occur during physiologic movements with corresponding changes in midsagittal spinal canal diameter (P < 0.05). Image quality was excellent or good in 90% of the cases. CONCLUSIONS: Dynamic weight-bearing MRI provides an innovative method for imaging complex cervical spine disorders. This technique is noninvasive and has adequate image quality that may make it a good alternative to cervical myelography.
 

lobelsteve

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And finally, just because this is the internet...Dont try this in your scanner.

Br J Radiol. 2000 Feb;73(866):152-5.


Upright dynamic MR defaecating proctography in an open configuration MR system.

Lamb GM, de Jode MG, Gould SW, Spouse E, Birnie K, Darzi A, Gedroyc WM.

Interventional Magnetic Resonance Unit, Imperial College School of Medicine, St Mary's Hospital, London, UK.

We describe our experience evaluating an MR proctography technique using an open 0.5 T MR system. Evacuation of a gadolinium-containing rectal contrast agent was dynamically imaged in the upright position using a fast gradient echo sequence. Anatomical and functional abnormalities were documented. Results from 40 patients who underwent this technique are reported. The method is proposed as an alternative to conventional fluoroscopic proctography.
 
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rexed

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Searched the forums and found this thread...

Has the technology changed since these postings?
Seems like it's a good idea but sounded like there were issues
with quality of images which is my major concern (0.6T?)

Anyone have any updated experience with these units?

Thanks in adavance!
 

ampaphb

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Almost all the stand up units are owned by mills in my region.

The game they play is, patient is in an MVA. Lawyer sends pt to PCP/PM&R, who initiates PT. Ultimately, recumbent MRI is obtained.

If read by typical plaintiff's radiologist, pathology is found at virtually every level. If read by a legitimate radiologist, there may well be no significant findings.

PCP/PM& sends patient to spine surgeon who operates on anything with a pulse. Surgeon obtains stand-up MRI (typically one in which he has an investment). I have never seen a stand-up MRI read as normal.

In my area, stand up units are employed to justify a second bite at the imaging apple, and are one more way to escalate the medical costs in a system where the ultimate payout is typically a multiple of those very costs.
 

Tenesma

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i have a patient with SIGNIFICANT pain behaviors --- and based on quick exam you would be convinced he has an L5/S1 radic... however MRI is normal, EMG is normal and thorough exam is inconsistent at best...

surgeon sending for dynamic MRI ---- will get those images and post and see if there is a realy difference...
 

SSdoc33

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i have a patient with SIGNIFICANT pain behaviors --- and based on quick exam you would be convinced he has an L5/S1 radic... however MRI is normal, EMG is normal and thorough exam is inconsistent at best...

surgeon sending for dynamic MRI ---- will get those images and post and see if there is a realy difference...


let us know. i have some patients where i could swear they'd have a herniation, but imaging is fine.

i ama bit hesitant to embrace any technology which finds MORE abnormalities than the recumbant. seems like it would add some more low-hanging fruit for the surgeons....
 

PMR 4 MSK

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Add in the fact that radiologists are now over-reading the crap out of MRI's, since they are getting to be bigger and bigger targets of lawsuits. 3 years ago, and MRI report would talk about DDD/bulges, HNP's and stenosis. Now they talk about every nook and cranny of the spine, and anything that might "displace" a nerve root. I see reports all the time describing 5 or more "displaced" nerves, and several "minute disc protrusions." They often, however, ignore what's important to me - namely the morphology of the facet joints and surrounding soft tissues, instead focusing everything on disc and nerve.

Now give them a new technology to milk the medical cow, specifically one like this that purports itself to be superior to supine MRI by showing dynamic changes, a medium that is not supported as different/superior in the literature. I imagine soon the combo chriopractic/MD/computerized traction clinics (DRX 9000 anyone?) will soon incorporate these for all their personal injury and MVA cases.
 

Tenesma

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That is why i would recommend that you have a chit-chat with your regular radiologists and tell them what you are looking for... and most have been receptive.... and they also frequently look at the age of the patient now...

so if a 28 year old is getting an MRI of the spine and it looks normal - it is okay to say it is normal, instead of reading every disc as bulging and every level of having mild stenosis.
 

lobelsteve

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I agree with above. I am lucky enough to have a radiologist in house. We read the films together so I can bias his report based on the clinical info I feed him as the images come over the PACS. A great way to learn spine/joint is to sit there and ignore my patients. For $50 he can dictate whatever I need (but the check has to clear first).... (yes, its a joke).
 

analgesic

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Hi everyone,

I think the importance of this new mode of imaging is that we finally have a modality to view the sequelae of axial loading. Bare in mind most of our patients experience there pain when they are either sitting or standing. Although such an instrument can be criticized as being over sensitive, it does give us a lot more info than the standard recumbent MRI toward formulating our clinical management. Of course, this is a magnet for WC or PI attorneys but perhaps this offers a more valid tool to identifying spine pathology as it is truly experienced. If you look at the case study below I am sure any of us would agree that these images could make a difference in clinical management. Bare in mind that this is an extreme example.:idea:

http://www.fonar.com/casestudy/su_casestudy_2.htm
 

PMR 4 MSK

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Hi everyone,

I think the importance of this new mode of imaging is that we finally have a modality to view the sequelae of axial loading. Bare in mind most of our patients experience there pain when they are either sitting or standing. Although such an instrument can be criticized as being over sensitive, it does give us a lot more info than the standard recumbent MRI toward formulating our clinical management. Of course, this is a magnet for WC or PI attorneys but perhaps this offers a more valid tool to identifying spine pathology as it is truly experienced. If you look at the case study below I am sure any of us would agree that these images could make a difference in clinical management. Bare in mind that this is an extreme example.:idea:

http://www.fonar.com/casestudy/su_casestudy_2.htm

The recumbant image provided shows significant stenosis at L3-4 and not just "a modest bulge", and should have been enough to explain her symptoms most likely. The findings of spondylolisthesis in the upright position would have been found if someone had done standing flexion and extension X-rays for about 1/10th (or less) of the price of this MRI.
 

ampaphb

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Hi everyone,

I think the importance of this new mode of imaging is that we finally have a modality to view the sequelae of axial loading. Bare in mind most of our patients experience there pain when they are either sitting or standing. Although such an instrument can be criticized as being over sensitive, it does give us a lot more info than the standard recumbent MRI toward formulating our clinical management. Of course, this is a magnet for WC or PI attorneys but perhaps this offers a more valid tool to identifying spine pathology as it is truly experienced. If you look at the case study below I am sure any of us would agree that these images could make a difference in clinical management. Bare in mind that this is an extreme example.:idea:

http://www.fonar.com/casestudy/su_casestudy_2.htm
1) Case study
2) N=1
3) Industry Sponsored
4) Your source is the manufacturer's website advertisement??? :bang:
 
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rexed

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The findings of spondylolisthesis in the upright position would have been found if someone had done standing flexion and extension X-rays for about 1/10th (or less) of the price of this MRI.

X-ray? What is this fancy new "x-ray" you speak of? :laugh:
 

nvrsumr

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Had a patient come in with dynamic lumbar MRI yesterday read by his "board certified in radiology" chiropractor. The patient had no idea he hadnt seen a physician. I have never seen a report this long before. I guess this is reason 101 to be able to read your own films.
 
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analgesic

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1) Case study
2) N=1
3) Industry Sponsored
4) Your source is the manufacturer's website advertisement??? :bang:


Ampaphb,

I am not utilizing this case study as means to publicize dynamic MRI as a new gold standard. I am merely stating that we should always seek a more functional approach to examining our patients in the manner in which they experience their pain. If the image quality was equivalent, why would you get recumbent xrays/MRI if the person experiences a lot more pain when they are sitting or standing? :bang:
 
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analgesic

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The recumbant image provided shows significant stenosis at L3-4 and not just "a modest bulge", and should have been enough to explain her symptoms most likely. The findings of spondylolisthesis in the upright position would have been found if someone had done standing flexion and extension X-rays for about 1/10th (or less) of the price of this MRI.

PMR 4 MSK,

I agree that standing flex/ext films could have revealed the spondylo but not the added distortion of the disc at L3/L4 induced by the axial loading. Bare in mind that your hind site is 20/20. With no history of trauma and a good lumbar lordosis on recumbent imaging, what would have prompted you to order flex/ext films in this patient?
 
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ampaphb

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Ampaphb,

I am not utilizing this case study as means to publicize dynamic MRI as a new gold standard. I am merely stating that we should always seek a more functional approach to examining our patients in the manner in which they experience their pain. If the image quality was equivalent, why would you get recumbent xrays/MRI if the person experiences a lot more pain when they are sitting or standing? :bang:
and if yo mama had b*lls she'd be yo' daddy, but she doesn't, so she isn't.
 

Tenesma

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why would no history of trauma or a "good" lumbar lordosis preclude flexion/extension films.... there is such a thing as degnerative spondylolisthesis...

if i have a patient who describes significant changes in pain based on positioning I usually get a flexion/extension film... it's dirt cheap and has uncovered some nice finds...
 

analgesic

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why would no history of trauma or a "good" lumbar lordosis preclude flexion/extension films.... there is such a thing as degnerative spondylolisthesis...

if i have a patient who describes significant changes in pain based on positioning I usually get a flexion/extension film... it's dirt cheap and has uncovered some nice finds...


Hey Tenesma,

I was under the impression that Degenerative Spondylolisthesis is more common after the age of 65 and typically occurs in females. Bare in mind this female was 57 and without any evidence of a pars defect or facet arthrosis my suspicion would have been low. Enlighten me for I don't quite understand why you would get routine flex/ext films any time your patient exhibits significant changes in pain with positioning. There are several reasons why a patient could experience significant pain with change in positioning (Muscle, Iliolumbar ligament, PLL, ALL, disc, facet, spondylo, compression fracture, etc.)
 

Tenesma

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???

i was referring to the case you mentioned on that web-site...

in that case the patient required mechanical support to stabilize her walking... status post fusion... of course, i would get a flexion/extension film...

so you are telling me a patient post-fusion with radicular symptoms, inability to walk without support and severe low back pain, you are going to get a FONAR MRI because she is under the age of 65 - and by the way how do you know she doesn't have a pars defect?
 

analgesic

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???

i was referring to the case you mentioned on that web-site...

in that case the patient required mechanical support to stabilize her walking... status post fusion... of course, i would get a flexion/extension film...

so you are telling me a patient post-fusion with radicular symptoms, inability to walk without support and severe low back pain, you are going to get a FONAR MRI because she is under the age of 65 - and by the way how do you know she doesn't have a pars defect?

Hi Tenesma,

If you are referring to the case I mentioned, you should note that the patient had a fusion after not before the FONAR MRI-

A spinal fusion was performed at L3-4 one month after the patient's Upright&#8482; MRI scan. The surgical outcome was positive. To date, almost four years post-op, the patient remains symptom free and reported to FONAR, "Thank you for giving me my life back."

I never claimed that she didn't have a pars defect. I was stating that in the absence of a pars defect that my suspicion of a spondylo is not that high. I would be surprised if she didn't have a pars defect. I would agree that in the face of ongoing radicular symptoms sp fusion with inability to walk that I would be concerned of either a pseudoarthrosis or an unstable fusion. Such a clinical picture would definitely mandate flex/ext films. I hope you agree. I have no preference toward FONAR or any other upright MRI company. I do think that we should explore more dynamic ways to image our patients specifically that relate to the positions in which they experience their pain.
 

Tenesma

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at the beginning: A 57-year old woman presented with pain of one year's duration following failed back surgery performed in 2001*.

as a footnote: * laminectomy and L45S1 fusion

....

anyhow... i agree that dynamic imaging is reasonable in a lot of these cases and that is why i get flex/ext. x-rays with a regular MRI --- basically gives me the info I need for MOST patients... i have yet to see a dynamic MRI that changed my opinion, but I have seen it used as an excuse for surgery with not so favorable outcomes.
 

analgesic

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at the beginning: A 57-year old woman presented with pain of one year's duration following failed back surgery performed in 2001*.

as a footnote: * laminectomy and L45S1 fusion

....

anyhow... i agree that dynamic imaging is reasonable in a lot of these cases and that is why i get flex/ext. x-rays with a regular MRI --- basically gives me the info I need for MOST patients... i have yet to see a dynamic MRI that changed my opinion, but I have seen it used as an excuse for surgery with not so favorable outcomes.


I missed that foot note. I see your point and agree flex/ext films would have been cheaper and prudent in this case scenario.
 
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