A question that comes up frequently in our office has to do with whether or not a patient needs spinal x-rays as part of their initial evaluation. The short answer is occasionally. For a very long time, it has been commonplace to visit a chiropractor and upon your initial visit, you receive spinal x-rays. Though we agree diagnostic imaging, including x-rays, MRI, CT scans, etc. are great tools to use, we also believe that there are many factors a doctor must take into account when determining if x-rays are appropriate. For this reason we collect a detailed history and perform a thorough examination to see if any findings suggest the necessity of diagnostic imaging. Unfortunately, there are some scary things that can cause pain such as cancer, infections or fractures and diagnostic images can be very helpful in determining if your pain is being caused by one of these things.
The following is a list of “red flags” or indicators that diagnostic imaging should be used. These are according to the American College of Radiology Appropriateness Criteria and are specific to low back pain (other complaints may have slightly different criteria). They are as follows:
- Recent, significant trauma, or milder trauma for those people older than 50
- Unexplained weight loss, unknown cause or onset
- Unexplained fever
- History of Cancer
- History of Intravenous drug use
- Prolonged use of corticosteroids and/or osteoporosis
- Age over 70 (50 if osteoporotic or have known compression fractures)
- Focal neurologic deficit with progressive or disabling symptoms
- Symptoms with duration longer than 6 weeks
- Pain at rest that is not changed with movement
The use of MRI is warranted by:
- Progressive objective (measureable) neurologic signs/motor weakness
- Suspected Cauda Equina Syndrome
- Signs of possible infection
- History of Cancer and new onset of pain
- Trauma and age over 70, or significant osteoporosis
- 4-6 weeks of failed conservative care (particularly with radiculopathy or stenosis)
- Prior spine surgery with new or worsening symptoms
Occasionally, new patients will present to our office with one of these findings in their history. Those patients will promptly be referred to a local imaging facility where a radiologist will conduct the proper follow-up testing in order to rule out anything scary. However, most new patients do not meet these criteria.
In addition to the Appropriateness Criteria, there are other reasons we do not typically take x-rays during your first visit. One of them being that a static picture of you standing against a board tells us very little about what happens to your joints when you are moving throughout your activities of daily living. You see, you are a dynamic being. You move all day long. Rarely are you standing like a statue against the wall unless you happen to be one of the guards at Buckingham Palace. Every position you move to, your spine changes with you and rarely looks like the picture on the x-ray. If you refer back to our first and second posts, you will recall that we are concerned with your ability to move well. An x-ray certainly shows us your bones, but tells us very little about how you utilize coordination, stability, balance and body awareness to control not just your bones, but the muscles, ligaments, tendons and fascia surrounding the bones, and therefore, tells us very little about your quality of movement.
Another reason we do not typically take x-rays on the first visit is that findings on imaging such as degenerative changes and osteoarthritis can often times lead a doctor to falsely assume that these are the cause of your pain. The reality is many people with absolutely no pain at all will frequently have these findings on imaging. Studies have shown as high as 75% of asymptomatic people have at least one cervical disc bulge and 85% of asymptomatic adults have osteoarthritic findings on knee imaging. This could mean that had we taken an x-ray before you became symptomatic, it may have looked the same and showed the same degenerative changes prior to your onset of pain.
So here is what your first visit will consist of:
- A detailed history, including history of your current complaint, past medical history, family history, and a few others
- A thorough, case based examination which may include vitals, orthopedic tests, range of motion and functional movement screens, neurologic testing, and any other testing your presentation may warrant
- Further diagnostic testing if indicated such as imaging and laboratory testing
- Diagnosis and education about that diagnosis
- Homework such as exercises or stretches to help you get continued relief when you are not in our office
Imaging studies are certainly an important tool that can provide a physician with lots of information. However, utilizing them when not indicated can have unwanted side-effects such as needlessly increasing patient cost, unnecessary radiation exposure and also hindering the speed of recovery due to assuming certain findings to be the cause of pain.
If you have any further questions, please do not hesitate to contact our office.
Bedson J and Croft PR. “The Discordance between Clinical and Radiographic Knee Osteoarthritis: A Systematic Search and Summary of the Literature.” BMC Musculoskeletal Disorders. 2 Sept. 2008. Web. 7 May 2015.
Davis PC, Franz JW, Cornelius RS, et al. ACR Appropriateness Criteria® low back pain. Available at http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/LowBackPain.pdf. American College of Radiology. Accessed May 7, 2015
Matsumoto M, Okada, E, Ichihara D, et al. “Age-Related Changes of Thoracic and Cervical Intervertebral Discs in Asymptomatic Subjects.” Spine 35.14 (2010): 1359-364. Print.