Why do we Take X-Rays?
If you asked 10 doctors, you might get 10 different answers. One answer might actually be “I don’t take x-rays.” I have worked with many DCs and have found a widely varying view on the indications for an x-ray. It ranges from some doctors who insist on x-raying every patient, to some who x-ray no one. In fact, some almost hold in disdain those that do x-ray their patients.
Why such a wide diversity of opinion in a given profession? We know of course that our profession as a whole encompasses a divergent collection of procedure and philosophy. So why should the subject of x-ray be any different? I don’t consider my job in this journal to try to tell doctors what they should do. I have my personal opinions, but I would rather motivate you to think about subjects and draw your own conclusions. This article is going to cover some elements of why we take x-rays and give some reasons to support the different views on this subject.
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Ethical Issues
To begin, I would like to completely disregard two reasons that I feel have no place in this discussion. The first reason being that x-rays are taken to increase revenue in a given practice. This obviously has no place in an ethical and moral discussion of a given medical procedure.
The decision to order x-rays should never be based on a financial incentive. This is not to say however that a doctor may not make a decision to have an x-ray in his or her office as a revenue generator, just that the decision itself on whether a patient needs x-rays should not be based on a financial incentive. The second reason which I do not consider to be valid is to help to protect oneself from malpractice. Since the welfare of the patient must always come first, this reason will naturally resolve itself if the tenant of doing what is best for the patient is always kept in mind.
History
Let us start with another question. Why did the chiropractic profession early in its development begin x-raying patients? X-ray radiation was discovered at almost the same time as the inception of the chiropractic profession. It was a novel practice at the time to be sure, but it obviously provided the first rudimentary view into the internal structure of the human body without actually having to cut into it.
Initially, no negative side effects were known and thus no reason was apparent not to utilize this new imaging technique. So, what were those early chiropractors looking for with x-ray? I would suppose that with the prevalent subluxation based philosophy of the time, they wanted to demonstrate graphically the bone out of place concept. What better way to do it than to actually show the position of each of the vertebra in relation to each other.
The problem eventually arises, however, in how to interpret these images. Is there really such a thing as a vertebra being misaligned? Does an x-ray image truly demonstrate the relative misalignment of one vertebra on the next? Are there normal ranges in which an apparent degree of misalignment is permissible? These were all difficult questions to answer at a time when x-ray images were still in the development stage and there were virtually no scientific studies to address these issues.
Support for Chiropractic
This brings us to the first of my reasons on why we take x-rays. That would be to demonstrate a subluxation. Many x-ray analysis systems have been used over the years and continue to be taught and used in the chiropractic setting. Different views exist on the reliability of these systems. Nevertheless, many practitioners continue to analyze x-rays with systems of varying degrees of complexity and achieve excellent outcomes with their patients. To sum up, the first reason I have given, x-rays can support the philosophical basis for chiropractic.
Patient Education
Patient education is another reason chiropractors use to validate x-rays. The images serve to demonstrate the subluxation complex that is the root component of the philosophy. Such a personal visual representation can have a dramatic impact on the patient, and it can help impress the tenets of the subluxation complex.
Diagnosis
Another major reason for obtaining x-ray studies is to diagnose or exclude pathology. This is considered to be the primary reason for an x-ray by many practitioners. Radiography is indeed an excellent tool for the diagnosis of many conditions, but it also has many limitations which I am sure the readers of this column are aware. If this is the primary reason for taking an x-ray, then it would be prudent to have a reasonable degree of suspicion that a given malady is present to warrant radiation exposure to the patient. Thus, a flow chart type of diagnosis paradigm would likely be utilized to determine whether or not x-rays would be helpful in making the diagnosis.
Another reason for routinely x-raying patients would be to exclude conditions that, if left undiagnosed, would pose a threat to the patient’s health when a high-velocity manipulation was administered to a given area. Some conditions may be extremely difficult if not impossible to detect without imaging, and these conditions may have a profound effect on treatment options available. These conditions could include congenital, as well as, developmental abnormalities. An example of this type of diagnosis is the detection of an os odontoideum which are inherently unstable. A high-velocity thrust at the C1-C2 level in a patient with an unstable os odontoideum could result in injuries ranging from cord contusion to partial cord transaction and varying degrees of paralysis. Although the inherent risks of high-velocity manipulation are relatively few, the very physical nature of chiropractic treatment may be an attractive reason for x-raying patients.
Conclusion
Regardless of the reason that a particular doctor may have for taking x-rays, I think we can all agree that it is still a valuable tool for the diagnosis and treatment of our patients. The right to take x-rays in Illinois is an important part of our scope of practice. It is one of the fundamental elements of our diagnostic armamentarium.
