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Why Not X-ray Every Patient?

sethtkintigh

Updated: Aug 12, 2022

One of the questions that we get asked frequently at our practice is “Why don’t you x-ray every patient?” Some people love that we don't x-ray everyone because it saves them a few bucks on their initial exam. Others are concerned, asking: “What if we are missing some arthritis or a disc herniation because we didn't take an x-ray to look inside?” So we wanted to take some time to give our reasoning for taking the stance of only x-raying patients when it is indicated in their history and exam.

Here are some helpful definitions to make the read a little easier.

Definitions:

X-Ray (Radiographs): An imaging technique used to see images of bony tissue (and very little soft tissue. This is not the best way to see soft tissue and shows no clear definition of soft tissue including discs, ligaments, muscles, and tendons).

Musculoskeletal Conditions: musculoskeletal conditions are conditions that involve the muscles, bones, ligaments, and joints of your body. A pulled hamstring or a sprained ankle would be examples of musculoskeletal conditions. Most low back and neck pain fall under this category.

Conservative Trial of Care: A conservative trial of care is what we do in our office. It is trying to take care of a musculoskeletal condition without invasive measures such as surgery. A typical conservative trial of care is consistently working with whichever healthcare provider you are doing your trial of care with over a period of about 4 to 6 weeks.

Clinical Guidelines: These are recommendations for the best way to treat typical conditions. These guidelines are created by looking at all of the available and up to date research then determine the treatments and procedures that lead to the best results and make the biggest impact in the lives of those living with these conditions.

Reasoning:

Now that you have some basic understanding of our terminology, let’s walk through the reasoning. Overall, there really is one simple reason we do not X-ray every patient that walks through our door. As an office that operates under an evidence-based practice model, we need to be able to justify every action we do in our office through the combination of scientific research, our clinical experience, and the goals of our patients. When it comes to X-ray, the research simply does not support imaging every patient¹. In fact, it actually supports the complete opposite. A systematic review of current clinical guidelines actually discourages the use of diagnostic imaging and specifically X-ray for musculoskeletal conditions¹. What they do recommend is a thorough history and physical exam¹. If the findings from these two things point toward a musculoskeletal condition, then a conservative trial of care is indicated before any images are taken.

Another reason we do not image every patient is because there are a fair number of positive findings even in people who have no pain when performing these studies. A great example of this is found in the study performed by brinjikiji et. all. in 2015 that looked at the results of imaging studies across many patients of many ages that had no symptoms of low back pain at all.

The table below shows the percentage of patients in the study that had findings like degenerative disc disease or arthritis in their low back yet they have absolutely no pain or complaint.

Findings

Age

Age

Age

Age

Age

Age

Age

20

30

40

50

60

70

80

Disc Degeneration

37%

52%

68%

80%

88%

93%

96%

Disc Signal Loss

17%

33%

54%

73%

86%

94%

97%

Disc Height Loss

24%

34%

45%

56%

67%

76%

84%

Disc Bulge

30%

40%

50%

60%

69%

77%

84%

Disc Protrusion

29%

31%

33%

36%

38%

40%

43%

Annular Fissure

19%

20%

22%

23%

25%

27%

29%

Facet Degeneration

4%

9%

18%

32%

50%

69%

83%

Spondylolisthesis

3%

5%

8%

14%

23%

35%

50%

If this percentage of people with no pain have these findings on images taken, then how can we know for sure that what we are seeing on the image is what is causing the pain? The answer is that we can’t. This is where knowing the history of your complaint and being able to do a thorough exam is going to yield more useful information than only looking at a picture of your back. Arthritis and disc degeneration is simply part of the normal aging process. According to the findings above, four out of five 50 year-old people without back pain will have degeneration of the discs in their backs². So then is the degenerated disc in your back really the cause of the pain? It could be part of the contributing factors. But it is unlikely to be the sole cause.


Do we ever x-ray any patients?

Yes, of course we refer patients for imaging when it is indicated. According to clinical guidelines, there are three indications for imaging (most commonly x-rays but also MRI and CT):

  1. There is suspicion of serious pathology. This is why a thorough history and examination are important. We ask questions that will expose any “red flags” that would make us suspect something more sinister being the underlying cause for your complaint. An example of this would be someone who has a history of cancer and has started having back pain that is worse at night with no position that brings relief. That is why we take the time to carefully talk about your condition and ask questions about other body systems as well. We must rule out red flags.

  2. The patient has failed to respond to a conservative trial of care. If we have been working with you for four to six weeks and have seen no change in your condition, then imaging is warranted because a majority of musculoskeletal complaints respond favorably to conservative trials of care within this amount of time. However, if you have failed to respond, sometimes more aggressive treatment options must be pursued and those almost always require advanced imaging.

  3. If potential findings would change the course of care. A great example of this would be someone who has been in a car accident and is having low back pain. The differential diagnosis could be a muscle spasm in the low back due to the amount of forces that were transferred through your back during the accident. In our office we would treat that with muscle work and some gentle adjusting to the low back and pelvis. However, another differential diagnosis could also be a fracture of the vertebrae. We would not treat that in our office and the treatments list above would actually be inappropriate for a fracture. So the results of the imaging would dictate which treatment/referral route we took. Therefore it would be appropriate and actually prudent to get advanced imaging for that patient.

So, in summary, here is why we don’t x-ray everyone:

1) We can take a good history of your condition and do a thorough physical exam to stress the suspected tissues and confirm they are the pain generators. Looking at the information above, we know we can actually trust the history and exam more than the images. Why wouldn't we use this cheaper alternative that doesn't expose our patients to any amount of radiation?

2) If we did confirm the suspected condition on x-ray, it would not change our treatment plan at all because we know there are likely these changes present anyway due to normal aging processes.

3) The current clinical guidelines actually discourage the use of imaging on most musculoskeletal conditions. We choose to follow these guidelines so that we can continue to deliver the best possible care to our patients and get them healthy as quickly, safely, and inexpensively as possible.


Questions? Feel free to call our office at 231-366-6035 or email us at watersedgespine@gmail.com.


References:

  1. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O'Sullivan PPB. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020 Jan;54(2):79-86. doi: 10.1136/bjsports-2018-099878. Epub 2019 Mar 2. PMID: 30826805.


  1. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.

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