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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]

From: Current evidence for spinal X-ray use in the chiropractic profession: a narrative review

Clinical suspicion Alerting clinical featuresa Recommended imaging, referral or clinical action
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 referralb
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 referralb 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 referralb
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 referralb
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 referralb
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 referralb
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 • DXAc 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)
  1. aSingle risk factors are usually not sufficient to indicate imaging referral. Clinical suspicion of the condition must also exist
  2. bIt may be appropriate to defer imaging referral until specialist review
  3. cDual-energy X-ray absorptiometry