Milwaukee Board Certified Chiropractic Orthopedist and Herniated Disc Doctor writes:
"I had x-rays and MRIs and they say nothing is wrong except arthritis."
"My doctor says my insurance company tells him I don't need x-rays of my back and that I should just take these drugs and my back pain would go away. Well, it didn’t. My back keeps hurting and all they do is keep giving me drugs. What’s wrong?"
Both of these stories point out the missed opportunity of spinal x-rays.
Sometimes people come to us with page after page of x-ray, CT and MRI reports and still have never had a good explanation of why they have not gotten any better. On the other hand we see people come to us with long-standing back pain that they can't get rid of and who have never been x-rayed. Some insurance companies refuse to pay for x-rays in the first thirty days, yet Medicare thinks the x-ray is important.
So what is the proper use of x-rays for back pain?
There are two primary purposes for spinal x-rays in the evaluation of back pain.
The first purpose is to make sure there is not a disease causing the pain, something really wrong that needs immediate medical care. The decision making process to rule out disease is similar among different types of doctors so all doctors are trained to use x-rays for this purpose.
There are cases where x-rays are clearly necessary, like when a severe trauma might have broken a bone, when a person has a history of cancer, or the sudden onset of severe pain. In older people the risk of bone disease or underlying disease like cancer becomes higher, so x-rays are likely to be more important to find a medical problem.
But most people with back pain do not have a disease or true medical emergency that has to be ruled out. In most people under age fifty the likelihood of medical problems causing or mimicking back pain is quite small. So x-rays for those people are less likely to reveal a hidden cause of back pain and will not be recommended routinely for this purpose.
The second purpose for spinal x-rays in the evaluation of back pain is to help decide between different treatment options.
Most doctors begin treatment for back pain with drugs. If the doctor is planning on prescribing drugs then there is no information from the x-rays that is going to determine which drug to give you and x-rays would not help in most cases. If the doctor's choices are therapy or simple exercises or general spinal manipulation, then again there is no real benefit gained from x-rays that would make one treatment more helpful than the other.
If the only goal of treatment, whether drug or spinal manipulation is to reduce the pain, then there is no reason for taking an x-ray. Even some spinal manipulation can be performed to reduce pain without risking harm.
Studies show that most back pain is really caused by abnormal mechanical function of the spine. Drugs can’t fix that. Reducing pain can occur without restoring normal function or mechanics. If the goal of treatment is not just to reduce the pain but to correct the mechanical problem that is causing the pain, then the most helpful treatment must restore the spine back toward the normal. That requires an accurate measurement of what a normal spine is.
One sign of abnormal mechanics and spinal function is abnormal posture, like your head being too far forward or your pelvis twisted in relation to your feet. But while a posture exam can show some gross positional changes of the spine, abnormal mechanics can't be determined by just looking at the spine from the outside. There are over 130 million possible combinations of distortion that the spine can be in. Errors in treatment may occur as a result of lack of knowledge of the positioning of the spine.
X-rays have been used for evaluating medical problems for over a hundred years. During that time spinal experts have found that by accurately placing the person while taking the x-ray we can make accurate measurements of the shape of the spine. And by measuring thousands of x-rays and comparing them with sophisticated mathematical models we can establish a normal position for the bones of the spine. Just like a normal blood pressure, there is a normal position for your spine. This normal is used for establishing the presence or absence of a mechanical problem and for monitoring progress.
The information about the mechanics of the spine found on an x-ray can change the force, direction or even the location of the adjustment to the spine deciding the success of the outcome. This gives valuable additional information from the x-ray beyond the primary use of detecting diseases. So X-rays are the blueprint of the spine. But only if the doctor is trained in the measurement and what to do with them.
When someone with back pain goes to a doctor who will give drugs, the doctor has only one reason for taking spinal x-rays - to make sure there is no underlying disease that is causing the pain in your back. But when that same person goes to doctor who knows how to help restore the function of the spine, then there are two reasons for using spinal x-rays.
The first reason is the same one as a drug doctor has, to rule out underlying disease. So for this reason most people don't need an x-ray from a non-drug doctor either. But there is another reason x-rays are helpful for a doctor who is working to restore the function of the spine, x-rays can show the doctor how the spine has malfunctioned, from which the doctor can determine a plan for restoring function. X-rays are a valuable outcome assessment tool when used properly. They are wasted when not used properly.
If there is no suspected disease to rule out, spinal x-rays should only be taken by a doctor who is trained to maximize the information that can be gleaned from them and use them to help you correct the abnormal structure detected. So the ban on x-rays taken by untrained doctors is a good thing. But the doctor who knows how to extract detailed mechanical information from them should be encouraged to take them for the benefit of the patient. And if you wish to correct the structural cause of your back pain you should go to a doctor who is trained in the proper use of x-rays.
So should you have spinal x-rays? Ask your doctor what he can find out from the x-rays and how it will help in managing your case. If the answer is "It is just routine", or just "to make sure you don't have a disease", then you might wonder. But if the doctor tells you how the information will alter your treatment plan for the better, then you might just choose to have the x-rays.