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Chiropractors have historically performed x-rays as part of a new patient assessment, thereby delaying treatment until visit two. This policy arguably improves care plan compliance. However, “compliance” is often synonymous with “over utilization”. The emerging health care model necessitates providing the most clinically efficient and cost effective care.

Evidence-based recommendations from the American College of Physicians (ACP) and the American Pain Society (APS) suggest that routine spinal imaging of benign lower back pain may be unnecessary. Guidelines suggest “imaging only for patients who have:

  • severe or progressive neurologic deficits or
  • signs or symptoms that suggest a serious or specific underlying condition” (1).

With regard to cervical spine injuries, the American College of Radiology suggests imaging when there is a dangerous mechanism of injury. High-risk injury candidates include those:

  • over 65 years of age
  • have radiating neurologic signs or symptoms
  • have midline cervical spine tenderness or
  • significant (greater than 50%) loss of range of motion  (2)

Radiographs are also appropriate for patients with “red flags” including a history of:

  • cancer
  • unexplained recent weight loss
  • bone disease
  • systemic disease
  • inflammatory arthropathy
  • steroid use
  • immune suppression
  • fever
  • nocturnal pain
  • prior spine surgery
  • patients with suspected congenital deficit or instability
  • those whose pain is usually severe, progressive, prolonged or unaffected by position

Radiographs may also be needed to rule out suspicion of bony pathology like vertebral compression fracture or spondylolysis/ spondylolisthesis.

In many cases, evidence-based providers no longer perform x-rays as part of an initial workup for uncomplicated mechanical spine pain. There are a percentage of patients whose history or exam necessitates films. Occasionally this means delaying treatment…and expectations. Patients who seek our services are looking for immediate attention. Telling a patient that you will not be treating them on the first visit can prove to be a tricky conversation. Check out this ChiroUp Defining Moments video that provides a template for this conversation.

1. Chou R,  Fu R,  Carrino JA,  Deyo RA.  Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463.-72
2. Stiell IG,  Wells GA, The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients JAMA October 17, 2001, Vol 286, No. 15

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman


Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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