Question
QUESTION: I have been seeing a chiropractor for many years for recurrent back and neck pain. I have a history of osteoarthritis.  Never once has my chiropractor either asked to see nor suggested that I have any type of x-ray.  What is the "standard of care" regarding the ordering of x-rays by a chiropractor as part of either initial diagnosis or ongoing treatment of an individual receiving chiropractic care?  Thank you very much

ANSWER: Steven,

Thank you for your question.

Numerous large-scale prospective studies have found that no patient had a clinically significant spinal injury if they had no spinal pain, no distracting pain, no neurological deficits, and if they were alert, awake, oriented, and not intoxicated (Marion DW et al. Practice Management Guidelines for Identifying Cervical Spine Injuries Following Trauma, EAST Practice Parameter Workgroup for Cervical Spine Clearance, chapter 3, 1998).

There have been no prospective and retrospective studies regarding the use or non-use of any single group of imaging studies for the accurate determination of spinal instability; therefore, there can be no "standard" for this parameter (EAST Practice Parameter Workgroup for Cervical Spine Clearance, 1998).

Other studies agree with strong recommendations and moderate-quality evidence for patients with nonspecific back pain that clinicians should not routinely perform imaging studies, including radiographs, CT scans, and MRI, or other diagnostic tests without a relatively compelling reason (Barclay L, Guidelines Issued for Management of Low Back Pain, Medscape Medical News, 2007).

Evidence-based criteria suggest that a focused history and physical examination should help categorize patients into 1 of 3 broad groups: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause (Guidelines Issued for Management of Low Back Pain, 2007). Evaluation of psychosocial risk factors is essential to predict the risk for chronic, disabling low back pain (Guidelines Issued for Management of Low Back Pain, 2007).

Additionally, a 2001 study in the British Medical Journal stated:

"Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status... Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography" (Kendrick D. et al. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ 2001;322:400-405).

A series of radiographic guidelines known as the Canadian C-Spine Rule have been developed to delineate criteria for avoiding potentially unnecessary cervical spine radiography in patients with a history of trauma. These criteria include:

- the absence of tenderness in the middle of the neck
- the absence of neurological signs and symptoms
- a normal level of alertness
- no evidence of intoxication
- the absence of clinically apparent pain that might distract the patient from the pain of a normal neck injury

(Hoffman JR et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Eng J Med 2000; 343:94-9).

The following factors are generally considered as possible (but not absolute) indications for spinal x-rays:

- a history or laboratory studies indicating malignancy or infection
- chronic spinal pain
- neck pain in children
- a history of spinal surgery
- greater than 50 years of age
- trauma (excluding the factors mentioned above)
- history of osteoporosis or ankylosing spondylitis
- long-term corticosteroid use
- neurological signs and symptoms
- unexplained weight loss (more than 10 pounds in less than 6 months)
- drug or alcohol use
- immunosuppression
- compensable spinal injury
- back pain not relieved by conservative therapy over one month
- back pain worse with rest
- low back pain

(French et al. Risk Management for Chiropractors and Osteopaths: Imaging Guidelines for Conditions Commonly Seen in Practice. Australas Chiropr Osteopathy. 2003 Jul;11(2):41-8).

In general, despite their prevalence in clinical practice and patient expectations, x-ray findings tend to correlate poorly with low back pain symptoms (French et al. Risk Management for Chiropractors and Osteopaths: Imaging Guidelines for Conditions Commonly Seen in Practice. Australas Chiropr Osteopathy. 2003 Jul;11(2):41-8).

Patients with neck and back pain and radiating symptoms into the arms or legs may (but not always) require an MRI scan rather than plain-film x-rays (French et al. Risk Management for Chiropractors and Osteopaths: Imaging Guidelines for Conditions Commonly Seen in Practice. Australas Chiropr Osteopathy. 2003 Jul;11(2):41-8).

Patients with neck and back pain and radiating symptoms into the arms or legs with no improvement with conservative treatment over a 6 to 12 week period, who may be under consideration for spinal surgery, who lose control of their bladder and bowels, who have poor voluntary muscle control, or who have recurrent pain after spinal surgery usually do require an MRI scan (French et al. Risk Management for Chiropractors and Osteopaths: Imaging Guidelines for Conditions Commonly Seen in Practice. Australas Chiropr Osteopathy. 2003 Jul;11(2):41-8).

As you can see, the decision to take or not take x-rays, or to then refer the patient for advanced diagnostic imaging, should be based on the patient's history, symptoms, and response to conservative care (if applicable), rather than as a matter of routine practice.

I hope that this helps to answer your question.



---------- FOLLOW-UP ----------

QUESTION: Thank you very much for your thorough response to my initial question.  I would like to be more specific, if you will permit.  In my current situation, I have been seeing a chiropractor for 20+ years.  I see him sporadically, but on a regular basis, perhaps 1-2 times per year, for the same concerns, ie lower back and neck pain.  Most recently, I had a series of 3 appointments with him, and my symptoms, which included some tingling in the skin over my right knee (this was the first time this symptom had appeared) were not resolving. I understood that this symptom was possibly an indication that some nerve impingement was occurring in the area of my spinal cord.  After the most recent adjustment, 2 days later I had acute sciatic pain on the right side and I had to go the ER.  X-rays and a CT scan were taken indicating moderate-advanced spondylosis of some of the lumbar vertebrae, moderate-advanced narrowing of the foramina, displacement (spondylothesis?) of 2-3 mm of some of my lumbar vetebrae, and hypertrophy of some lateral ligaments. I am currently scheduled to have an MRI.
So my second, more specific question is, given my history of osteoarthritis, along with the fact that my "chronic" lower back symptoms continued to recur, would it have been prudent for my chiropractor to have ordered x-rays at some point in time before continuing with my treatment?  Furthermore, as it turned out, given the findings of these x-rays, if these images had been available to my chiropractor prior to the most recent treatment, might not his treatment have been modified, or not done at all?  And, lastly, and possibly the question which is probably the most "sensitive" is, did the most recent chiropractic treament precipitate and or accelerate the curreent problems that I am having in my lumbar region?  
I am a health care practitioner, so I am fully aware that many/most professionals are either hesitant or totally resistant to offer an opinion which in any way might be construed as passing judgment on a fellow practitioner,  especially if this opinion is that there might have been some type of negligence involved.  I suspect that this will be the case with my correspondence with you.  All I can request and hope for, is for you to be as honest as you possibly can, and adhere to the principles of the oath that each of us in the health professions must ascribe to, ie..And Above Else, Do No Harm.
Thank you for your time.
Steven

Answer
Steven,

I am happy to answer your questions in as much as I can provide general information; it would be neither ethical nor helpful to comment on the specific aspects of your case, as I do not have first-hand knowledge of your clinical situation. I will provide you with an evidence-based response to part of your question, and offer an opinion based on what the literature says.

First, from the information you gave me, it appears that you have significant degenerative changes of your lumbar spine. There is no significant association between spondylisthesis of a lumbar vertebra (defined as forward movement, or translation, of one vertebra relative to another) and a predisposition to disc herniation.

However, a 2009 study in the medical journal Spine found that concurrent lumbar and cervical arthrosis was present in 80% of the study population. The authors also found that lumbar arthrosis precedes cervical arthrosis, suggesting an underlying component for spinal osteoarthritis (Master D, Eubanks J, Ahn Nicholas. Prevalence of concurrent lumbar and cervical arthrosis: an anatomic study of cadaveric specimens. Spine 2009: 34(8);E272-275).

This study highlights the fact that neck and low back osteoarthritis is a common condition. While an x-ray would demonstrate the radiographic characteristics of degenerative joint disease, there is no evidence to suggest that this would affect the outcome of manual spinal therapy.

In a 2008 analysis published in the Journal of Manipulative and Physiological Therapeutics, the author stated that "... disk herniation after treatment for low-back pain consists exclusively of individual cases and case series" (Rubenstein S. Adverse effects following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks? J Manip Phys Ther 2008: 31(6);461-464).

The author goes on to say:

- The evidence cannot be interpreted as demonstrating causality (between serious adverse effects and manipulation);

- The lack of a control group in observation research makes it difficult to answer the question whether the effect or outcome would have occurred had the individual not been exposed to the suspected trigger or (presumed) "cause";

- Case reports and case series represent weaker evidence because they include only the exposed individuals (eg, those who have undergone spinal manipulation)... and thus, the lack of a suitable comparison hinders the interpretation;

- Although a risk-benefit ratio is difficult to calculate (because of the lack of control groups in research), there are a number of systematic reviews that demonstrate that spinal manipulation is superior to placebo or natural course for neck or low-back complaints;

- The vast majority of adverse effects (reported in the literature resulting from spinal manipulation complications) are typically benign and self-limiting, and the incidence of severe complications after chiropractic care/manipulation is extremely low.

In a 2007 study published in the Journal of Clinical Biomechanics, the authors found that disc prolapses (or herniations) can result from various complex load situations and degenerative changes in the intervertebral disc, and that the highest risk of prolapses can be found in healthy and mildly degenerated discs, not in the presence of severe osteoarthritis or severe degenerative disc disease (Schmidt H, Kettler A, Rohlmann A, Claes L, Wilke HJ. The risk of disc prolapses with complex loading in different degrees of disc degeneration - a finite element analysis. J Clin Biomech 2007: 22(9); 988-998.

In a 2004 review of the literature in The Spine Journal, weeding out all of the lower-grade studies reported up to that point, the authors reported that in cases of mixed and acute lower back pain, spinal manipulative therapy was found to be almost identical to medical care for pain and disability in the short and long term (Brontfort G, Haas M, Evans R, Bouter L. Efficacy of spinal manipulation and mobilization for low back pain and neck pain; a systematic review and best evidence synthesis. Spine (4) 2004: 335-356).

That report agrees with other reviews in the literature. An earlier study, published in 1993 in the European Spine Journal stated:

"Side effects and complications of cervical and lumbar spine manipulation are rare. Taking in to account the yearly number of manipulations performed by a single physician in Switzerland and the rate of complications, it can be calculated that a physician practicing manual medicine will encoutner one complication due to manipulation of the cervical spine in 47 years and one complication due to lumbar spine manipulation in 38 years of practice. However, it is important that a careful clinical assessment is carried out to avoid complications due to manipulation carried out on the basis of inappropriate indications(Dvor醟 J, Loustalot D, Baumgartner H, Antinnes JA. Frequency of complications of manipulation of the spine. A survey among the members of the Swiss Medical Society of Manual Medicine. Eur Spine J. 1993 Oct;2(3):136-9)".

In a 1989 study published in the Journal of Manipulative and Physiological Therapeutics, the authors stated:

"We describe the case of a patient with a lumbar disc herniation who underwent a course of side posture manipulation. Despite the appearance of an enormous central herniation on the CT scan, the patient improved considerable during only 2 wk of treatment. The disparity which so commonly exists between radiological and clinical findings is depicted in this case. Further, it is emphasized that manipulation has been shown to be an effective treatment for some patients with lumbar disc herniation. While complications of this form of treatment have been reported in the literature, such incidents are rare." (Quon JA, Cassidy JD, O'Connor SM, Kirkaldy-Willis WH.  Lumbar intervertebral disc herniation: treatment by rotational manipulation. J Manipulative Physiol Ther. 1989 Jun;12(3):220-7).

Finally, more data on the effects of manipulation with regard to disk herniations show that it is virtually impossible to cause a lumbar disk herniation through spinal manipulation. The author who performed a systematic review of the literature stated:

"The only loading conditions known to cause posterior disk prolapse involve a combination of compression, lateral bending, and forward bending. and standard lumbar spinal manipulation in the side posture position does not involve a combination of these movements. Many authors agree that the axial rotation of the lower lumbar vertebrae is limited to 2?to 3?by impaction of the zygapophyseal (facet) joints, which prevents tearing of collagen fibers of the annulus within the physiological range of torsion, and torsional stresses just great enough to damage the facet joints do not generate enough torque to rupture the disk.

Others, however, found that annular fibers restrict rotation first, 0.8?before the facets act as a second barrier, and this indicates the annulus can be injured with rotation. Bogduk suggests that after the facets impact and prevent further motion around the normal axis of rotation, sufficient force would then change the axis of rotation of the vertebrae from somewhere within the vertebral body out toward the impacted facet such as to cause a lateral shearing force through the disk. He suggests that 3?rotation of a vertebrae causes 4% elongation of the collagen fibers of the annulus, and collagen fibers suffer microscopic injury at this point. Any further motion, such as flexion or shearing forces, would exceed the 4% limit of collagen elongation and this could cause an annular tear without facet failure. An extra 3?to 4?of rotation may be available at each lumbar joint when the spine is flexed.

When flexion, rotation, and compression are combined over an adequate length of time, annular separation and subsequent prolapse of annular material will occur. Brinckman and Porter  concluded that for a disk prolapse to occur, there needs to be both an annular fissure and a fragment within the disk. these researchers sliced from the anterior through the posterior annulus leaving only 1 mm of annulus intact and produced only a small bulge of 0.8 mm with compression and flexion. But when a small fragment of disk material of the size frequently seen at diskectomy was inserted, it took only a small compression load and flexion of less than 10?to prolapse extruded fragments through a complete annular tear. This type of loading is considered to be well within everyday physiological conditions and could happen with a cough, sneeze, laugh, straining at stool, or a stumble.

It may be that for spinal manipulation to cause increased symptoms of disk herniation or cauda equina syndrome, the disk must already be fragmented and fissured such that any increased strain, like that imposed by normal daily activities, will cause a rupture and prolapse. Considering CES occurs most of the time in the absence of manipulation, at least some of the cases attributed to spinal manipulation could have had the same outcome without manipulation. The practitioner in most cases apparently does not actually cause the injury but aggravates a preexisting lesion for which the practitioner is consulted. A clinician who administers treatment during the prodrome of a disk herniation is at risk of being identified as the cause, if leg pain and neurological deficit ensue. Gentle technique and limitation of lumbar flexion during rotational manipulation may further reduce the risk to patients presenting with LDH (Oliphant D. Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations: A Systematic Review and Risk Assessment. J Manipulative Physiol Ther 2004 (Mar); 27 (3): 197?10).

I think that you can see from all of this published data that the odds are far and against a chiropractor causing a disc herniation as a result of manipulation, and that the preponderance and consensus of the evidence to date is clear that while complications of spinal manipulation are possible, it is very unlikely that a patient may be predisposed to a disc herniation as a result of manipulation.

I hope that this helps to answer your question.