By Dr. Trina Ting
As chiropractors, we are fully trained in interpreting x-rays (radiographs), and on how to take them. We take radiology for all 3 academic years and our fourth and full clinical year, learning how to read x-ray pictures of various conditions and also learn on how to take our own x-rays and operate our own machines. Did you know OHIP still covers the fee for x-rays ordered by chiropractic doctors? They won’t pay for the radiologist to read the report (which we still order for the patient as a second opinion) because we are so well trained in interpreting radiographs. In the medical world, only specialized doctors (radiologists) can read x-rays and your family doctor simply reads the report they wrote.
In our office, we refer out to x-ray clinics who can operate the machines much more efficiently than we can. When we are able to do so, we look at the images ourselves and write our own reports for the files. Chiropractors can currently refer for x-rays to independent clinics, but MRIs, CT scans and ultrasounds will require a medical doctor referral. We can write letters to your doctor to ask them to consider further imaging based on our exam findings.
But why would your family doctor deny a request for x-rays and MRIs for your chronic low back pain? Here are some reasons:
1. The findings in the radiographs will not change the treatment options
The vast majority of radiograph exams in the absence of red flag symptoms (more on that later) in the spine will often show conditions such as degenerative joint or disc disease. While the condition is titled a disease, it is simply the wear and tear due to age or repetitive injury. Treatment options remain non-surgical.
2. Minimize radiation exposure: Radiation accumulates in our body and cannot be expelled. As such, we are cautious to x-ray those who are young due to organ damage and potential cancer effects. This relates to the first point, that why expose the patient to unnecessary radiation if the treatment recommendations will not change based on the findings.
3. Findings on X-Rays and MRIs are NOT correlative to clinical symptoms: In simple terms, you could have severe back pain and completely normal spine x-rays, and the reverse can be true. They have done studies in which MRIs on healthy individuals revealed disc bulges in their spines. Disc bulges and herniations can be the source of severe spinal pain, but NOT ALWAYS. While imaging is important in certain cases, we unfortunately have to break it to patients that the pictures don’t give you the answer you want to hear: that the findings on the x-rays do not explain why you’re feeling this way.
Ask yourself: what is it you really want, when you ask for an x-ray? In my experience, the patient wants to know two things:
What do I have?
Can it be fixed?
Radiographs can sometimes help to answer these questions, but not always. A proper chiropractic and orthopedic examination has to be done to answer these questions. So when do I send patients for x-rays or refer back to their MD for MRIs?
1. The presence of Red Flag Symptoms: The definition of “Red Flag” can vary depending on the condition, but when it comes to the spine, we look out for:
Pain that is unrelenting, unresponsive to treatment (physio, chiropractic, any non-surgical measures)
The same pain worsens during the night and awakens you from sleep
Night sweats that are new and sudden onset (ie not the same hormonal night sweats you have had for years)
Sudden, explained weight loss
Sudden onset of neurological symptoms (weakness, loss of balance, numbness or tingling that doesn’t make sense on orthopedic exam)
*These are just some red flag symptoms, please consult with your chiropractor or family doctor for a more thorough work up.
2. Recent Trauma (Falls or Contusions)
Eg. Car accidents, falls especially in women over 55 due to the possibility of osteoporosis, anything in which we might suspect a fracture or dislocation in cases such as sports injuries
3. We suspect certain types of arthritis or other spinal or joint conditions that could be visible on x-rays
We won’t usually send out for x-rays if it’s just osteoarthritis (AKA wear and tear arthritis), but if there are clinical symptoms that make us suspect other arthritic conditions such as rheumatoid arthritis or ankylosing spondylitis, or even bone cysts. Even if such findings reveal these types of problems, or even severe arthritis, chiropractic care can still help in pain management and optimizing function.
In short, there has to be a really good reason to expose someone to unnecessary radiation. In addition to those reasons, we also have to ask: will the results change what we do for this patient?
In many cases, treatment helps to relieve the symptoms within a couple of weeks, and the need for further imaging is no longer apparent. We monitor our patients to consider x-rays for the future.
The other question we sometimes get is that are x-rays required first in order to have chiropractic care? The short answer is no. A good, thorough clinical workup that we do on our initial visits can lead us to the diagnosis in the large majority of cases. Be assured that the reason our initial visits are lengthy is because we have to determine IF you need further testing and care beyond our scope, including the need for x-rays. I have sent patients for x-rays after the initial visit, but those cases are the minority.
Don’t get discouraged when your x-rays or MRI/CT scans show no findings. The lack of findings on your scans can actually be a good thing: it means the likely absence of an active disease such as cancer or arthritis. It in no way invalidates what you are feeling and how you are functioning, because we understand as chiropractors your symptoms are getting in the way of your life.
Our job is to return you back to full function and optimum health, reaffirm why you are feeling this way and give you answers that typical medical exams cannot. More importantly, we can give you a solution to your problem and work with you to find it.
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