When is imaging necessary for back pain?

Every chiropractic office is different. Many "old school" chiropractors will still take x-rays of every single patient. I do not. If after doing a history and exam I feel you need to get imaging done to help us formulate a better treatment plan, then I will refer you out to have those images taken. 
Reasons I may order imaging:

• To rule in/out a fracture
• Your symptoms and exam do not match up
• You have an underlying medical condition
• To measure a progressive scoliosis 
• You have not responded to conservative treatment 
• You exhibit any of the following "Ottawa rules" (1)
• You have progressive muscle weakness
• You were involved in some type of accident

Reasons I would NOT order imaging:

• To draw lines on it and scare you into thinking you need a $2000 treatment plan

There is a time and place for imaging. Typically, it's not needed on the first visit. If someone takes images of your spine, ask them why they need to take the images, ask them to describe everything they see and WHAT IT MEANS. 

If my patient walks in with an imaging report, the first thing I do is sit down with them and go over what all those words mean and what we do from there. 

It is important to note that imaging will show structural changes, pain is not always caused by a structural problem. A systematic review showed that 37% of 20-year-olds and 96% of 80-year-olds have disc degeneration in the form of a disc bulge or disc protrusion WITHOUT ANY SYMPTOMS (2)! Another study showed that only 3-4% of people with a disc herniation or stenosis were symptomatic (3). 

Soooo what does all that mean? It means your imaging could look "terrible" and you could have no pain/symptoms at all OR your imaging could look "normal" and you could have a lot of pain/symptoms. 

Take away. Sometimes imaging is necessary. If you have imaging taken, be sure someone takes the time to explain it to you. Otherwise, conservative treatment such as chiropractic care or physical therapy should be your first step in dealing with pain. 

Reference:
1. Ottawa ankle rules | Radiology Reference Article | Radiopaedia.org
2.Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations
3. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging

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