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GONSTEAD FINAL REVIEW
SUMMER 2000
Rick’s Casino!
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Born: July 18, 1898
Died: October 2, 1978
80 years old
Graduated from Palmer in 1923
Used HIO w/ mechanical engineering = Gonstead Technique
Naturapathy degree received.
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
2. Smaller projected Vertical (Diagonal)
obturator foramen measurement
3. Decreased lumbar lordosis (Hypolordosis)
4. Raises femur head level (Increases leg length)
5. Causes Spongy edema at PI margin of SI jt
6. Leaves sacrum Posterior on involved side
Toe OUT
Flaccid Gluteal Musculature
PI ILIUM
1. Side of Longer innominate
2. Larger projected Vertical (Diagnoal)
obturator foramen measurement
3. Increased lumbar lordosis (Hyperlordosis)
4. Lowers femur head level (decreases leg length)
5. Causes Spongy Edema at PS margin of SI jt
6. Leaves sacrum Anterior on involved side
EXT Rotation
Toe IN
Tight Gluteal Musculature
Wide Ilium Shadow
Obturator Foramen Narrower in Horz plane
Obturator Foramen smaller w/ ASIN
Narrow Ilium Shadow
Obturator Foramen Wider in Horz plane
Obturator Foramen wider w/ PIX
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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
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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 = “-“
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CHAPTER 6: LUMBAR MISALIGNMENTS
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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:
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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:
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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:
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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
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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
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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
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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.
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LISTING BODY ROTATION (LUMBARS)
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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
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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
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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
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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
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CERVICAL MISALIGNMENTS C2 THROUGH C7: CHAPTER 8
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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
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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:
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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
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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
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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
Virtually impossible to reposition an inferior cervical vertebrae with patient supine
Lower cervicals are less apt to rotate than are the higher ones.
The AXIS is very subject to body rotation.
Still - ONLY thrust into open wedge, contact point is now the LAMINA
When a cervical vertebrae rotates so SP moveds toward closed side of wedge, the lamina on
opposite side is the contact (i.e., Open side of wedge)
Lateral wedging is determined by plane lines drawn through vertebral bodies
Draw (AP film): Line drawn parallel to tips of lateral projections. Dots placed on these points
and line drawn
If tips of lateral projections are eroded, lines should be determined from the vertebral plates
adjacent to disc in question.
Axis Body Rotation:
A) Dot placed in middle of base of odontoid process
B) Another one placed at lamina junction above SP
C) Draw line through these points
D) Inferior end of line indicates direction of Spinous laterality
- Example: If SP is left, lower end of line will be to the left of the upper end
E) Compare shapes and sizes of transverse foramina: Side of Spinous laterality becomes
obscured, opposite side enlarges
F) Axis lateral wedging: Draw axis plane line along inferior border of body
G) On Lateral View: When the entire segment misaligns Inferior , use “Inf” added to end of
listing
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ATLAS AND OCCIPITAL CONDYLE MISALIGNMENTS: CHAPTER 9
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Atlas is AS important as every other vertebra of the spine
82% chance of the misalignment of the atlas being compensatory
Atlas differs in the kinds of nerve fibers it can compress
Tissues of the head, heart, lungs, liver, and legs
MECHANISM OF UPPER CERVICAL SUBLUXATION
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Upper cervical articulations are those immediately above and below atlas
Include: Atlanto-axial articulation (between lateral masses of atlas and the superior articular
process of the axis)
Atlanto-occipital articulation (between lateral masses and the occipital condyles)
The difference between the above two articulations is that they have no Disc between them
Vertebrae above disc must be realigned to correct nerve irritation
Instead of the interarticular tissue being an intervertebral disc, it is the CAPSULAR
LIGAMENT which protrudes and compresses the adjacent nerve fibers.
If Nerve pressure is found at the level of one of the articular capsules between the Atlas and the
Axis, a subluxation of the ATLAS exists.
If Nerve pressure is found at level of a capsular ligament between atlas and occiput, then the
OCCIPUT is subluxated.
Atlas must be evaluated in relation to the axis only.
Adjusting the atlas would not improve relationship between the occiput and the atlas, the
Misaligned occiput should be adjusted to align with the atlas
Atlas is subluxated, compensatory misalignment often occurs between atlas and occiput.
Restoring atlas-axis relationship will automatically correct atlas-occipital alignment.
Nerve pressure is produced by a protruding articular capsule, and that capsule could be above
or below the atlas ring
In any given pair of apposed vertebrae, the subadjacent vertebrae serves as the supporting
foundation for the vertebra ABOVE it (Foundation Principle)
Foundation Principle applies to all segments with the following two exceptions:
A. Sacral Base Posterior: Sacrum must be adjusted to the 5th lumbar. Can not reposition 5th
lumbar into an A-P position. Sacrum has no weight-bearing structures = no problem
B. Coccyx: Non-weight bearing structure, coccygeal segment is repositioned to the sacrum,
which supports it from above.
ATLAS-AXIS SYNOPSIS:
1. Atlas subluxation occurs from the atlas misaligning with the axis.
2. Nerve pressure results from protrusion of one of the capsular ligaments between the inferior
articular process of the atlas and the superior articular process of the axis.
3. Correction: Repositioning the atlas on the axis.
4. Occipital subluxation occurs from the occiput misaligning with the atlas.
5. Nerve pressure results from protrusion of the right or left capsular ligament between the superior
articular process of the atlas and the corresponding condyle.
6. Correction: Occiput is repositioned on the atlas.
UPPER CERVICAL FIXATION:
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Whenever nerve pressure exists, another finding is fixation
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Normal articular motion is greatly reduced ON THE SIDE of the protruding capsular oligament
Vertebral fixation is determined by MOTION Palpation.
Protrusion of one of articular capsules between the atlas and occiput compreses First Spinal
nerve
Atlanto-Axial protrusion compresses spinal cord or fibers of SECOND spinal nerve
Atlas can have a TP compress the Vagus nerve – happens when atlas becomes rotated on axis
Atlas can also cause nerve dysfunction through irritating superior cervical ganglion of
symathetic chain.
Superior ganglion lies medial to the Vagus nerve, and can compress if Atlas TP rotates
Anteriorly
Lower C-spine segments have more influence on the atlas since adjusting a lower subluxation
will often ameliorate the atlas by compensatorily changing its position on the axis.
ATLAS MISALIGNMENTS
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View from Lateral x-ray
Atlas rotates around odontoid process of axis, so odontoid is a point of reference
Odontoid process is represented by a line which traverses it longitudinally.
First:; Two dots placed one in center of base of odontoid, and antoehr so it bisects odontoid
near superior margin. Line drawn through these dots is the “ODONTOID LINE”
Line drawn Perpendicularly to odontoid line is placed in middle of axis body =
“ODONTOID PERPENDICULAR LINE”. Should always be 90 degrees to odontoid line
“AP ATLAS PLANE LINE”: Place 2 dots on atlas, one in center of anterior tubercle, other in
center of posterior arch near posterior tubercle
When Atlas/Axis have perfect alignment the A-P atlas plane line and Odontoid perp line will
be parallel.
Plane of theAXIS represented by the “AXIS PLANE LINE” = Plane of the axis body as viewed
on AP film.
Plane of the ATLAS represented by the “TRANSVERSE ATLAS PLANE LINE” = drawn
through like points on either side of atlas, through the “transverse-lateral mass junctions”
(points at which superior and inferior borders of the TP’s join the lateral masses
When the Transverse atlas plane line and the axis plane line appear parallel, atlas and axis are
aligned
Atlas is prevented from misaligning Posterior by the Odontoid process.
Atlas first misaligns Anterior.
Since all Atlas misalignments include Anterior misalignment, the
FIRST LETTER: is “A” for Anterior
After slipping Anterior, atlas will usually misalign one of two ways:
A. AP atlas plane line & Odontoid perp line will Converge anterior:
- Atlas will be inferior
B. Atlas will misalign Superior, causing AP atlas Plane line/ Odontoid Perp lines to Diverge
anterior
C. SECOND LETTER: “S” or “I” for superior or inferior, or a “-“ if parallel
D. THIRD LETTER: Denotes misalignment in the Lateral direction (R or L)
- Laterality is derived from AP x-ray indicated by wedging of axis plane line/transverse
atlas plane line
When Atlas misaligns laterally to RIGHT: Diverging of atlas/axis plane lines on the Right
Same for Left
Atlas is raised higher on side of Laterality
FOURTH LETTER: A or P (Ant/Post) Lateral mass laterality (Start on book page 123)
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