AT EVERY MPC SEMINAR and in depositions or court appearances, there are always the same major questions: Are X-rays (VSC listings) necessary? Are X-rays necessary if I have an MRI?
Chiropractic X-rays today appear to be a controversial issue for some DCs. Why? (Look at Palmer chiropractic history of X-rays for VSC component diagnosis)
Many answers depend on the DCs’ personal and professional choices, patient complaints, patient history, patient injury (current or past), clinical factors, diagnosis made, attorney involvements, etc. Remember, an MRI is just a limited test.
You all know what the chiropractic scope of practice is per your state law. (See the first MAPS article). Following the standards of care (SOC), the standards of practice (SOP), and the pillars of practice (POP) it also depends on your specific diagnosis and the specific technique(s) you choose to use in your clinic as the treating primary doctor (physician).
“Weight-bearing X-rays stress views (flexion, extension, motion) can show instability. X-ray analysis (i.e., X-ray, mensuration, Pennings) also shows soft tissue damage”
I will tell you malpractice attorneys say, “NO X-RAYS, NO DEFENSE.”
Here are attorneys’ legal arguments in front of the judge and jury:
Chiropractic is a specific healthcare delivery system for the specific diagnosis of VSC. The chiropractic adjustment is to be a specific technique applied in a specific direction for a specific measured outcome assessment. The DC must know and document that there are no spinal abnormalities, congenital defects, or contraindications to any manipulation.
Attorneys question that without a specific VSC X-ray listing, how does the DC know in which direction the vertebrae are twisted (subluxated) and rotated? A DC cannot tell a specific spinal axial rotation without an X-ray. Diagnostic X-rays with specific VSC directional listings are to be in the DC chart-SOAP notes, (review technique protocols, Activator, Cox, Gonstead, Palmer, Thompson, etc.). Third Parties (i.e., Medicare) state that each vertebra (VSC) in each spinal region must be identified and recorded when it is adjusted (CMT).
Remember, a subluxated vertebra (VSC) can only go anterior or posterior, superior or inferior, and right or left. X-ray mensuration is a real diagnostic tool.
Attorney question: How is there a specific adjustment on a specific vertebra in a specific direction without a specific VSC X-ray listing?
Simple legal answer: NO X-RAYS, NO DEFENSE
MAPS: ACE
The next MAPS issue to address is: Do I need X-rays if a patient has an MRI?
Answer: The diagnosis of a specific VSC (eight physical components and eight chemical components) at a specific spinal level is necessary. The best imaging tool for the assessment of spinal biomechanical lesions is weight-bearing films.
In my opinion, as well as that of experts such as Dr. Terry Yochum, Dr. Deborah Pate, and Dr. Krause, spinal X-rays assess bony structures and how they articulate, axially rotate, and deviate from their normal juxtapositions. Thus, the assessment of the joint spaces under the influence of gravity is important. Also, X-rays can be an important kinetic study (i.e., flexion, extension, lateral bending, oblique studies, etc.).
Chiropractic X-rays demonstrate the VSC osseous components (abnormal components such as kyphosis and scoliosis), axial rotation, etc. MRIs demonstrate soft tissue (i.e., cartilage, ligaments, muscles, tendons, etc.). The majority of MRIs are done in a non-weight-bearing position (I do like weight-bearing MRIs for some confirmatory diagnostic components).
Cost of X-rays per region: Approximately $100
Cost of MRIs per region: Approximately $500 or more
Chiropractic X-rays are high resolution, two-dimensional, and can assess bone or joint abnormalities or disease, soft tissue calcification, and VSC components (i.e., RT, LT, rotation, superior, inferior, anterior, posterior positioning, axial rotation, etc.). An abnormal MRI for a trauma victim (MVA) may not demonstrate small ligamentous structures that stabilize cervical-lumbar VSC segments.
Weight-bearing X-rays stress views (flexion, extension, motion) can show instability. X-ray analysis (i.e., X-ray, mensuration, Pennings) also shows soft tissue damage. Chiropractic physicians, especially those trained and specializing in Spinal Concussion-WADS2 and musculoskeletal trauma disorders (i.e., MVA, Spinal Concussion WADS2 injuries), know X-rays are a key component to diagnosing, treating, and documenting the patient properly while being a great DC defense.
Note: You simply cannot run your fingers down a spine and diagnose a comprehensive VSC and all its components and be specific (i.e., RT, LT, anterior, posterior, axial rotation, etc.) You can palpate edema, fixation, spasms, etc.
A recent Journal of Clinical Medicine article titled “Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine” reported that 91.9% of DCs in the United States state that X-rays are very important regarding biomechanical diagnosis (analysis) (VSC) of the spine; 82% state X-rays are vital to practice; and 67.4% of X-rays aid in measuring outcomes (necessary).1
However, it is the treating DC’s choice and final decision whether to take X-rays, refer out for X-rays, or not to take X-rays. However, remember that malpractice attorneys state, “No X-rays, no defense.” At the B.J. Palmer Chiropractic Clinic, X-rays were a key component to successful chiropractic diagnosis, care, and outcomes for decades.
Note: Having high student loan payments is not an excuse for not having all the equipment you need to diagnose and care for VSC’s properly, in my opinion.
Special side note: I recently had dinner with the new interim president of our hospital. I just helped establish a panel of DCs for hospital employees. The president stated that MDs, DOs, and DPTs order labs, X-rays, and MRIs often to confirm and monitor patients. He was confused about why some chiropractors do not want to be specific in their diagnoses, care, rehab, and monitoring of the patient’s progress. He wanted to know that all DCs on the new hospital panel have X-rays in their office for patient safety and proper care.
See you soon at an MPC CE Seminar.
*These are opinions and suggestions. This is not to be considered as legal advice.
Dr. KSJ Murkowski, D.C., is an internationally recognized chiropractic leader, educator, and motivational speaker. He serves as President of Master Practice Counselors and has earned numerous honors, including Michigan Doctor of the Year (twice) and multiple meritorious awards. A former state president and board chairman, he has testified before the U.S. Senate, contributed to ICD-10 coding for the WHO, and serves as an expert witness across North America. He is also a proud father of three accomplished chiropractic doctors. If you have any questions call 517-784-9123 or email [email protected]
Reference
1. Amone PA, Kraus SJ, Farmen D, Lightstone DF, Jaeger J, Theodossis C. Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession. J Clin Med. 2023 Mar 10;12(6):2169. doi: 10.3390/ jcml2062169. PMID: 36983168; PMCID: PMC10054546.
