Table 1 Summary of current evidence based guideline recommendations for diagnostic imaging of the spine for chiropractors [7, 8, 13, 45, 82, 124, 129, 130]

Spinal fracture (cervical)

Canadian Cervical Spine Rule (C-Spine Rule) [13]

History of cervical trauma and any one of (assessment to be performed in order):

1. Presence of at least one high risk factor (age of 65 years or above; dangerous mechanism of injury (e.g. fall of greater than 5 stairs); extremity paraesthesias)

2. Absence of all low risk factors (simple rear-end motor vehicle accident; sitting position at presentation; ambulatory at any time post trauma; delayed onset of neck pain; absence of midline c-spine tenderness)

3. Inability to actively rotate neck 45 degrees left and right

• Cervical X-ray: AP, APOM, and Lateral

• May also require CT or MRI for complete assessment

Spinal fracture (other region)

Spinal pain after recent history of significant trauma with multiple risk factors:

• Older age (above 65 years for women, above 75 years for men)

• History of osteoporosis

• Prolonged corticosteroid use

• Severe trauma

• Contusion or abrasion

• X-ray

• If negative X-ray result and strong clinical suspicion consider MRI

Cancer

Major risk factors for cancer:

• New onset of spinal pain with history of cancer

• Multiple risk factors or strong clinical suspicion of cancer (breast, lung, and prostate are the most common primary sites)

Weaker risk factors for cancer:

• Age greater than 60 years

• Unexplained weight loss

• Pain with rest or at night

• Failure to improve after one month with conservative care

Major risk factors present:

• Immediate imaging: MRI (if MRI unavailable, X-ray suitable)

• Blood tests

No major risk factors present:

• Trial of appropriate conservative therapy prior to further diagnostic workup

Infection

New onset of spinal pain with risk factors of infection:

• Fever or chills

• History of infection

• History of intravenous drug use

• Recent spinal surgical or investigative procedure

• Pain with rest or at night

• MRI and blood tests

• Specialist referral^b

Spondyloarthropathy

Chronic pain (greater than 3 months) with risk factors of spondyloarthropathy:

• Younger age at onset (less than 40 years)

• Insidious onset

• Improves with exercise

• Alternating buttock pain

• Pain at night

• Positive family history

• Extremity articular symptoms

• Improvement with non-steroidal anti-inflammatory drugs

• Extra-articular symptoms (I.e. psoriasis, inflammatory bowel disease, uveitis)

Strong clinical suspicion:

• X-ray and blood tests

• If negative X-ray result and strong clinical suspicion or positive blood tests consider MRI

• Specialist referral^b

Lower clinical suspicion:

• Trial of appropriate conservative therapy prior to further diagnostic workup

Radiculopathy

Back or neck pain with leg or arm pain, sensory loss, weakness, or decreased reflexes

Single-level radiculopathy:

• Trial of appropriate conservative therapy prior to further diagnostic workup

Multi-level or progressive neurological symptoms (especially motor or reflex deficits), or surgical candidates:

• MRI

• Specialist referral^b

Lumbar spinal canal stenosis

Risk factors of neurogenic claudication:

• Older age

• Buttock, thigh or leg pain

• Worse with walking/standing

• Relieved by sitting or flexed postures

Non-surgical candidates:

• Trial of appropriate conservative therapy prior to diagnostic workup

Surgical candidates:

• MRI

• Specialist referral^b

Spinal cord compression

Risk factors for cervical myelopathy:

• Neck pain with multi-level, progressive upper limb neurological symptoms (especially motor or reflex deficits)

• Older age

• Increased lower limb reflexes

Risk factors for cauda equina syndrome:

• Multi-level, progressive lower limb neurological symptoms (especially motor or reflex deficits)

• New bowel or bladder dysfunction

• Saddle anaesthesia

Acute/severe symptoms:

• Emergency referral, no prior imaging

Chronic/less severe symptoms:

• MRI

• Specialist referral^b

Arterial dissection, stenosis, or aneurysm

Cervical spine risk factors:

• Severe, persistent or unusual neck pain or headache

• Cranial or upper limb neurologic symptoms

Thoracic spine risk factors:

• Severe chest or back pain

• Hypotension

• Absent distal pulses

Lumbar spine risk factors:

• Severe abdominal, back, or groin pain

• Hypotension

• Absent distal pulses

Acute/severe symptoms:

• Emergency referral, no prior imaging

Chronic/less severe symptoms:

• Ultrasound or MRI

• Specialist referral^b

Osteoporosis

Major risk factors:

• History of fracture as a result of minimal trauma

• History of prolonged corticosteroid use

• Older age (greater than 65 years in females, greater than 75 years in males)

• Premature menopause in females

• Hypogonadism in males

• Predisposing condition (I.e. rheumatoid arthritis, hyperthyroidism, hyperparathyroidism, chronic kidney or liver disease, coeliac disease);

Weaker risk factors:

• Parental history

• Low physical activity

• Low body weight

• Poor nutrition

• Poor balance

• Frequent falls

• DXA^c scan of spine and proximal femur

Progressive spinal structural deformity

Child or adolescent:

• Rigid coronal or sagittal curvature

• Positive Adam’s test

• Rib humping

Adult:

• Rigid coronal or sagittal curvature with either acute presentation of curvature, or recent progression of curve

• X-ray

• Specialist referral for identified underlying pathology or large cobb angle (> 25 degrees)