What is a Spine Stress Test?

What is a Spine Stress Test?


  The spine is a complex functional anatomic structure. The human spine has adapted to upright stature and must withstand forces several times the weight of the body while allowing complex motion and protection of the sensitive spinal cord and nerve roots. Stress tests are designed to uncover problems that are not apparent on testing performed when the body is at rest.

Cardiologists use a form of Stress Test to determine if there blockages in the coronary arteries in patients that are experiencing chest pain during activity but not at rest. In these cases the chest xray and the EKG of the heart are usually normal when the the patient is at rest. A cardiac stress test increases the functional demands on the heart and tests for areas where the blood flow is restricted and thereby preventing the heart from meeting the demands of the Stress applied.  A stress test evaluates the functional reserve of an organ and uncovers abnormalities that are missed (false negative results) in tests with the organ at rest.

   Spine surgeons and attorneys are familiar with another form of Spinal Stress Test/Standing Flexion/Extension Radiographs of the spine. Conventional radiographs (AKA “x-rays”) of the spine are obtained with the patient lying down in a position where the spine is at rest and there are limited stresses on the spine. Standing Flexion/Extension radiographs test the spine under physiologic loads and evaluate for excessive spinal motion that is known as “segmental Instability”. This radiographic form of Spinal Stress Test has been accepted by insurance companies and surgeons as the Gold Standard for evaluating for “spinal instability” for which the preferred treatment is spinal fusion.
Unfortunately, Flexion/Extension views evaluate the bones but not the discs and nerves because these structures are not visible using radiographs (i.e. x-rays). Soft tissue structures (e.g. intervertebral discs and nerves) are best seen using MRI and may be compressed in one position (during weight-bearing and with flexion/extension) whereas there is not disc herniation or nerve compression when the stresses are removed from the spine when the patient is lying down while the patient is supine.

Stress Test MRI displays the 30-40% of abnormalities that are present when the patient is standing but not visible when the individual is scanned when the patient is supine and the stresses are relieved (and the patient’s symptoms are relieved.

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Posted in News-Brio San Antonio

Stress Test MRI: “Worth Weighting For”

Stress Test MRI: “Worth Weighting For”


The spine is similar to tires on your car: All tires appear normal when the car is on the rack and there is no weight on the tire. It is only when the weight of the car is paced on the tries that the tires appear flat. 

The intervertebral discs of the spine are the same. Most conventional MRI examinations are performed with the patient supine with no weight-applied to the disc and the disc often appears normal (similar to the deflated tire with the car on the rack). In both the supine MRI and the tire on the rack, the test is a falsely negative test where the test appears normal but because no physiologic loading is applied to the spine during conventional non-weight-bearing supine imaging.

Stress Test MRI(TM) is a unique physiologic testing of the spine using a special type of Tiltable MRI(TM) that examines the spine while sitting or standing during physiologic loading conditions and during supine non-weight-bearing conditions. Just as with the auto tire, abnormalities are demonstrated only during weight-bearing approximately 30-40% of the time and explain why the patient has symptoms while standing and yet the conventional MRI was normal or failed to explain the positional symptoms.

If your patient reports symptoms that are worse when bearing weight and the insurance company will authorize only one diagnostic test after radiographs, then the most sensitive and accurate test Stress Test MRI(TM) using a TiltableMRI(TM). It is accurately treat an abnormality if the conventional supine MRI fails to shows it.


Flat Tire

Posted in News- Salu Brio MRI

Stress Test MRI™

Stress Test MRI™

A Unique Test for Positional Symptoms

     Many individuals experience symptoms only when standing or sitting and relief or decrease in the symptoms while lying down. When an individual is standing, the weight of the body compresses the intervertebral discs of the spine and can reveal disc herniations and resultant compression of neural tissues that are not present when the patient is lying supine and the disc is not compressed or stressed by the weight of the body.

     The shape of intervertebral discs and many other soft tissues in the body deform when compressed by the weight of the body while individual is standing or sitting and decompress while lying down without body weight. Flexion and extension of the spine also apply a compressive stress to the intervertebral discs and apply a stress to the stabilizing ligaments. Ideally an MRI examination would be performed during weight-bearing and with flexion and extension in order to examine the body during real life conditions. A Stress Test MRI™ is a comprehensive examination of the body and displays 30-40% more findings than MRI examinations with the patient supine without weight-bearing. The best indication for obtaining a Stress Test MRI™ is when there are symptoms that are increased in severity or only occurring during weight-bearing.


Supine Position “Negative” MRI

Stress Test MRI


Sitting Position Disc Herniation with Cord Compression Matching Clinical Myelopathy

     Stress Test MRI™ examination was performed of a patient with myelopathic symptoms during weight-bearing that were increased in severity when looking downward (i.e. cervical flexion). The axial T2-weighted image obtained in the conventional supine position showed minimal right paracentral disc bulge with no evidence of neural compression. These supine images are similar to those obtained in conventional non-weight-bearing MRI examinations. As part of the Brio San Antonio Stress Test MRI™ axial T2-weighted images were also obtained in the weight-wearing position with the body weight added to the intervertebral discs. The Stress Test MRI™ images displayed a right paracentral disc herniation and compression of the right side of the cervical spinal cord that was not present on the non- weight-bearing images obtaining during the same examination.

Posted in News- Salu Brio MRI

Dynamic Cervical Cord Compression: Demonstration Using Weight-Bearing MRI Using Tiltable Esaote G-Scan MRI

Dyn.HNP.SupC4.5_25_22    Dyn.HNP.SitC4.5_25

Dynamic Cervical Cord Compression: Demonstration Using Weight-Bearing MRI Using Tiltable Esaote G-Scan MRI

Author: Dr. Douglas K. Smith, Musculoskeletal Imaging Consultants

Positional Cervical Cord Compression by Cervical Disc Herniation 

     During my past 25 years of spinal radiology practice, I have encountered numerous individuals that report myelopathic symptoms (i.e. bilateral radicular symptoms) when they are sitting or standing but the symptoms are relived when they lie down. Traditional MRI scans of these patients obtained in the spine position frequently showed flattening of the cervical spinal cord adjacent to a small disc herniation although there was no cord contact by the disc herniation. There was cerebrospinal fluid (CSF) between the disc herniation and the cervical cord. I noticed that the flattening of the cervical cord matched the shape and location of the disc herniation.

     Last summer I had the opportunity to read the MRI examinations form the second Tiltable MRI scanner installed in the United States. The Esaote G-Scan Brio MRI scans individuals in both the supine and upright (weight-bearing sitting) position. Immediately, I saw the explanation for what I had been observing for 25 years. The supine images showed the same finding I had observed over the years: a small disc herniation with adjacent flattening of the cervical cord but CSF between the disc herniation and the cervical cord (Figs. 1A and 2A).


Figure 1A Supine C4-C5


Figure 2A Suprine C5-C6

     The axial images with the patient bearing weight in a sitting position showed increased size of the disc herniation with cord compression and obliteration of the CSF between the disc herniation and cervical cord. These dynamic disc herniations with dynamic cord compression are frequently associated with dynamic myelopathy. Individuals frequently report reproduction of their symptoms in the sitting position where the cord is compressed. This is frequently described as positional numbness or weakness in the hands or feet while sitting and especially with cervical flexion. The attached images (Figs. 1B and 2B) show increased size of the disc herniations with cord compression not present at the same levels in the supine position (Figs. 1A & 2A).



Figure 1B Sitting C4-C5


Figure 2B Sitting C5-C6


     The sagittal plane T2-weighted images show similar findings. The supine images show disc herniations (Fig.3A) with impression on the thecal sac but no cord compression. The sagittal images with the patient sitting applies body weight to the discs, causing them to increase in size, with dynamic compression of the cervical spinal cord. At the same time, the patient experienced muscle spasm and reproduction of bilateral upper extremity extremity numbness and weakness and muscle spasm producing image unsharpness.

     Tiltable MRI scanning provides an un precedented opportunity to see why patients hurt or have neurologic dysfunction when they are standing or bearing weight when previous MRI examinations have been negative or have failed to explain their symptoms. SEE WHAT YOU HAVE BEEN MISSING!!

     In the setting of personal injuries, Tiltable MRI at Salubrio MRI makes the difference between a dismissed case and getting the injured party the treatment for the injuries sustained during the accident.

     Spinal surgeons find their surgical pre-authorization applications are more successful when accompanied by pictures showing neurologic compression during weight-bearing whereas images while supine show no neurologic compression. Traditional supine non-weight-bearing MRI examinations would fail to show the neurologic compression required to justify surgical treatment. In this setting, a Tiltable weight-bearing MRI  showing why the patient hurts is priceless to the suffering patient.


Figure 3A Sagittal Supine


Figure 3B Sagittal Sitting

Salubrio Tiltable weight-bearing MRI is the “MRI WORTH WEIGHTING FOR”!!!

Posted in News- Salu Brio MRI

Metal Artifact Reduction Sequence MRI (MARS) – Cervical Spine

Metal Artifact Reduction Sequence MRI (MARS) – Cervical Spine

     Cervical Spinal Fusion: The Advantages of Combining Metallic Artifact Reduction Sequences (MARS Protocol) with Low Filed Strength MRI on an Esaote G-Scan Brio Tiltable MRI™.

     Metallic implants and fixation plates are an inherent part of spinal fusion surgery and metallic implants have the potential of creating “metallic artifact” during magnetic resonance imaging (MRI) because implants that have any forromagnetic properties will induce a local magnetic field when placed within a magnetic field. This induced field or artifact has the appearance of a black area surrounded by a bright ring on MRI.

     The size of the artifact is related to three primary things: 1. the size, composition and orientation of the implant; 2. the strength of the MRI (i.e. the stronger the MRI (high field strength) the greater the artifact; and 3. use of any metallic artifact reduction sequences (MARS protocol).

     Implant Composition: Many contemporary implants are constructed of Titanium and the induced artifact is inherently small. However, there may be impurities in the production method that introduce contaminants with ferromagnetic properties. For this reason, even identical implants from different production batches may have strikingly different artifact profiles.

     MRI Field Strength: One of the greatest advantages of lower field strength MRI scanners for spinal MRI is that they produce much less artifact than high field strength MRI. In the example below, an individual was scanned in a 1.5 Tesla GE MRI using MARS protocol to reduce the artifact from the cervical fixation plate Figure 1). Despite use of MARS protocol, the black metallic artifact extended into the spinal canal and obscured visualization of the spinal cord. In order optimize evaluation of the spinal cord and fixation plate, the same individual was re-examined using a the Salubrio Esaote G-scan Brio Tiltable MRI (TM symbol) using MARS protocol within a few days of the initial MRI. There is minimal artifact. The artifact on the spinal cord is absent and the marrow signal adjacent to the fixation screws can be evaluated. The signal-to-noise is comparable to the high field strength MRI.

     MARS Protocol: Metallic artifact reduction sequences (MARS protocol) were created to mitigate the inherent problems problems with high field strength MRI scanners. High field filed strength MRI scanners (1.5T and 3.0T) have the advantages of faster scanning and higher signal-to-noise ratios. These are very important for many types of imaging but come at a cost- larger metallic artifacts. Even micro-metallic artifact from a needle injection or shaving of bone from a laminotomy can produce limiting artifact using high field strength MRI. In most cases the inherent low metallic artifact induced by low filed strength MR makes the use of MARS protocols unnecessary although MARS protocols can further mitigate metallic artifact in problem cases.

     I believe that low field MR  should be the first MRI of choice when there are metallic implants in the spine that would produce undesirable metallic artifact using high field strength MRI.

     Please follow us on Twitter and visit our website. We are available for Management of MRI scanners or Expert Teleradiology Services.  

GE 1.5T

Non-Brio 1.5T Cervical

Mars Cervical Brio

Brio San Antonio .25T Cervical


Posted in News- Salu Brio MRI

MRI of the Brachial Plexus using Esaote G-Scan Brio Low Field Strength MRI

MRI of the Brachial Plexus using Esaote G-Scan Brio Low Field Strength MRI


     The brachial plexus is the collection of nerve fibers extending between the nerve roots exiting the lower cervical and upper thoracic spine (i.e. C5-T1) and regrouping 4 times before ending as the terminal branches in the axilla. The five nerve roots collect to form three trunks: the upper (C5 & C6); the middle C8 & T1). Each of these three trunks divide into anterior and posterior divisions (6 total) that regroup to form three cords named according to the position of the cord to the subclavian artery. The posterior cord is formed by the posterior divisions of all three trunks. The lateral cord is formed from the anterior divisions of the upper and middle trucks (C5-7) and the medial cords formed bye anterior divisions of the lower cord (C8 & T1).

     Optimal MRI imaging of the brachial plexus using low field strength MRI scanners is technique dependent. The brachial plexus can be considered The five nerve roots exist the cervical spine exit the spinal canal through the neural foramina of C5-T1 The roots  and three trucks within the scalene muscles are typically examined during the MRI of the cervical spine and are best examined on the axial, coronal and sagittal oblique images (perpendicular to the long axis of the cervical neural foramina).

     The MRI of the brachial plexus typically concentrates on the appearance of the divisions, cords and branches in relation to the subclavian. The optimal imaging planes for the brachial plexus are the coronal oblique, axial oblique, and sagittal oblique planes in the long and short axes of the subclavian and axillary segments of the artery around which the are distributed. Esaote G-scan Biro MRI utilizes 2-plane localization so optimal imaging planes can be selected along the long and short axes of the subclavian artery. The imaging planes produce imaging planes along the long axis and short axis of the brachial plexus components. 

    1A                                         1B


    1C                                          1D






     The first images (1A and 1 B) show the coronal oblique and the axial oblique images through the brachial plexus. The right subclavian artery has fast blood flow and is black. The divisions and cords and branches are the tubular structures alongside the black subclavian (medial segment) and the lateral axillary segment of the artery). Figures 1C and 1D show sagittal oblique images through the brachial plexus and demonstrate the more medial trunks (1C) the more lateral cords (1D). Figure 2A shows a diagrammatic representation of the brachial plexus from an anterior view. Figure 2B shows an anatomic dissection of right brachial plexus.

     If the examiner uses carefully designed imaging panes and is meticulous about technique one can obtain quality MRI imaging of the brachial plexus using Esaote G-scan Brio MRI.


Images provided courtesy of Brio San Antonio, San Antonio Texas. www.salubrioMRI.com

Posted in News- Salu Brio MRI

Brio Adding More!!

Brio San Antonio is growing and getting stronger every day. Brio San Antonio has now reached some new accomplishments.

Brio San Antonio is now ACR Accredited!!!
Athena Health2  
You can now order through Athena Health!!!

athea ordering

One_Call2    TX7AV

You can now order through One Call Medical!!!

Humana is Here!!!


Posted in News- Salu Brio MRI

10 Megatrends Shaping Healthcare’s Next 10 years

10 Megatrends Shaping Healthcare’s Next 10 years


Megatrend #1: Consumers Take Charge

Diego Miralles, MD, Head of Janssen Healthcare Innovation, points out that “Empowering and trusting consumers with their own information could unleash huge efficiencies in healthcare.” As patients have both more information about health issues and better tools for monitoring their own behaviors and health status, they are gaining more control over their care. Consider that in the U.S .alone more than 75% of healthcare costs result from chronic diseases—many of which are preventable with the right behaviors—and the importance of consumers taking charge of their own health is clear. Sub-trends supporting “consumers in charge” include:

  • The birth of insurance Marketplaces, resulting in the “Insured Consumer.” Healthcare Marketplaces will result in new shoppers comparing plans and prices. At the same time, high-deductible and cost-sharing plans will lead to a new awareness of care costs—and new options, such as limited provider networks, for lowering expenses.
  • The “information everywhere” phenomenon, leading to the “Engaged Consumer.” Transparency is the word of the decade. From the prices of drugs and hospitals to the clinical facts about conditions to the scoop on doctors and treatments shared on social media, any information we want will be readily available.
  • The explosion in self-care, creating the “Responsible Consumer.” Consumers will be increasingly responsible for managing their own health. As a result, we’ll see fast growth in home-based self-care, as well as self-monitoring technologies. Initiatives such as “pay for performance” and “patient-centered medical home” will further spur the self-care trends.
  • Health communities, supporting the “Active Consumer.” Community action will be the new foundation for building better consumer behaviors, including improved diet and exercise habits. From employers to social services to public health to providers, organizations and individuals will join together to encourage healthy lifestyles and reduce the costs of chronic, preventable diseases.

Megatrend #2: More with Less: From Volume to Value

Doing more with less is an over-arching theme of our revamped healthcare system. Across the board, stakeholders will need to support higher quality, better outcomes and greater patient satisfaction —all while reducing costs. “Value” will be a central focus, as we seek to improve the results we achieve for every dollar we spend. Six “sub-trends” will support the megatrend of delivering the best performance with the least expense:…



Courtesy of http://www.lexology.com


Posted in News- Salu Brio MRI

HHS’s mixed messages:identifying a federal healthcare program when you see it


HHS’s mixed messages:identifying a federal healthcare program when you see it

Recent seemingly contrary determinations by the U.S. Department of Health and Human Services (HHS) have fueled industry speculation regarding whether qualified health plans (QHPs) available on the health insurance exchanges would be considered “federal health care programs,” and thus subject to the various fraud and abuse laws applicable to such programs, including the federal anti-kickback statute.

A QHP’s status as a federal healthcare program has been of particular interest to providers that may be considering subsidizing QHP premiums for individuals purchasing coverage on the marketplace. Federal law generally defines a “federal health care program,” as “any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government” (other than the Federal Employee Health Benefits Program). If QHPs are found to be federal healthcare programs, such practice could arguably expose providers to sanctions under the anti-kickback statute, which is a broadly worded prohibition on the offer, payment, solicitation or receipt of remuneration intended to influence the referral of items or services to be paid for by a federal healthcare program.

(Read More)


Courtesy of  http://www.lexology.com/

Posted in News- Salu Brio MRI

Positional Neuropathy While Standing?

Dynamic Foraminal Stenosis


Supine           For.Sten.WB_09

       Supine                    Weight-Bearing

Positional Neuropathy While Standing?


How often have you heard someone say that when he stands up he experiences focal pain, numbness or weakness in a particular nerve root distribution that is relieved by lying down. The positional nature of the symptoms and the neural dysfunction suggest that there is nerve root compression or irritation while standing and relived while supine (non-wright bearing). It should not be surprising that MRI imaging performed in supine position would fail to demonstrate the nerve root compression that is only present when the individual is supine.

The sagittal T2-weighted image on the left was obtained in the supine position through the right L4-5 neural foramen and shows fat surrounding the right L4 nerve root. The sagittal image on the right was obtained while standing and shows loss of vertical disc height, overriding of the fact joints and an intraforaminal disc herniation with positional dynamic nerve root compression.

These images display the importance of weight-bearing MRI imaging for the evaluation of patients with positional pain or neuropathy that is worse when standing or weight-bearing.

Posted in News- Salu Brio MRI
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