When do you need an x-ray for back pain? This is a question I get asked on a regular basis. Many people that I meet are under the impression that a chiropractor needs x-rays of the spine to diagnose. Perhaps surprising, it’s quite rare for an x-ray to be the sole factor that provides a diagnosis for low back pain. Diagnosing low back pain is a rather complex task that takes many factors into consideration. These factors include (but are not limited to) the history of the condition and positive tests during the orthopedic examination. In other words, most cases of lower back pain can be diagnosed through a discussion of your condition and a physical examination. So why not x-ray? When do you need x-rays for back pain?
X-rays involve exposing patients to radiation. Although the exposure might be considered minimal, needless exposure to radiation doesn’t make sense for anyone. The diagnostic benefit of the study must outweigh the harmful exposure to radiation. In many cases of uncomplicated new lower back pain, x-rays will not provide insight into the nature of the condition nor will they have any bearing on the treatment approach. In cases like this, x-rays should be avoided. Furthermore, imaging and special diagnostic tests can sometimes lead a patient (and practitioner) down an unnecessary diagnostic path. Incidental findings can confuse practitioners and worry patients. We can view things that aren’t related to the current complaint, and they then require further tests to clarify the findings. Often, this does not add to the diagnosis nor do these further queries amount to anything of importance.
So, when are spinal x-rays necessary? A very large focus of the chiropractic education is diagnosis and being able to identify worrisome symptoms. Some of these symptoms are referred to as “red flags”, and their presence makes an x-ray appropriate. Examples of red flags include signs or symptoms suggestive of cancer, infection or severe neurological injury. These include night pain, unexplained weight loss, numbness in the saddle area and the loss of bowel/bladder control. “Red flags” are not the only reason to refer for x-rays though. Sometimes we see patients in our Burlington chiropractic clinic who have persistent lower back pain that has failed to respond to various treatments (chiropractic, massage therapy, acupuncture, and physiotherapy). In the case of a herniated lumbar disc causing symptoms of unrelenting sciatica that has not responded to any form of treatment, a surgical consult might be warranted so an x-ray before this might make sense. Failure to respond to treatment is a good reason to refer for x-rays, but remember, this concern might either relate to an undetected “red flag” or it may mean that you’re considering surgery for your back pain.
X-Rays and Patient Safety
Perhaps it is common that patients can become frustrated when their doctors don’t refer them for special tests related to their back pain. Keep in mind that your doctor is likely acting in your best interest. There are guidelines for referral, and the reasoning doesn’t always relate to the cost of the test. Many of the reasons for not referring are for patient safety. Good practitioners use the best available evidence to guide their clinical decisions, including when to send for spinal x-rays. Evidence-informed practitioners will make decisions based on what the most recent literature suggests combined with what they know about you as a person and what is right for you.
If you found this blog interesting, check out a website called “choose wisely.” It has some really great information on it about when doctors refer for tests and why they sometimes don’t refer. The site encompasses many different areas of healthcare, not just lower back pain. It will help you understand some of the common challenges that medical professionals face when tasked with the burden of ordering tests. Sometimes the internet can spread misconceptions and bad advice, scaring patients into thinking that diagnostic imaging is necessary for all types of back pain. Choose wisely does a very good job at explaining that challenge so patients and practitioners can make good decisions regarding treatment and diagnosis for various areas of health.