There is an alarming trend in Chiropractic that is being propagated by some Chiropractic schools and Chiropractic organizations and put into practice by newer Chiropractors in the field. The current trend is that Chiropractors should avoid utilizing X-rays with some exceptions for patients experiencing pain in the past 6 weeks.
I will spare you the political discussion within the Chiropractic profession, as it is likely not relevant to the readers of this blog. However, just to give a little insight into this conundrum I will say that if you are familiar with the authors of guidelines like this you will undoubtedly recognize that many of them have familiar ties with insurance companies as "independent" medical reviewers, or ties with organizations whose primary purpose is to save insurance companies money. (If you would like to know more, feel free to pull me aside in the office and I will give a deeper explanation). Essentially, what they are contending is that alignment of the spine and state of the physical structures of the spine as visible on X-ray are not important in terms of back pain, unless the pain is chronic in nature.
Determining what examinations to perform in the office is a complex scenario which involves a multitude of factors including the patient's history, exam findings, and their presentation in the office just to name a few. Many of these new statements coming out in terms of limiting X-ray scope oversimplify the issue by utilizing selective scientific literature that supports their position (cherry picking) and ignores publications contrary to their purpose.
Which brings me to my next point.
A study published in August of 2017 in the journal "Spine" shed some light on the importance of X-ray in practice. Link to the abstract can be found here, keep in mind it is not an open access journal so if you want to read the entire paper you have to pay for access.
Here is a rundown. The paper was a systematic review and meta analyses, which means that the authors searched through existing studies that looked at lumbar lordosis angles viewed BY XRAY in patients who were experiencing back pain as well as patients who were not experiencing pain (control groups) and performed a statistical analysis of all the studies combined. They ended up including 13 different studies that looked at a total of 796 patients with low back pain and 927 people without low back pain.
Their analysis showed a correlation between loss of curve in the low back and low back pain. The authors noted: "Strong relationship between low back pain and decreased lumbar lordotic curvature, especially when compared with age-matched healthy controls." They further noted: "Among specific diseases, LBP by disc herniation was shown to be substantially associated with loss of lumbar lordotic curve."
In summary, patients whose x-rays showed loss of curve in the low back were correlated with back pain far more than those who had lost less of their curve. Does that mean that loss of curve in the low back is the only thing that causes back pain? NO. That is an over simplification. This study is showing a correlation between loss of curve and pain. No more no less, however it does have significant implications.
How can we, as Chiropractors, determine loss of curve? Can we tell by having the patient do some exercises? No. Can we tell based on simple posture assessments? No. The gold standard for evaluating angles of the spine is via X-ray and X-ray alone.
This is why it is important in many many instances to view the spine through radiography. Sub standard examination will yield sub standard results.
1. Chun, Se-Woong, et al. "The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis." The Spine Journal 17.8 (2017): 1180-1191.