Do you really need those X-Rays?  Evidence suggests NOT.

There are many differences between how clinicians approach spinal treatment and/or pain.  Some approach generally from a structural model, pointing out misalignments on x-rays and indicating that these spinal misalignments are what is causing the patient’s dysfunction or pain.  Or a clinician might see a herniated disc on an MRI and use that as evidence to operate/intervene at that location.

Others approach treatment generally from a functional model, in that human structure is a dynamic system that requires motion and the right amount of mobility and stability in the right places as well as proper motor control to manage the system.  A common example of this is when we see arthritis (degeneration) in the lower back and lower cervical spine where the body tends to value stability over mobility and will provide a poor version by laying down extra bone if we don’t provide the normal and necessary functional stability through muscular coordination.  One area will pick up the slack of another area if it isn’t doing its job.  X-rays are generally much better at confirming suspicions or ruling out pathology than they are at actually making a diagnosis.  A functional exam will show where there is dysfunction and give clues about how to fix it.  An x-ray can tell you something is going on in a place, IF it’s bad enough and been there long enough.

Our approach is from the Functional Model and here’s why:

-Pain cannot be seen on x-rays similar to how looking at a picture of a phone doesn’t tell you if it’s ringing.

– Pathological processes in the low back such as degeneration and disc herniation are seen frequently on asymptomatic (no symptoms) patients even with advanced imaging such as CT scans and MRI (between 28-50% of the time).  In the cervical spine, there is an even higher percentage of asymptomatic people with imaging abnormalities of degeneration and disc hernia[1,2].

“It is now acknowledged that most structural pathologies are present in asymptomatic individuals in nearly equal degree as they are in those who are asymptomatic.”

-Interestingly, patient satisfaction has been found to be higher when x-rays were taken, but patients were also more likely to report a longer duration and greater severity of pain, reduced functioning, and poorer health status than those who had not had x-rays.  Patients tend to think that x-rays make for a more thorough exam and will reveal things that can be missed by history and examination.  This has implications for clinicians to make sure they are communicating well with patients and also reassuring them that a competent history and examination is more than 99% sensitive for identifying “red flags” of serious disease such as cancer, infection, fracture, and other sinister neurological disorders. [3]

• With the last 2 points in mind, the problem with overusing imaging, besides the additional cost, is that many individuals who have pain unrelated to the structural findings will be mislabeled/misdiagnosed and may therefore receive unnecessary treatments.   Additionally this may lead patients to unnecessarily think of themselves as “sick” when in actuality most of these structural changes are more related to age than symptoms.

The structural model also relies on the outdated philosophy of thebiomedical model in which pain is closely associated with the amount of tissue damage or structural change and then attempting to fix the problem by intervening directly at the structural site.  The more accurate and emerging model, the Biopsychosocial model, approaches pain as a much more complex experience of function and emotion.  According to the International Association for the Study of Pain (IASP), pain is not simply the result of structural injury or pathology but is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage…[4]

Lastly, the point of this post is not to slander x-rays and imaging.  X-rays can be a very important tool when necessary. Unfortunately they are often used irresponsibly, creating assumptions and leading the clinician and patient down the wrong path.  Many times whether they are taken or not doesn’t change the treatment, so unless “red flags” are present, there is generally no reason to take them at the onset of care.  And finally, research tells us that in low back pain patients, taking x-rays as a general screening tool does not improve patient outcomes.

Given the current state of evidence, if a clinician feels that their care and treatment is improved by using x-rays as a screening tool, the burden is now theirs to prove that case.

The role of science is not to provide everlasting truth;
but rather, to provide a modest obstacle to everlasting error. 
– Author Unknown

Sources

1.) Boden SD. McCowin PR, David Do, Dina TS, Marke AS, Wiesel S. Abnormal magnetic-resonance scans of the cervidal spine in asymptomatic subjects. J Bone Joint Surg 1990b;72A: 1178-1184

2.)Philips HC, Jahanshahi M. The components of pain behavior report. Behav Res Ther 1986;24:117

3.)Liebenson, Craig. “Putting the Biopsychosocial Model into Practice.”Rehabilitation of the Spine. Baltimore: Lippincott Williams & Wilkins, 2007. 77. Print.

4.)Liebenson, Craig. “Putting the Biopsychosocial Model into Practice.”Rehabilitation of the Spine. Baltimore: Lippincott Williams & Wilkins, 2007. 73. Print.