515- Exploring Weight Bearing MRI: The New Frontier in Cervical Spine Diagnostics for Chiropractors

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we are back with more research, a brand new study out of the European Journal of Radiology. This one's about weight bearing MRIs of the cervical spine. Fantastic study with a lot of clinical implications for your practice. Before we get started, special shout out to a new partner, Shockwave Centers of America. Fantastic shockwave units. And I had the privilege of sitting down face to face with Dr. Dan, one of the owners. You're gonna see that content coming out soon, but if you're interested in bringing Shockwave into your practice, I'll drop a link down in the show notes. They're willing to hook you up with $500 off their affordable units plus an additional cart by being a listener of this podcast. I'll drop the link down in the show notes. Be sure to check them out. But today's episode, all about research, weight bearing MRI of the cervical spine. So if you've ever had a patient. I know I have. Whose MRI looked normal, but every single time they stand up, extend, rotate, move around, their symptoms basically light up like a Christmas tree. This study is for you because it's exactly what this research is all about, Meaning how weight bearing MRIs might finally help us understand what's been hiding in plain sight. Now for a number of years, I had a handful of imaging centers spread throughout the United States. We did vertebral motion analysis, which was upright analysis of the spine in motion, controlled flexion extension. We used full size C arms to really take a peek at angulation translation and disc height to a tenth of a millimeter. And we found there was a lot of people with negative MRIs, CTs, or X rays, but once you got them upright and moving, everything changed. So this study is specific interest to me, but because I've seen this firsthand now, this is a brand new study. It's a scoping review that came out again 2025. I'll drop a link down in the show notes, but this is not a technical paper. This is about how the next generation of spinal imaging might completely change how we evaluate how we educate and how we communicate with our patients. So again, this was a scoping review. So that means that the authors weren't testing one specific hypothesis. Basically they combed through every relevant Data study between 2008 and 2015 to map out what we currently know about upright, dynamic or weight bearing mri, specifically of the cervical spine. So this matters for a variety of different reasons, but every MRI that you, you and myself that we look at today, you know, every single disc bulge, you know, instance of foraminal stenosis, it's, it's overwhelming the amount of them that are taken with the patient lying down. So there's just no weight, there's no load, and there's no compressive forces. So it's not an accurate interpretation of how the spine functions in real life. Now, part of that's pragmatic historically. You know, machines that are where the patient is lying down or recumbent, they're just how the machines were made, right? Upright MRI is something that is. It's not new, as in yesterday, but it's pretty new. And we see more and more of these machines coming into play, but the technology tends to be a little bit more expensive. And MRI units for imaging centers aren't cheap. I mean, often these are million dollars plus. And that's before building out around the machine. That's before all the licensing, all of the restrictions. These things are not cheap. So when we see technology advancing in the radiology space, often there's a big delay between when the technology is present and when it is, I'm going to say, then present in the practice. Right. It takes a long time because of the expense. So the researchers in this study were asking a few questions. One, what happens when you look at the cervical spine under load, seated, standing, or moving through flexion extension? Love that one. The second one was, what do we see that's missed in a standard recumbent mri? And then does that change the diagnosis? Does it change surgical planning or even chiropractic care? So they included nine studies covering everything from degenerative disc disease and radiculopathy to Chiari malformations, cervical imbalance challenges, and ligamentous instability. And what they found was that posture changes everything. Probably no surprise there. In extension, the spinal cord narrows dramatically, sometimes dropping 10, 20% or more. And that's linked to ligament buckling. And it can be very much tied to symptomatic stenosis. And specifically in patients with C6 radiculopathy, up to 85% showed foraminal narrowing, and extension to that was not visible in the supine position. I'm gonna say that one more time. For people with C6 radiculopathy, up to 85% showed foraminal narrowing and extension that was not visible in the supine position. That is a lot of false negatives. Right. So being able to see that, absolutely critical, as opposed in being able to say to a patient, here's what's going on, as opposed to a patient. And you've seen dozens, if you've been in practice long enough, hundreds of patients who have clean imaging yet are symptomatic. And that's really confusing for a patient. And it's challenging because they don't want to be made out to be liars. They know they're not making up the symptoms, they're really feeling it. But when the imaging comes back clean and negative, man, that is a dicey spot to be in psychologically for our patient. Also, regarding CSF flow, CSF flow at the C2 level dropped by nearly 58% when upright compared to lying down. And that means posture alone can change cerebrospinal fluid dynamics. Big, big deal. And patients with kyphotic or imbalanced cervical alignment showed significantly more motion at the craniocervical junction compared to those with normal lordosis. So, in plain English, when patients stand up and the spine behaves naturally, that's different. And sometimes it's radically different. And those changes very well may explain why, why many patients have symptoms that don't line up with their quote unquote, normal imaging. So let's go one level deeper and unpack a few things. Specifically, cervical myelopathy. Weight bearing MRI often reveals that the real severity of that stenosis. The cord can look, and often does look totally fine on a supine or recumbent scan. But when the patient gets into extension, that is when the compression shows up. Same thing with radiculopathy. Dynamic MRI can capture foraminal stenosis. That only happens when the neck starts moving. It's finally catching exactly what's going on. And to frame this out for you, remember your foraminal canals. There's some play here, but in General, you're looking at 3, 4, 5 millimeters wide, 6, 7, 8 millimeters tall. So when you have translation, that's occurring, and let's say that's 2 millimeters of translation, that's a big deal. You're taking up 25 to 30% of the space. So it's creating stenosis. However, if you're not capturing this dynamically and you're just taking a static image, it might look totally normal. And that's pretty wild. But it's happening each and every day, really. It's happening thousands and thousands of Times, each and every day. And with sagittal imbalance, you know, altered alignment, it just doesn't look bad. It changes motion patterns, specifically at the cervical craniocervical junction. And that's really important when we're looking at symptoms like dizziness, headaches, upper cervical instability, and of course, Chiari malformations and connective tissue disorders. Small postural shifts can make a massive difference in that tonsillar position. So this research absolutely shows us that the anatomy we're seeing on a traditional MRI might only be telling us half the story, if not less. And as a chiropractor, this is really important because weight bearing MRIs aren't just about surgical decision making. This is really about validating what we have been saying as chiropractors forever, which is functional aspects matter, function matters. And we know a patient's spine is not static, it's dynamic, it's adaptive, it's sensitive to things like posture and load. And now we see the science catching up for that. So as a chiropractor, this type of research opens the door for better correlation between patient symptoms and imaging findings. Very overdue. More informed clinical decisions when we look at things like instability, alignment, movement patterns, and also just better communication with, with radiologists and other providers who may not have historically appreciated the functional component. So when we can speak to our patients and say, here's why you hurt when you look up, your spinal canal is closing down when you extend, and they can visualize that live with you, it's massively powerful patient education and it is ultimately a direct bridge between what we see clinically and, and what's visible on the imaging. And I am passionate about this topic. Part of it's because of the business that I've had. When we were analyzing spines upright in motion, we'd see about a 30% false negative across the board, meaning about 30% of the patients that we would scan had quote, unquote, normal imaging prior to our upright and flexion extension based scanning. And to be clear, this is flexion extension taking eight frames a second, utilizing ct. So we were getting a video. And this is really important when you're taking a neutral a flexion and extension 3 views. That way the patient's musculature will compensate. In other words, when you say, okay, flex one, they might not be flexing all the way or extend and they kind of just don't move their neck, you're not getting a very true picture. The other thing is, then there's a moment where you're saying, okay, you know, flex down, move your chin towards your chest and there's a moment in time before you shoot the image. If it's just the, this would be like reading the first two pages of a book, the middle two pages of a book, and the last two pages of a book. You're missing a lot of the material, right? So a true scan that shoots a video throughout, you really see a lot that even if you're taking upright flexion extension, you're typically missing with that because a lot happens between neutral and endpoint. So easy ways, these are easy conversations to have with patients because if you're going to recommend this, letting people know, hey, most MRIs are done while you're lying flat, but your pain usually shows up when you're standing, when you're sitting, when you're moving around. So that's like, you know, checking your brakes when your car is parked. Like, we, we want to see you in action, we want to see your spine under load so we can see how your posture changes the pressure that happening, that's happening on your nerves and discs. And sometimes the problem only shows up when you're upright in this further, I'm gonna say, showcases that movement motion is medicine and sometimes it's actually the test. So letting people know, hey, movement helps us find what's working and what's not. That's why we focus on restoring normal motion, not just looking at static pictures. So there's a lot of reinforcement messaging that you can have. Now, I know not everybody might have access to an upright mri, but, but taking a look and seeing what's available in your area if you, especially if you haven't in a few years is a really, really good idea. So this is great for report of findings. So if a patient says, hey, my MRI looked fine, you know, you can let them know. That's a great start. But that scan was taking when you were lying down. We want to see what's happening when you're in motion or under weight bearing, which is often very, very different. And this can help immediately. I'm not trying to talk about overdoing imaging or something. I'm talking about actually getting to the cause of the problem. And this can immediately position you as that doctor, as that chiropractor who understands function, not just the findings that are on their previous imaging. Also, it can reinforce the value of what you're doing. So when you perform posture emotion based assessments, you're doing a functional MRI basically in real life. And you can let them know, hey, recent studies show that many Problems only show up under load. That's why we focus on how your spine moves and functions, not not just how it looks or feels. And also this is opportunities to collaborate with local imaging centers. If you're in a city that has upright or town that has upright MRIs, reach out to them. You know, offering that option for patients with complex challenges or posture dependent symptoms could really enhance your credibility, especially when we're talking about chronic or post traumatic patients. So this can also be really important for online content. You can let people know why your MRI might be missing the real cause of your neck pain and kind of riff on that for a little while, summarizing everything we discussed today. How weight bearing imaging and functional assessments and functional assessments can reveal the hidden causes that regular scans cannot. So the bottom line is that traditional MRIs show the spine at rest. But me, you, our patients, they live, they move and they hurt under load. So weight banger MRIs, when there's the opportunity to do that, can let us see the spine the way that the patient actually feels it. And we're able to see a lot. We're not finding stuff, we're not making up stuff that's not there. We're seeing what actually is. So research is still really early on this. There's small studies or mixed methods, they're limited access, but the direction is really, really clear. From what I can see, the future of spinal imaging is undoubtedly functional and that fits perfectly with what you and I already do best, which is understanding that relationship between structure, function and movement. So the next time you hear a patient say my MRI didn't show anything, you can smile and confidently let them know that's because they weren't looking at the way you live your life. So I loved this study. I hope you did as well. A lot of great take home messages there. Additionally, big shout out to Leander Tables. As a listener to this podcast, they're gonna hook you up with $1000 off their series 950 fantastic table, great company, great people. You can click on down below, have a conversation with them, let them know you're a listener and they will hook you up with that discount. Additionally, if this is your first episode listening or your 500 whatever, thank you so much for taking the time to tune in. If you have not left a rating or review, please take a moment and do so. Scroll on down, tap some stars, leave a line or two, a text. I read every single line. So I'd love to hear from you if you have anything you'd like me to highlight in the future. Jeff the evidencebasedchiropractor.com thank you so much for tuning in. Thank you for being a chiropractor. Have a fantastic week in practice and I will talk to you soon.

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