Guidelines in the Use of Radiography in Chiropractic

For more than 80 years, x-ray has been an integral part of chiropractic and many developments in use of postural x-ray are attributed to chiropractors.¹ X-ray has been utilized to determine the pathological or anatomical abnormalities and to provide information relative to the structural and functional status of the musculoskeletal system.² Investigators^1-15 have found that x-rays make good policemen but poor counselors when it comes to predicting the outcome of patient care. Poor correlation between many radiographic findings and symptoms has been reported. Ongoing research into the effects of x-rays to the body predicate the use of common sense in the ordering of x-ray studies.^15-19 Since radiographic studies are useful in some, but not all, instances in determining the patient's diagnosis and because of the possible radiobiological effects of x-ray, The American Chiropractic College of Radiology has published guidelines for the use of radiography in chiropractic (Table 1). Routine radiography and repeat radiography are elaborated upon in this paper.

Certain generalized clinical findings (Table 2) have been correlated with a higher incidence of pathological and/or mechanical abnormalities which can be further differentiated through the use of x-ray. These clinical findings, although generalized, help to define those patients in which x-rays should be a part of their diagnostic work-up. Many conditions result in back or neck pain but serious pathological diseases as opposed to biomechanical failures are rare enough that routine radiography or radiography as a screening procedure of patients cannot always be justified. Kovah, et al., in 1983²⁰ observed that 55% of the x-ray studies taken at National College of Chiropractic in 1982 were read normal. Liang, et al., found that the probability of specific diseases requiring specialized treatment to be higher in referral practices than in primary care practices. They quote a study in which 18.4% of the patients required specific treatment. A retrospective review of the x-ray studies reported on by this author from 3-12-90 through 3-23-90 (350 studies) reveals 41 (11%) patients with significant radiographic findings which required alterations of patient treatment recommendations. Therefore, there is approximately a 10-20% chance of finding a significant pathology on x-ray. Through adequate clinical screening those patients likely to have a positive x-ray finding can be selected. Routine radiography without the focus provided by a thorough clinical evaluation is overexposing the patient to x-ray.

For this reason, repeat radiography must follow the same criteria (Table 2) with the addition of the following guidelines:

1. When a exam is to be repeated, full studies are rarely necessary. One or two views are usually enough to provide adequate comparison. Example: The initial abnormality appeared on a flexion or extension lateral cervical film. Repeat views in flexion and extension views allows comparison for the progression or stabilization of the abnormality.
   


2. Patient symptomatology persists or worsens after spinal manipulation is initiated. For instance, possibility of occult fracture or unsuspected pathology.
   


3. To study the development of arthritic changes after trauma (hyperflexion/hyperextension), repeat x-rays prior to four months post injury are of little help. If the patient has spondylosis at the time of the injury, changes in the arthritic process may not be visible for a year or more post injury.
   


4. Certain conditions taken on an individual basis, like idiopathic scoliosis, inflammatory arthritis, benign tumor growth, occupational exposure, exposure to carcinogens, etc., may require periodic follow-up x-rays.
   


5. There is only one reason to x-ray the non-discogenic patient within four weeks of the initial x-ray study that is to evaluate persistent, acute symptomatology which is often significant enough to make spinal manipulative therapy impossible to perform or limited to mild applications only. The patient may have deep bone pain, restricted range of motion, arthralgia or neurological deficit which could indicate an underlying tumor or inflammatory disease. In the discogenic patient, or the patient suspected of having an intervertebral disc herniation, MRI (Magnetic Resonance Imaging) or CT (Computed Tomography), not further plain x-ray, is recommended.

If questions arise regarding how best to approach a repeat radiographic study, consultation with a D.A.C.B.R. (Diplomate American Chiropractic Board of Radiology) can be helpful.

As we move into the 1990's, federal regulations and legislation are likely to place parameters on the use of x-ray. We will be required eventually to maintain records for each patient's exposure. Two states, Vermont and Illinois have already enacted laws requiring a maximum permissible dose for patients. Strict guidelines limiting the use of the skull x-ray in trauma centers and the chest film in hospital admissions have been set. With the ever increasing public awareness of the potential hazards of excessive radiation, it is only prudent that this profession begins to think of these guidelines as well.

Table I

Radiographic Guidelines for Use in Chiropractic

The American Chiropractic College of Roentgenology hereby adopts and establishes the following guidelines for the use of radiography in chiropractic:

1. Routine radiography of any patient should not be performed without due regard for clinical need.
   


2. Any offer or advertising of free x-rays to actual or potential patients shall be accompanied by a statement that, to avoid needless health hazards associated with ionizing radiation, no such free x-ray will be given unless there is a prior observable clinical need for it.
   


3. Avoidance of split screen radiographic techniques or other mechanisms which compensate for tissue thickness by altering the screens or the light emission from the screens, such as the occluding of one of the screens of the cassette, is recommended.
   


4. Repeat radiographic evaluation of the patient should not be undertaken without significant observable clinical indication, as determined by the treating chiropractic physician.
   


5. Pregnant females should not be radiographed unless the patient's symptoms are of such significance that the proper treatment of the patient might be jeopardized without the use of such radiographs.
   


6. Radiographic procedures should not be undertaken without the use of appropriate compensating filters and gonad shielding, except where such gonad shielding would exclude an area from examination which is clinically necessary to examine.
   


7. Females with reproductive potential, or where the possibility of pregnancy exists, should be radiographed only where clinically necessary and, preferably, during the first ten days following onset of menses.

The above guidelines are based on the recognized principle that exposure to unnecessary ionizing radiation represents an unwarranted health hazard.

The guidelines are consistent with rules of conduct when employing radiographic procedures common throughout the health care community and are consistent with those recommended by the Center for Devices and Radiological Health, Food and Drug Administration of the Department of Health and Human Services.

Revised, and approved: Houston, Texas, November 3, 1984.

Table 2

Selected Clinical Indications for Initial X-ray Examination1-15

1. Trauma -- Examples include:
   a. Fall from a height
   b. Motor vehicle accident
   c. Direct blow
   d. Workers' compensation injury/litigation
   (If the patient does not fit any of the following criteria, then x-ray is not required unless the patient does not respond readily to treatment within two to four weeks.)
   


2. Unexplained weight loss of 4.5 kilograms or more over the preceding six months.
   


3. Unrelenting pain at rest.
   


4. Evolving neurological deficit suggestive of intervertebral disc pathology, stenosis or tumor.
   


5. Known history of cancer, corticosteroid use, IV drug use, use of blood thinners, and known endocrine diseases.
   


6. Pinpoint bony tenderness over the vertebral spinous process.
   


7. Painless loss of joint play indicating a transitional segment or block vertebra or some other form of spinal fusion.
   


8. Step defect in spinous alignment suggestive of spondylolisthesis.
   


9. Significant scoliosis is observed from the physical exam.
   


10. Patient over age 50.
    


11. Suspected spinal instability.

References

1. Philips, R.B., et al. Low Back Pain: A Radiographic Enigma. JMPT 1986; 9(3): 183.
2. Philips, R.B. The Use of X-Rays in Spinal Manipulative Therapy: IN. Haldeman, S., editor. Modern Developments in the Priniciples and Practice of Chiropractic. East Norwalk, Conn. Appleton-Century-Crofts 1980; 189-208.
3. Deyo, R., et al. Observer Variability in the Interpretation of Lumbar Spine Radiography. Arthritis & Rheumatism; 28(9): 1066-1070.
4. Libson, E., et al. Oblique Lumbar Spine Radiographs: Importance to Young Patients. Radiology 1984; 151: 89-90.
5. Scavone, J.G., et al. Anteroposterior and Lateral Radiographs: An Adequate Lumbar Spine Examination. AJR 1981; 136: 715-717.
6. Frymoyer, J.W. Back Pain and Sciatica. New England Journal of Medicine 1988; 291-300.
7. Liang, M., et al. Roentgenograms in Primary Care Patients with Acute Low Back Pain: A cost-effectiveness analysis. Arch of Int Med. 1982; 142: 1108-1112.
8. Frazier, L.M., et al. Selective Criteria May Increase Lumbosacral Spine Roentgenogram Use in Acute Low Back Pain. Arch of Int Med. 1989; 149: 47-50.
9. Deyo, R.A. Plain Roentgenography for Low-Back Pain: Finding Needles in a Haystack. Arch of Int Med, 1989; 149: 27-29.
10. Hall, F.M. Back Pain and the Radiologist. Rad 1980; 137: 861-863.
11. Scavone, J.G., et al. Use of Lumbar Spine Films, a Statistical Evaluation at a University Teaching Hospital. JAMA 1981; 246: 1105-1108.
12. Mootz, R.D., et al. Minimizing Radiation Exposure to Patients in Chiropractic Practice. ACA Journal of Chiropractic, April 1989.
13. Deyo, R.A., et al. Diagnostic Imaging Procedures for the Lumbar Spine. Ann of Int Med, 1989; 111(11): 865-867.
14. Eisenberg, R.L., et al. Compensation Examination of the Cervical and Lumbar Spines: Critical Disagreement in Radiographic Interpretation. AJR 1980; 134: 519-522.
15. Gehweiler, J.A., et al. Low Back Pain: The Controversy of Radiological Evaluation. AJR 1983; 140: 109-112.
16. McNeil, B.J. Use of Medical Radiographs: Extent of Variation and Associated Active Bone Marrow Doses. Radiology 1985; Vol. 156: 51-56.
17. Maurer, E.L. Biological Effects of Diagnostic X-ray Exposure: An update of principles, revised maximum permissible dose recommendations, and new patient protection legislation. AJCM Sept. 1988; 1(3): 115-118.
18. Villforth, J.C. Medical Radiation Protection: A long view. AJR 1985; 1114-1118.
19. Hall, E.J. Radiobiology for the Radiologist, 3rd ed., 1988; New York, N.Y., J.B. Lippincott Company.
20. Kovach, S.G., et al. Prevalence of Diagnosis on the Basis of Radiographic Evaluation of Chiropractic Cases. JMPT 1983; 6(4): 197-201.