The panel's findings on radiography in section four, "Special Studies and Diagnostic Considerations," are perhaps of greatest concern with respect to chiropractic practice. Plain x-ray was not recommended in the routine evaluation within the first month of symptoms except in the presence of "red flags" that suggest the presence of fracture, dislocation, tumor, infection or malignancy.1
In the practice of medicine the avoidance of routine usage of plain x-ray during the first month of symptoms is reasonable. The panel's recommendations with respect to conservative medical care are mostly passive (drugs, brief rest, avoidance of provocative activities, etc.), and radiographs will not make a significant difference in such an approach. In medical practice treatment begins and ends with the symptomatology. Positive radiographic findings such as degenerative changes and biomechanical alterations may exist in the absence of symptoms. The predictive value of plain x-ray for the presence of absence of symptoms is therefore limited.
In the practice of chiropractic however, other factors must be considered for the indications of diagnostic x-ray. Historically the use of radiography in chiropractic centered around the assessment of static intervertebral phenomena. Stress radiography was added to the routine examination when ligament integrity was suspect. Such "functional views" have been proposed as valuable in determining intervertebral motion characteristics,2 and are used to augment or replace other dynamic assessments.
There are those that believe that chiropractic treatment is appropriate for pain relief only. Many chiropractors and some chiropractic educational institutions only take x-rays of a patient if fracture of pathology is suspected, much the same as their medical counterparts. On the contrary, there are those that believe that the benefits of chiropractic adjustments may include the restoration of biomechanical and physiological function, performance enhancement, the maintenance of health, and the prevention of degenerative changes. These more liberal applications of chiropractic care lead to indications for radiographic assessment in a relatively greater variety of cases.
Radiographic assessment allows for diagnosis of soft tissue damage of the intervertebral segment. Such damage is frequently the cause of temporary or permanent disorders of the spine.2 It is reasonable to assume that an individual presenting for treatment for spinal related pain or other symptoms is likely to have a history of paraspinal ligament damage, provided psychosomatic disorders can be ruled out. Any ligaments may be subject to plastic deformation or creep. Intervertebral displacement occurs secondary to excessive loading beyond the ligament's fatigue tolerance.3,4 In other words, previously injured ligaments will allow distortion of the alignment of the vertebra(e) they are meant to support.
It's my opinion that the application of the force required to cavitate an intervertebral articulation is a relatively invasive maneuver. To introduce a force into the spine sufficient enough to produce abrupt intervertebral movement and cavitation, without previously determining the presence or absence and, most importantly, the direction of any creep deformation at the level(s) being adjusted, is to invite further ligament injury. The chiropractor has responsibility to protect the patient at all times by insuring that the treatment rendered is safe, as well as maximally effective. It is not possible to be reasonably certain that one is not damaging the ligaments when adjusting the spine unless one has assessed the presenting spinal integrity prior to treatment.
Another important reason that radiographic examination is requisite for proper administration of the adjustment is that the symptomatic level is not necessarily the level to be adjusted. A hypermobile articulation may cause spinal related pain, yet it is generally not indicated to adjust hypermobile levels. Radiographic examination is the most useful tool for locating such contraindications for the chiropractic adjustment. The use of stress radiographs, for example, are likely more accurate in assessing the intricacies of intervertebral dysfunction than manual methods. Since an adjustment is not a benign procedure, it is important that the force be directed where appropriate.
The individual presentation of each patient dictates the proper radiographic examination. The health care needs of the patient are primary but must be considered in light of the socioeconomic situation in each case. The minimum radiographic examination, when indicated, includes two views of the area of primary complaint, preferably perpendicular to each other.5 Additional projections, such as oblique and stress radiographs, may be exposed to supplement the examination when additional information is required. Routine usage of lumbar oblique radiographs were not recommended by the panel as they significantly increase the exposure to the patient without the enhancement of patient outcomes.1
There exists a technical debate in chiropractic over the use of sectional or full spine radiography on routine presentations. The primary reasons for the use of sectionals are that the smaller the area being viewed the clearer the focus, and that it is generally easier to consistently get good radiographs when not exposing different densities of tissues. Many also feel that limiting the assessment to the area of symptomatic complaint is indicated to reduce the patient's exposure to radiation.
There are several reasons that full spine radiography rather than sectionals may be indicated for a given case. When the entire spine is to be viewed on plain film, a properly exposed full spine radiograph will offer diagnostically useful information with comparatively less patient exposure than sectional analyses which require projectional overlap.
During the course of care, patients may idiopathically develop symptoms in another region of the spine not being adjusted, especially in chronic situations. Additionally, the response to an adjustment in one area is often seemingly enhanced by adjusting other asymptomatic areas. Neurologic convergence in the central nervous system and/or biomechanical factors may be responsible for this apparently natural association between different spinal areas of treatment. This interdependency of the different spinal regions indicates a full spine examination for most patients.6
Junghanns states: "The total picture epitomizes the compromise of specific posture influence and specific functional disablement and shows on which level the disability originated. It shows spinal column curvatures in the sagittal and frontal level, and in the pelvic position. At the same time it can serve as the standard for a later comparison on the state of the spinal column under the stresses of everyday life."2 For the above reasons, full spine visualization is preferable whenever indicated in chiropractic care.
The panel cited several studies that suggest that imaging studies are not to be relied upon alone in spinal assessment.1 Corroboration with the history or other exam findings is necessary to understand the significance of results of imaging studies. It is important to remember that plain film radiographs are static, two-dimensional instantaneous shadows of the patient. Often the most misaligned motion segments as viewed on radiographs are compensations for subluxations elsewhere. Freely movable areas may compensate for the restricted areas when the individual is weightbearing and moving about. Global abnormalities in structural alignments may also result from intersegmental fixed positional dyskinesia. For the above reason and others,2 weightbearing views are usually preferable to recumbent views in the chiropractic assessment of spinal biomechanics.
The following clinical situations illustrate the integration of diagnostic criteria. Examination of the sacroiliac and lumbar spine may take various paths. In assessing the sacroiliac area for motion abnormalities, inspection, motion palpation, and/or lateral bending radiographs are readily available options. The most tested of the above procedures is the Gillet motion palpation test, with preliminary indications that the intraexaminer reliability of the assessment may be acceptable.7,8
Radiographic findings are important for differentiating patients with lumbar and sacroiliac problems. The standing lateral radiograph is a useful way to assess the structural position of the lower spine and may quickly point to one area or the other as being potentially involved. A lumbar retrolisthesis indicates likely disc and posterior joint capsule injury,9 while a gross abnormality of the lumbar lordosis may imply a compensatory reaction from a lower level, such as the sacroiliac joint. A properly exposed well positioned standing lateral lumbar radiograph, and a Gillet motion palpation test of the sacroiliac articulations, in combination with a history of the timing and location of the pain, are valuable components for this type of evaluation.
Clinical guidelines are useful for patients and doctors concerned with standards of practice. The protocol and indications for radiography however are quite different for medical versus chiropractic care.
References
- Bigos SJ, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline. Agency for Health Care Policy and Research, U.S. Dept. of Health and Human Services, Rockville, Maryland; 14:59-67.
- Junghanns H. Examination of the spinal column. In: Hager HJ, ed. Clinical Implication of Normal Biomechanical Stresses on Spinal Function. (English language edition) Rockville: Aspen, 1990:175-192.
- Goel VK, Voo L-M, Weinstein JN, et al. Response of the ligamentous lumbar spine to cyclic bending loads. Spine 13:294-300, 1988.
- Liu YK, Goel VK, Dejong A, et al. Torsional fatigue of the lumbar intervertebral joints. Spine 10:894-900, 1985.
- Yochum TR, Rowe LJ. Essentials of Skeletal Radiology. Williams & Wilkins, Baltimore, 1987.
- Voutsinas SA, MacEwen GD. Sagittal profiles of the spine. Clin Orthop 1986, 210:235-242.
- Herzog W, Read LJ, Conway PJW, Shaw LD, McEwen MC. Reliability of motion palpation procedures to detect sacroiliac joint fixations. JMPT 1989, 12:86-92.
- Wiles MR. Reproducibility and interexaminer correlation of motion palpation findings of the sacroiliac joints. J Can Chiro Assoc 1980, 24:59.
- Kirkaldy-Willis WH. The three phases of the spectrum of degenerative disease. In: Kirkaldy-Willis WH, ed. Managing Low Back Pain. Churchill Livingstone, New York, 1983:75-89.
Mark Lopes, DC
Fremont, California