X-ray technology has been used by chiropractors since the early 1900s. Originally, it was used to visualize the alignment of spinal vertebrae and direct appropriate treatment. Based on the state of knowledge at that time, it made sense. More recently, evidence about the diagnosis and management of spinal pain has prompted a transition from a static mechanical model, which supports the use of x-rays, to a patient-centered model within a biopsychosocial context. When you combine this with the low diagnostic yield of most radiographic findings and an increased awareness of the risks associated with x-ray exposure, the routine used of imaging must be questioned and considered within the context of existing evidence. To illustrate, current evidence-based practice guidelines recommend limiting imaging to cases of suspected underlying serious pathology or trauma.
This review summarized the current evidence for the use of spinal x-rays within chiropractic practice, with consideration given to the related risks and benefits…LOG IN OR SUBSCRIBE TO ACCESS THIS REVIEW!
“Spinal X-Ray Use in Chiropractic – Current Evidence”
This paper was published in Chiropractic & Manual Therapies (2018) and this Review is posted in Recent Reviews, Clinical Testing & Procedures, Clinical Practice and the 2019 Archive.
spinal imaging
So - when SHOULD we x-ray?
Evidence-Based Recommendations for Diagnostic Imaging of the Spine for Chiropractors:

Spinal Fracture (cervical):
  • Alerting Clinical Features: Canadian C-Spine Rule – history of cervical trauma – performed in this order: 1) at least one high risk factor (age 65+, dangerous mechanism of injury, extremity paresthesias); 2) absence of all low risk factors (simple rear-end MVA, sitting position upon presentation, ambulatory at any time post trauma, delayed onset of neck pain, absence of midline tenderness); 3) inability to actively rotate neck 45 degrees right and left.
  • Imaging, Referral or Clinical Action: cervical x-rays (AP, open-mouth, lateral); perhaps CT or MRI.
Spinal Fracture (other region):
  • Alerting Clinical Features: spinal pain after significant trauma with multiple risk factors – older age (65+ for women, 75+ for men), history of osteoporosis, prolonged use of corticosteroids, severe trauma, contusion or abrasion.
  • Imaging, Referral or Clinical Action: x-ray (if negative with strong clinical suspicion – obtain MRI or CT).
  • Alerting Clinical Features: new onset spinal pain with history of cancer, prior cancer, unexplained weight loss, pain at rest or at night, failure to improve with one month of conservative care, age > 60 (especially with first time spinal pain – most will have had back pain by this point!).
  • Imaging, Referral or Clinical Action: MRI preferable, x-ray if only/immediate option, blood tests.
  • Alerting Clinical Features: new onset spinal pain with risk factors – fever or chills, history of infection, history of IV drug use, recent surgical procedure, pain with rest or at night.
  • Imaging, Referral or Clinical Action: MRI and blood tests, specialist referral.
  • Alerting Clinical Features: chronic pain (> 3 months) with risk factors – age < 40, insidious onset, improves with exercise, alternating buttock pain, pain at night, positive family history, extremity articular symptoms, improvement with NSAIDs, extra-articular symptoms (psoriasis, inflammatory bowel disease, uveitis).
  • Imaging, Referral or Clinical Action: x-ray and blood tests (if negative and strong clinical suspicion seek MRI), specialist referral pending imaging/lab results.
  • Alerting Clinical Features: back or neck pain with leg or arm pain, sensory loss, weakness or decreased reflexes.
  • Imaging, Referral or Clinical Action: single level radiculopathy = conservative care first; multi-level or progressive radiculopathy = imaging and specialist referral.
Lumbar Spinal Stenosis:
  • Alerting Clinical Features: older age, buttock/thigh/leg pain, worse with walking/standing, relieved with sitting or flexed postures.
  • Imaging, Referral or Clinical Action: non-surgical candidates = trial of appropriate care before further workup; surgical candidates = MRI and specialist referral.
Spinal Cord Compression:
  • Alerting Clinical Features: Risk factors for cervical myelopathy – neck pain with multi-level, progressive upper limb neurological deficits (especially motor/reflex), older age, increased lower limb reflexes. Risk factors for Cauda Equina Syndrome (CES) – multi-level, progressive lower limb neurological deficits (especially motor/reflex), new bowel or bladder dysfunction, saddle anesthesia.
  • Imaging, Referral or Clinical Action: acute/severe symptoms = emergency referral; chronic/less severe symptoms = ultrasound or MRI with specialist consultation/referral.
Arterial Dissection, Stenosis or Aneurysm:
  • Alerting Clinical Features: Cervical spine risk factors – severe, persistent or unusual headache, cranial or upper limb neurological symptoms. Thoracic spine risk factors – severe chest or back pain, hypotension, absent distal pulses. Lumbar spine risk factors – severe abdominal, back or groin pain, hypotension, absent distal pulses.
  • Imaging, Referral or Clinical Action: acute/severe symptoms = emergency referral; chronic/less severe symptoms = ultrasound or MRI with specialist consultation/referral.
  • Alerting Clinical Features: major risk factors – history of fracture with minimal trauma, prolonged corticosteroid use, older age (65+ in women, 75+ in men), premature menopause, hypogonadism (males), predisposing condition (RA, hyperthyroidism, hyperparathyroidism, chronic kidney or liver disease, celiac disease); minor risk factors – parental history, low physical activity, low body weight, poor nutrition, poor balance, frequent falls.
  • Imaging, Referral or Clinical Action: DXA scan or spine and proximal femur
Progressive Spinal Structural Deformity:
  • Alerting Clinical Features: child or adolescent – rigid coronal or sagittal curve, positive Adam’s forward bending test, rib humping; adult – rigid coronal or sagittal curve with either acute presentation or recent progression of curve.
  • Imaging, Referral or Clinical Action: x-ray and specialist referral if underlying pathology or large Cobb angle (> 25 degrees).

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