B r u c e F. Wa l k e r D . C . , M . P. H . , D r. P. H . †
M e l a i n i e C a m e r o n B . A p p . S c . ( O s t e o p a t h y ) , M . H . S c . ‡
H e n r y P. Po l l a r d Ph . D . , B . S c . , G r a d . D i p . ( C h i r o . ) , G r a d . D i p . A p p . S c . , M . S p o r t . S c . §
A n d r e w L . V i t i e l l o B . S c . , M . C h i r o . ||
J o h n W. Re g g a r s D . C . , M . C h i r o . S c . ||
Pe t e r D . We r t h B . A p p . S c . ( C h i r o . ) . ||
D a l e A . C o m r i e B . A p p . S c . ( C h i r o ) . ||
A b s t r a c t
This article is the second in a series of articles dealing with risk management in the practise of chiropractic and osteopathy, prepared by the COCA Risk Management Subcommittee.
B a c k g r o u n d :
Radiographic examination carries risks that must be weighed against the possible benefits when determining patient care.
O b j e c t i v e :
The objective of this article is to propose guidelines for the use of imaging in chiropractic and osteopathic practice.
D i s c u s s i o n :
Plain film radiography, CT scan, magnetic resonance imaging (MRI) and other forms of imaging are available for use in chiropractic and osteopathic practice in Australia. The astute practitioner utilises these imaging procedures for clinical decision making in order to make an accurate diagnosis that will determine a patient’s management. This article attempts to guide the practitioner in the proper use of these imaging procedures for different regions of the body.
I n t r o d u c t i o n
Chiropractors and osteopaths recognise that diagnostic x-ray examinations can assist in the diagnosis of musculoskeletal conditions. However, radiographic examination carries risks that must be weighed against the possible benefits. Every x- ray examination exposes the recipient to potentially harmful ionising radiation, the risk of which is well documented1. In the clinical decision-making process, the chiropractor or osteopath should be able to demonstrate the need for diagnostic x-ray examinations before they are performed.
As well as the cost and the potential for exposure to unnecessary radiation, normal plain film x-rays may create a false sense of security. Patients, and historically chiropractors and osteopaths, often harbour misconceptions about the utility and need for plain film radiography of the spine, especially the lumbar spine. Previous conventional teaching led many to believe that an x-ray would reveal the diagnosis, a normal x-ray excludes serious pathology or that the presence of age- related degenerative change can explain a patient’s symptoms.
Practitioners now have an ideal opportunity to dissuade patients from these misconceptions, and explain to them what evidence-based practice involves.
As primary contact practitioners, chiropractors and osteopaths in Australia have a responsibility to diagnose, or at the very least have a high index of suspicion about, conditions that are beyond the scope of the treatment they can provide.
Chiropractors and osteopaths therefore have the ability to perform or refer for imaging procedures needed to formulate a diagnosis and management plan, even if this management plan includes referral to an appropriate practitioner rather than providing treatment per se.
This paper in the COCA Risk Management series deals primarily with the decision to perform a plain film radiographic examination on a patient or not. Currently, Australian chiropractors and osteopaths may refer directly for other imaging, eg CT Scan or magnetic resonance imaging (MRI), however the patient will not receive a Medicare rebate.
This paper also briefly details the indications for these other
* C o r r e s p o n d e n c e
C e n t r e f o r C l i n i c a l E f f e c t i v e n e s s
M o n a s h I n s t i t u t e o f H e a l t h S e r v i c e s Re s e a r c h M o n a s h M e d i c a l C e n t r e , L o c k e d B a g 2 9 C l a y t o n V i c t o r i a 3 1 6 8 A u s t r a l i a . Ph : + 6 1 3 9 5 9 4 7 5 2 6
F a x : + 6 1 3 9 5 9 4 7 5 5 2
E m a i l : s i m o n . f r e n c h @ m e d . m o n a s h . e d u . a u
† D o c t o r o f P u b l i c H e a l t h S c h o l a r
S c h o o l o f P u b l i c H e a l t h & Tr o p i c a l M e d i c i n e J a m e s C o o k U n i v e r s i t y
To w n s v i l l e Q u e e n s l a n d 4 8 1 1 A u s t r a l i a .
‡ O s t e o p a t h i c M e d i c i n e U n i t S c h o o l o f H e a l t h S c i e n c e V i c t o r i a U n i v e r s i t y
M e l b o u r n e V i c t o r i a 3 0 0 0 A u s t r a l i a .
§ S e n i o r L e c t u r e r M a c q u a r i e U n i v e r s i t y
If a chiropractor or osteopath considers that an imaging procedure is indicated it is important that the patient notes reflect this whether the practitioner can refer directly or not.
It should be noted in the file that the patient was referred to their general practitioner with a note requesting consideration be given to the referral.
L i t e r a t u r e R e v i e w
The literature that has been consulted for the purpose of this article consists primarily of practice guidelines that have been developed by professional organisations2-6. The majority of these guidelines have been prepared for the purposes of formulating a diagnosis for a patient presenting with low back pain. For conditions other than low back pain, the literature is relatively scarce, and extrapolation has been made to apply it to all conditions that a chiropractor or osteopath may have to diagnose.
In Australia, there are Commonwealth and State government guidelines and regulations addressing every aspect of plain film radiography applying to all user groups. This article draws on both the existing government regulations and the published professional guidelines.
C o n t r a i n d i c a t i o n s f o r I m a g i n g
The following contraindications should be considered before referring a patient for plain film radiography or CT (Table 1)3. These are not absolute contraindications, however they should be considered in the context of the patient’s presenting complaint and the need for radiography.
3 ) I n f a n t s
Spinal radiography is usually not justified in infants and small children due to the high radiosensitivity of many body tissues in this population. Indications for plain film radiography in this age group are particularly low, as the ossification centres in the spine do not appear until the juvenile years. However, the presence of one or more of the following may justify the use of radiography:
* Developing or idiopathic scoliosis.
* Developmental or congenital defects producing aberrant spinal curvatures.
* Marked locomotor disturbances of the spine and pelvis.
* Suspicion of pathology.
* Significant trauma.
Concerns have been raised about the use of radiography in children by chiropractors8. Radiation dose to paediatric patients is significant and the risks of detrimental effects are higher for the child than the adult. Children have a much longer life expectancy, resulting in greater accumulation and time for expression of radiation damage. It is therefore important that radiation doses are kept to a minimum for children.
The Royal Australian and New Zealand College of Radiology (RANZCR) recommends that paediatric x-ray rooms have modern multipulse or constant potential x-ray generators which can produce the low mAs and very short exposure times required in paediatric radiology9. Good radiographic technique (tight collimation) and increasing tube filtration are essential. Radiation protection with appropriate screening should always be used for the breast, thyroid and pelvic regions. A radiologist with appropriate training and/or experience interpreting paediatric radiographs should provide the report9.
4 ) R a d i a t i o n E x p o s u r e
Recent exposure to high radiation doses, therapeutic or occupational, should preclude further radiation exposure.
5 ) P o s i t i o n i n g D i f f i c u l t y
This may apply in some patients due to a physical or mental state that prevents proper immobilisation or positioning for good radiographic detail.
I n d i c a t i o n s f o r I m a g i n g - G e n e r a l
The following selection criteria are worth noting in the clinical decision making process when considering whether a patient requires a plain film x-ray3.
1 ) P r e g n a n c y o r p o s s i b l e p r e g n a n c y
There are few conditions that would warrant the use of spinal irradiation during the early months of pregnancy. To avoid irradiation during early pregnancy, elective radiographic examinations should not be done in the second half of the menstrual cycle of women who are capable of reproduction7. 2 ) M o r b i d O b e s i t y
Body type and/or size may preclude good radiographic resolution, therefore leading to radiation of the patient but inability to obtain useful films.
Table 1. Contraindications for plain film radiography and CT x Pregnancy or possible pregnancy
x Morbid obesity x Infants
x Radiation exposure to high radiation doses x Positioning difficulty
The number, sequence and type of standard views for an examination should be problem oriented and have clinical efficacy in terms of impact on diagnosis, treatment or prognosis10,11.
A proper history and clinical evaluation of each patient must be performed to establish the necessity for a radiographic examination12,13. The history and clinical evaluation is a guide to not only which portion of the body should be imaged but also how many different views should be taken. In using radiographs as a diagnostic aid, all necessary views should be taken, but unnecessary projections and exposure should be excluded14.
It is necessary to take at least two views of an affected osseous area, preferably at right angles to each other in order to have minimum radiological impression. Frequently, it is advisable to make multiple projections, for example when there is an indication of possible fracture, significant pathology, congenital defect, or when an initial study is insufficient to make a comprehensive diagnosis3,15,16.
Repeat or serial examinations should be performed only to help confirm clinical suspicions of change that needs to be known for the benefit of the patient. If the patient makes an adequate clinical recovery, serial plain films would not normally be indicated. Exceptions are to check progress of fracture repair, infectious processes or scoliosis. If the patient does not make an adequate response, then serial plain films may be indicated, but this must be based upon a full clinical re-evaluation of the patient3.
A patient should never be exposed to unnecessary radiation.
Areas of exposure, as well as the number of exposures, should be kept to a minimum. Routine and/or repetitive radiographic examinations for demonstration of subluxations/osteopathic lesions, or as a screening procedure (eg pre-employment examination) are not appropriate11,17-25.
I n f o r m e d C o n s e n t
The referring practitioner should obtain consent from the patient. The reasons for the radiographic examination and the type of radiological exam required should be explained in advance and consent received. Parental or guardian consent should be obtained for minors and the mentally incompetent.
R e t e n t i o n & D i s p o s a l o f X - r a y F i l m
Initially, the treating practitioner owns the film. When the films and the report are delivered to the patient, the ownership
they keep ownership of the film. The patient who pays for the radiographs owns the report to the treating doctor, whether the report is delivered to the patient or the treating doctor.
Films must be kept for seven years from the date of last treatment, or longer if the patient still has ongoing symptoms.
Alternatively, they can be stored digitally, ie on a computer or CD Rom. When films are destroyed they must be done so as to preserve patient confidentiality6.
I n d i c a t i o n s f o r I m a g i n g – b y R e g i o n o r C o n d i t i o n
C e r v i c a l S p i n e Tr a u m a
Patients with or without trauma, who have no neck pain, are alert and otherwise competent and have no neurological symptoms or signs, have a negligible chance of having a cervical fracture26-35. Canadian physicians have developed a rule to apply to trauma patients who are stable and alert (see Table 2), that has a very high sensitivity in detecting fractures and reduces the need for unnecessary radiography36.
P l a i n F i l m s
A prompt diagnosis in cervical spine trauma is essential as neurological deficit can develop in hours. Predictors of an increased risk of spinal fracture or cord injury are34,36,37:
* >50 years of age.
* The nature of the injury, ie a fall, pedestrian struck by car, bicycle accident or car accident >50 km/hr.
* Transient loss of consciousness, unconsciousness, Glasgow coma score <12 (normal = 15)38.
* Neurological abnormality.
* CT finding of intracranial haematoma, brain contusion or skull fracture.
Plain film radiography should consist of a supine cross-table lateral film, followed by an anteroposterior (AP) view, AP open mouth (to show odontoid process) and oblique views.
The cervicothoracic junction must be displayed in all patients, therefore a swimmers view may also be required. Flexion-
Table 2. Canadian C-Spine Rule – criteria for avoiding cervical spine radiography in patients with a history of trauma36
x Absence of tenderness at the posterior midline of the cervical spine
x Absence of a focal neurologic deficit x Normal level of alertness
x No evidence of intoxication
x Absence of clinically apparent pain that might distract the patient from the pain of a cervical spine injury
muscle spasm can mask a traumatic subluxation39, however they may be justified in persistent cervical pain if ligamentous instability is suspected.
C T
CT is indicated in patients who demonstrate the following:
* Abnormal or inadequate plain films requiring further evaluation
* Normal plain films but unexplained neck pain and an increased risk of fracture or spinal cord injury (see above).
M R I
MRI is the optimal technique for studying soft tissue injury, particularly injury to the spinal cord.
M u s c u l o s k e l e t a l N e c k P a i n P l a i n F i l m s
Acute pain, stiffness or generalised tenderness alone generally does not justify a radiologic investigation, whereas neurological signs, point tenderness or a significantly decreased range of motion usually do.
Patients may require imaging when they have neck pain in the presence of (Table 3):
* History or laboratory features pointing to malignancy, eg sudden weight loss, night pain, malaise, elevated erythrocyte sedimentation rate (ESR), elevated alkaline phosphatase, increased serum calcium.
* History or laboratory features pointing to systemic infection, eg intravenous drug use, elevated temperature, night sweats, elevated white cell count (WCC).
* Chronic neck pain.
* Neck pain in children is very uncommon and may therefore indicate significant disease needing an investigation.
* History of cervical surgery.
* >50 years of age.
When imaging the cervical spine, AP, lateral (including cervicothoracic junction) and odontoid views are sufficient for patients without signs or symptoms of radiculopathy.
There is a poor correlation between symptoms and the degree of disc space narrowing or the size of osteophytes40, therefore the use of plain film radiography based solely on the suspicion of detecting these changes is not justified.
Patients with normal plain film radiographs and no neurological signs or symptoms need no further imaging.
Patients with radiographic evidence of cervical spondylosis or of previous trauma without neurological signs or symptoms need no further imaging.
C T
CT is indicated for cervical spine examination in some patients with trauma for better delineation of fractures or dislocations, but is significantly less accurate than MRI for demonstration of soft tissue lesions such as disc lesions or for the effects of osteophytes and discs on neural structures.
CT myelography can be substituted for MRI in patients where MRI is contraindicated.
M R I
MRI is the investigation of choice in patients with cervical radiculopathy, myelopathy, suspected spinal infection or tumour.
Patients with normal radiographs but persistent neurological signs or symptoms should undergo MRI if symptoms warrant.
Patients with radiographic evidence of cervical spondylosis or of previous trauma, and have neurological signs or symptoms, should undergo MR imaging when symptoms warrant. Patients with radiographic evidence of bone or disc margin destruction should undergo MRI.
L o w B a c k P a i n a n d R a d i c u l o p a t h y P l a i n F i l m s
The vast majority of uncomplicated acute low back pain (LBP) in adults is benign, requiring no radiologic investigation. Routine radiographic evaluation of patients with LBP is not justified. The routine use of oblique views of the lumbar spine is not recommended for adults in light of the increased radiation exposure41.
Further, two recent randomised controlled trials conducted in the United Kingdom42,43 have demonstrated that routine plain film radiography of the lumbar spine do not aid in the diagnosis and provided no benefits for the patient in terms of
Table 3. Possible indications for cervical spine imaging in patients presenting with neck pain
x History or laboratory features indicating malignancy x History or laboratory features indicating systemic
infection
x Chronic neck pain x Neck pain in children x History of cervical surgery x >50 years of age
physical function, pain or disability. Patients in one of the trials42 reported a higher level of satisfaction with their medical care when they received an x-ray, however this does not justify exposure based on the other findings, and highlights the need for practitioners to explain explicitly why a routine plain film is not necessary.
Radiographic findings generally correlate poorly with low back symptomology44-48.
Patients may require imaging who have LBP and the presence of any of the red flags listed in Table 4.
* No improvement with conservative treatment over 6- 12 weeks and surgery is being considered.
* Presence of motor signs, bladder dysfunction (usually retention) or loss of anal sphincter tone (faecal incontinence) suggesting cauda equina syndrome.
* Recurrent/persistent LBP and radiculopathy after spinal surgery.
M R I
MRI is the investigation of choice for:
* Patients with LBP and radiculopathy requiring radiologic investigations.
* Suspected spinal infection or metastatic disease.
* Cauda equina syndrome (bilateral leg weakness, urinary retention, faecal incontinence, saddle anaesthesia).
C T
CT is an alternative to MRI and especially useful when bone detail is required, eg fracture, posterior vertebral osteophyte encroachment, spinal canal stenosis, and apophyseal joint disease.
I s o t o p e B o n e S c a n s
The role of the isotope bone scan in patients with LBP has changed in recent years with the wide availability of MRI.
The bone scan is a moderately sensitive test for detecting the presence of tumour, infection, or occult fractures of the vertebrae but not for specifying the diagnosis2. The yield is very low in the presence of normal plain films and laboratory studies, and highest in known malignancy49. The test is contraindicated in pregnancy.
H e a d a c h e
Although headache is a common ailment presenting to chiropractors and osteopaths, the frequency of pathology underlying that headache is quite small. When considering such a common disorder as headache, the indications for the use of imaging procedures become particularly relevant. For frequent conditions such as headache, performing low-yield studies is more likely to result in false positive results, with the consequent risk of additional procedures, which may be both costly and distressing for the patient.
P l a i n F i l m s
Plain film radiography has little value in the assessment of headache.
C T a n d M R I
These modalities may be indicated for some types of headache, or populations at risk where these procedures are Normal plain lumbar x-rays may be sufficient for the initial
evaluation of the following red flags:
* Recent significant trauma (at any age).
* Prolonged steroid use.
* Osteoporosis.
* Age >50.
The initial evaluation of the LBP patient may require further imaging after plain films have been performed if red flags such as suspicion of cancer or infection are present.
Patients with LBP and radiculopathy generally require no imaging unless the following is present. If any of these are present then MRI is the imaging modality of choice, rather
Table 4. Possible indications for lumbar spine imaging in patients presenting with low back pain
x Trauma – recent significant trauma (any age) or recent mild trauma (>50 years of age)
x History of malignancy
x History suggests osteoporosis or ankylosing spondylitis
x Long term corticosteroid use x >50 years of age
x Neurological deficit indicating cauda equina syndrome
x Unexplained sudden weight loss (>4.5 kg in <6 months)
x Unexplained fever (>37.8oC) x Drug or alcohol abuse x Immunosuppression x Compensable back injury
x LBP not relieved by conservative therapy over one month
x LBP worse with rest x LBP – low back pain
Signs and symptoms, which increase the chance of positive imagery include:
* Thunderclap or sudden headache worse than anything previously experienced (subarachnoid haemorrhage).
* Sudden onset of new, severe, unilateral headache in a young person especially if associated with radiation to the neck and/or Horner’s syndrome (carotid or vertebral artery dissection and MRA may be necessary).
* New headache in a patient >60 years old, especially if associated with tender, non-pulsatile temporal artery (Temporal arteritis).
* New headache in HIV-positive individuals, cancer patients, and coagulation disorders or other populations at high risk of intracranial disease, should also be screened.
* Presence of a new focal neurological sign.
* Presence of signs or symptoms of raised intracranial pressure.
U p p e r L i m b P l a i n F i l m s
It is always important to remember that arm pain can be referred from the neck, and consequently additional views of the cervical spine may be justified in some circumstances.
Plain films of the region in question may be sufficient for the initial evaluation of the following:
* Acute trauma with suspicion of fracture or dislocation.
* Calcific tendonitis or other suspected soft tissue calcifications.
* Suspicion of skeletal pathology such as arthritis or bone tumour.
U l t r a s o u n d
Ultrasound is an excellent modality for the assessment of the rotator cuff50. A significant advantage is the absence of ionising radiation. The main limitation is operator skill, and should only be performed and reported by experienced operators using high quality equipment. For the elbow and wrist, ultrasonography is useful in the assessment of soft tissue mass, tendon and ligament injuries. Ultrasound may also be useful in the assessment of the cause of carpal tunnel syndrome.
M R I
MRI provides an accurate appraisal of the rotator cuff and may be used when ultrasound is equivocal, difficult or negative despite clinical suspicion51. The labral and ligamentous structures of the shoulder joint are also well demonstrated with MRI. MRI and MR arthrography are the imaging investigations of choice for the unstable joint. For
the elbow and wrist, MRI is useful in the assessment of soft tissue mass, tendon and ligament injuries and nerve entrapment syndrome.
C T
CT is used in the assessment of complex fractures and to diagnose osteocartilagenous loose bodies.
I s o t o p e B o n e S c a n s
This may be used to diagnose a possible fracture of the scaphoid and to assess bone tumours.
L o w e r L i m b P l a i n F i l m s
Additional plain films of the lumbar spine, or a more proximal joint, or more distal joint may be required if referred pain is suspected from these regions. In children with knee pain and negative plain films, primary hip pathology with referred pain to the knee should be excluded.
Normal plain film x-rays of the region in question may be sufficient for the initial evaluation of the following:
* Acute trauma with suspicion of fracture or dislocation.
* Suspicion of skeletal pathology or arthropathy such as an arthritide, gout, bone tumour or avascular necrosis.
More specifically for trauma to the knee, in patients of any age, except for infants, the clinical parameters for not requiring an x-ray following knee trauma are as follows52:
* Patient is able to walk without a limp
* Patient had a twisting injury and there is no effusion.
The clinical parameters for ordering knee x-rays in this population following trauma are as follows52-55:
* Joint effusion within 24 hours of direct blow or fall.
* Palpable tenderness over fibular head or patella.
* Inability to walk (4 steps) or bear weight immediately or in the clinic, or within a week of the trauma.
* Inability to flex knee to 90°.
It has been shown that following knee trauma, in the absence of immediate swelling, ecchymosis, deformity, increased warmth, or abrasion/laceration, normal x-rays are likely.
U l t r a s o u n d
Ultrasound is used to assess soft tissue mass, fluid collection (eg Baker’s cyst, haematoma) and tendonopathy. Rupture of Baker’s cyst may produce acute calf pain and swelling, mimicking deep vein thrombosis.
C T
CT is useful in the assessment of complex fractures.
M R I
MRI is useful for bony abnormalities, especially those not easily diagnosed by plain film such as early avascular necrosis and transient osteoporosis. MRI is the modality of choice for assessing derangement of internal structures, eg menisci and labral injury. Skeletal causes of pain not diagnosed by plain films and CT are often visualised with MRI, eg traumatic bone bruising. MRI is also useful in the characterisation and staging of bone tumours.
I s o t o p e B o n e S c a n s
Bone scans can be used in the assessment of occult fracture, early avascular necrosis, stress fractures and tumour. In patients with painful prosthesis, bone scans may assist in diagnosing loosening or infection.
A n o t e f o r c h i r o p r a c t o r s w h o p e r f o r m t h e i r o w n r a d i o g r a p h i c e x a m i n a t i o n s
For practitioners who perform their own radiographic examinations, the onus is on the practitioner to be aware of existing legislation and acceptable minimum standards. It is beyond the scope of this article to provide that information in detail, and the practitioner should consult the Commonwealth’s, and their own State’s, requirements.
However, in brief, before performing your own radiographs, practitioners should take note of the following:
* Assurance that equipment is functioning properly and is calibrated as required.
* Operation of equipment by qualified personnel.
* Appropriate preparation of the patient.
* Technique factors which will minimise exposure3. It is recommended that practitioners who perform their own radiographs on site should have a quality assurance manual outlining correct procedure and including: written policies regarding radiation protection; procedures to be performed;
records for each piece of radiographic equipment; records of photographic quality control for the past two years.
A written interpretation of each imaging study should be included as part of every patient’s permanent health care record. The report must be signed and dated by the practitioner performing the interpretation. Components of the written report include16,56:
* Patient identification.
* Location where radiographs were performed.
* Study dates.
* Views performed.
* Radiographic findings.
* Signature including professional qualifications.
* Recommendations for further studies if required.
C o n c l u s i o n
Imaging has been, and continues to be, essential in the evaluation of patients who present to a chiropractor or osteopath. However, it is important to consider the clinical yield likely, the deleterious effects and the cost of imaging prior to ordering a study. The critical issue is need for the study. The practitioner considering any type of imaging must consider this question: ‘Will the results of this study have an impact on the management I propose to deliver?’ If this question is asked and answered objectively in every case, there will more likely be proper utilisation of imaging studies.
This is particularly true of plain films.
The recommendations or guidelines presented in this article must be read as a whole and are subject to government regulations, guidelines, safety codes and technical recommendations that vary from State to State and govern radiographic practice by all health providers in Australia.
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