For musculoskeletal conditions like neck pain, many people think that X-rays are an essential part of the diagnostic process. However, this isn’t always the case. X-rays may not always provide useful information as to the cause of the patient’s condition, which can result in added costs and potentially inappropriate care, not to mention unnecessary radiation exposure. To help guide healthcare providers, including chiropractors, various associations and organizations have crafted guidelines on when to and when not to use X-rays.

Generally, when neck pain arises gradually or without trauma (a fall or car accident, for example), a trial period of treatment for two-to-four weeks without X-ray is usually appropriate, especially in those under 70 years of age. If the patient fails to respond to care or symptoms worsen, then X-rays may be advisable to further investigate the condition. Additionally, guidelines typically dissuade X-rays for populations may be more sensitive to radiation exposure, such as women who may be pregnant.

All clinical guidelines recommend imaging when there is suspicion of red flags like cancer, fracture, infection, and serious neurological impairments. Indications on a patient’s history or examination findings for red flags include the following: trauma; preceding neck surgery; osteoporosis risk; myelopathy (neurological symptoms); history of cancer; unexplained weight loss (a symptom of cancer); fever; history of infections (TB or HIV, for example); history of inflammatory arthritis; constant, progressive, non-mechanical pain; insidious progression of pain; signs of spinal cord compression (clumsy hands, altered gait, or disturbances of sexual, bladder or sphincter function; clinical signs of brain or spinal cord injury); Lhermitte’s sign (flexing the chin to chest or neck, produces an electric shock sensation down the spine and into the limbs); dizziness, drop attacks, or blackouts (indicative of vascular insufficiency, more common in the elderly); vertebral body tenderness (localized “exquisite” tenderness); lymphadenopathy/cervical rib; and pulsatile mass (carotid artery aneurysm).

In Chiropractic, the trend in the last 20 years has been that fewer patients require initial X-ray than what was once taught in many chiropractic colleges/universities. As new research evidence arises, guidelines will be updated to reflect the best evidence. In the end, the goal is to help achieve the most useful diagnoses for the patient’s present condition so that appropriate care can be provided to help them resume their normal activities in the safest and most cost-effective manner.