GONSTEAD FINAL REVIEW
SUMMER 2000
Rick’s Casino!
1. Born: July 18, 1898
2. Died: October 2, 1978
3. 80 years old
4. Graduated from Palmer in 1923
5. Used HIO w/ mechanical engineering = Gonstead Technique
6. Naturapathy degree received.
7. Lateral Film used to find:
- AP curves
- Spondylolysthesis
- Disc Conditions
- IVF encroachment
- Compression fractures
- ADI, C1-C2
- Abdominal Aortic Aneurysms
8. AP film used to find:
- Leg lengths
- Scoliosis
- Listings
- Accurate vertebral count
- Abdominal aortic aneurysms
9. Innominate bone: between ischium and iliac crest line
10. Just because innominate bone has a listing, does NOT mean it is subluxated – ALWAYS compare one side to the other.
11. ASIN Ilium:
AS ILIUM IN Rotation
1. Side of Shorter innominate Toe OUT
2. Smaller projected Vertical (Diagonal) Flaccid Gluteal Musculature
obturator foramen measurement
3. Decreased lumbar lordosis (Hypolordosis) Wide Ilium Shadow
4. Raises femur head level (Increases leg length) Obturator Foramen Narrower in Horz plane
5. Causes Spongy edema at PI margin of SI jt Obturator Foramen smaller w/ ASIN
6. Leaves sacrum Posterior on involved side
PI ILIUM EXT Rotation
1. Side of Longer innominate Toe IN
2. Larger projected Vertical (Diagnoal) Tight Gluteal Musculature
obturator foramen measurement
3. Increased lumbar lordosis (Hyperlordosis) Narrow Ilium Shadow
4. Lowers femur head level (decreases leg length) Obturator Foramen Wider in Horz plane
5. Causes Spongy Edema at PS margin of SI jt Obturator Foramen wider w/ PIX
6. Leaves sacrum Anterior on involved side
12. ALWAYS: 3rd letter is an “S”:
- Contact point will be Spinous process
- Do NOT need to list it – it is automatic
- Always SIMPLE scoliosis
- LOD: Lateral-Medial and P-A
13. 3rd letter is an “I”, MUST list contact point
- Always a ROTATORY scoliosis
14. 1st letter from L5-C2 = P
15. 2nd letter from L5-C2 = Spinous Laterality
16. ATLAS:
- AI: Nose & Chin Down (Lines converge Anteriorly)
- AS: Nose & Chin Up
17. Look at ATLAS:
a) Visual presentation
b) Motion palpation
c) Lateral x-ray
d) AP x-ray
- Patient will ALWAYS have restricted ROM to the side of Anterior Atlas
- Think of Atlas lateral mass being stuck against back of mandible
18. TWO Lines on Lateral film:
- Diverge anteriorly
- Converge posteriorly
- AP Atlas plane line & Odontoid perpendicular line will Diverge anteriorly and
Converge posteriorly
19. THIRD LETTER:
a) Side of involvement
b) Side of laterality
c) Side restricted ROM (Restricted Lateral flexion)
d) Side of Contact
e) Side 2 lines diverge on (Side of open wedge)
20. FOURTH letter:
- Narrowed = Posterior = “P”
- Widened = Anterior = “A”
- Equal = No Change = “-“
CHAPTER 6: LUMBAR MISALIGNMENTS
- X-ray analysis is a Comparative study
- Comparing the subluxated vertebrae with the vertebra directly below it, as well as, adjacent structures on adjoining segments
- Subadjacent vertebrae is used as a reference point.
- A vertebrae misaligns ON ITS Disc!, Then: misalignment is expressed in terms of changes between the two bodies
- Primary motion in lumbar spine is Flexion and Extension
POSTERIOR MISALIGNMENT:
- Except for the atlas, a vertebrae is UNABLE to move anterior
- Usually accompanying posteriority is Body Rotation
- Spinous process is a midline structure and rotates laterally in same direction that the posterior body rotates
- Body has rotated the SP either R or L
- FIRST LETTER: “P” for posteriority
- SECOND LETTER: “R” or “L” which designates the lateral position of the SP caused by body rotation
- Body rotated the spinous to left = PL
- Body rotated the spinous to right = PR
- PR and PL are NOT complete listings
LATERAL WEDGING:
- Occurs when Upper vertebrae tilts in relation to the Lower vertebrae
- Lines drawn on x-ray through superior/inferior endplates will form angles
- Nucleus goes laterally to the WIDE side of the wedge, as well as to the FRONT
- Nucleus goes ANTEROLATERALLY
- Lateral film will show: Wedged effect in the A-P direction
- AP film will show: Wedged effect in theLateral direction
- Vertebral body can rotate the SP to either the closed or open side of wedge.
- Body is raised on the side of open wedge = Superior
- Body is closed on the side opposite of open wedge = Inferior
- THIRD LETTER: “I” for inferior or “S” for superior. This letter denotes the position of the body ON the side OF spinous laterality.
- Remember:; Lateral film will only show inferiority by disc listing
- FOUR basic positions of lumbar spine subluxation with posteriority, rotation, & lateral wedging = PRS, PLS, PLI-M, PRI-M
LUMBAR SPINE CONTACT POINTS:
- Denotes on which anatomical structure the thrust is made
- 1 thrust is made to correct: posteriority, body rotation, and lateral wedging
- Point of contact will either be the Spinous process OR the mammmillary process
- Body rotated SP to OPEN side of wedge, listed PRS or PLS, contact is SP (no additional designation is needed for this listing)
- When SP is rotated to the CLOSED side of wedge, the Mammillary process on the opposite side (Side of OPEN wedge) is contacted
- Remember: The open wedge must ALWAYS be closed
- Nucleus pulposus is pushed further Anterolaterallly when body is lifted from low side to high side
- Body is directed DOWN on the high side, nucleus will be forced back toward the center
- For a Mammillary contact: the letter “M” is added to listing proceeded by a dash.
a) Listings are either PLI-M or PRI-M
Summary of two different conditions for listings:
1. If SP is rotated to open wedge side, complete listings are PLS or PRS. Contact is always SP
2. If SP is rotated to closed wedge side, it is listed PLI-M or PRI-M. Contact is always MP
NO LATERAL WEDGE
- If there is no lateral wedge between the subluxation and the subadjacent vertebrae, and JUST posteriority and body rotation (PL or PR), then POINT OF CONTACT MUST BE LISTED.
- PL or PR with NO scoliosis in the Lumbar Spine, Contact point is ALWAYS the SP
- Listing is PL-Sp or PR-Sp
NO LATERAL WEDGE WITH SCOLIOSIS
1. SP rotates to CONVEX side of scoliosis = SP is contact point
- No wedge, but still a lumbar scoliosis so listing would be: PR-Sp or PL-Sp
2. SP rotates to CONCAVE side of scoliosis = MP on Opposite side of concavity is contact
- Listings would PL-M or PR-M
3. Rule: Thrust is NEVER made in such a way as to increase lateral scoliosis, that is, thrusting into the Concave side of a scoliotic curvature.
FIFTH LUMBAR DIFFERENCES
- For the 5th lumbar: possible to have the open wedge, between the 5th lumbar and first sacral segment, on the side OPPOSITE the convexity of the scoliosis
- If this happens, SP may rotate to EITHER the open or closed side of wedge presenting these two specialized L5 listings: PLS-M or PRS-M
- SP rotates to Open side of wedge, but convexity is on opposite side, contact MP on Convex side. Listings would be PLS-M or PRS-M
- SP rotates to Closed side of wedge, and convexity is on same side, contact SP on that side. Listings would be PLI-SP or PRI-SP
- L5 Listings only: PLS-M, PRS-M, PLI-SP, PRI-SP
- These listings are Contraindicatory to ALL other levels but L5/1st Sacral segment
- Also contraindicatory to ALL other levels but L5/1st Sacral segment:
· The 5th Lumbar CAN be lifted laterally from low to high side
- Because of the differences occuring with 5th lumbar, the contact points are ALWAYS included
on ALL of the L5 listings.
LISTING BODY ROTATION (LUMBARS)
- Body rotation is determined by film analysis
- Dependable criteria for body rotation = Pedicle changes
A. Body rotates SP to the Right (PR):
- Right pedicle shadow = elliptical and transversely narrow, displaced laterally
- Left pedicle shadow = circular and transversely wider, displaced to midline
- Same rules apply for PL listing
- Another reliable source for Body rotation = Width changes of Inferior articular processes at Laminar junction
A. The width of inferior articular process is LESS on side of Spinous laterality
THORACIC MISALIGNMENTS: CHAPTER 7
- Thoracic segment must be moved P-A through the disc plane for correction
- Similar to lumbars: Posterior, circumrotation and lateral wedging misalignments
- Reference to direction of misalignment is ALWAYS made in relation to vertebrae below
- Thoracic vertebrae will rarely show inferiority on lateral film
- FIRST LETTER: “P” for posteriority
- Planes of facets influence vertebral slip
- Primary motion in thoracics is Rotation and Lateral flexion
- Body rotation: body rotates in relation to body of vertebrae BELOW it.
- Body also rotates SP laterally to left or right (PL or PR)
LATERAL WEDGING
- Present when vertebrae appears tilted on AP film in relation to subadjacent vertebrae.
- Nucleus has shifted from center
- SP to side of open wedge: PLS or PRS
- SP to side of closed wedge: PLI-T or PRI-T (“T” stands for Transverse Process)
- When a thoracic vertebrae rotates so SP moves toward Closed side of wedge, TP on opposite side (side of Open wedge) is contacted
MISALIGNMENT WITHOUT WEDGING WITH & WITHOUT SCOLIOSIS
1. No scoliosis: Planes of bodies are parallel, SP is contact point: PL-SP or PR-SP
2. Scoliosis: Planes of bodies are parallel, SP rotated to CONVEX side , so it is still contact point and listing is PL-SP or PR-Sp
3. Scoliosis: Planes of bodies are parallel, SP rotated to CONCAVE side, so TP on Opposite side (TP on convex side) is contact point: PL-T or PR-T
Extra:
- SP must be contacted as far Superiorward as possible
- Body rotation is corrected from SP or TP contact
- Thrust is directed THROUGH THE PLANE OF THE DISC
CERVICAL MISALIGNMENTS C2 THROUGH C7: CHAPTER 8
- When a cervical vertebrae subluxates, entire segment slips inferior, in addition to any other direction of misalignment.
- Observable on Lateral x-ray
- Compensating vertebrae are more obviously misaligned than the subluxated vertebrae.
- Compensations are commonly mistaken for the cause of the condition
- Optimal alignment = uniform lordotic curve
- Forward curve adds flexibility to the neck, decreased curve = increased shock to discs
- Flexion or Extension = Transverse Axis
- Head Rotation = Vertical Axis
- Lateral Bending = AP Axis
- Hyperlordosis = Lateral x-ray = Converging lines at point closer to spine
- Head is forced back = hyperextension = posterior arches absorb much of force
- Result of injury may be sprain, strain or fracture, but NOT subluxation
- Atlas and condyle are often subluxated form Hyperextension
- MOST cervical subluxation are the consequence of head being driven Forward
- One segment will receive MOST of the impact, resulting in it being the subluxated segment
- Flexion force, if severe enough, will injure the disc above the subluxated vertebrae.
- Greatest damage occurs in FRONT of the disc where point of impact is
- Hyperflexion can be complicated w/ blow to head (swimming pool, accident, etc)
DRAWING THE LINES/ INTERPRETING THE LINES
- Lines on Lateral film represent AP planes of vertebral bodies
- Line Drawing Procedure:
A. Dots at inferior margin of vertebrae, one anterior, one posterior
B. Dots should be placed on ALL the segments from axis to T1 before lines are drawn
C. Connect dots, lines should be drawn the full length of the leading edge
INTERPRETING:
- Inferiority is indicated by increased convergence of lines posteriorly
- Greater degree of inferiority, closer to posterior border of the vertebrae the 2 adjacent lines will intersect.
- Comparing amount of inferiority: The one segment with the lines crossing closer to the bodies has the greater degree of inferiority.
- When comparing, use the lines of two ADJACENT vertebrae
- Compensatory vertebrae: Lines on lateral film Diverge posterior, and Converge anterior, the vertebrae being represented by the Upper Line is compensatory
a) The posterior portion of the body has gone Superior, and the entire body has gone Anterior
- A vertebrae in an ANTERIOR COMPENSATION should NEVER be adjusted: will irritate and drive segment further.
COMPENSATION:
- Frequently, compensating vertebrae will be found higher in c-spine due to subluxated lower cervical
- If Lower cervical slips posterior, the compensation of upper segments will go anterior
- Lower subluxation will go posterior-inferior
- Inferiority increases as the nucleus pulposus goes further anterior, and the posterior disc wears thin
- AP ATLAS PLANE LINE: line drawn through the atlas, also represents plane of head (condyle)
- If subluxation includes body rotation, comensation will rotate in the opposite direction.
- If lateral wedging is involved, compensating bodies must wedge laterally on opposite side
- High incidence of Lower c-spine subluxation due to prevalence of hyperflexion injury.
- AP Film: body rotation and lateral wedging.
- Lateral film: Inferior misalignment, arrive at actual subluxation
a) The subluxated vertebrae will have MORE inferior misalignment than the one above or below.
b) There is a HIGH correlation between actual subluxation & the most inferior vertebrae in that area. Almost correspond 100%
c) If the doctor can not decide = pick the lower of the segments showing inferior misalignment
REPOSITIONING THE VERTEBRAE
- With subluxation: The Body misaligns on its disc
- To reposition vertebra onto its disc, neck must be flexed to opposite direction, spine extended so bodies are open in front.
- When a vertebrae has slipped inferior, nucleus has gone toward front of disc.
- Body must be directed superior so it can be lifted UP and OVER the nucleus
- If SP is the contact, fingers must be placed UNDER tip of SP, best done in SITTING or PRONE position