Sometimes there’s a mismatch between what a radiology report says about our x-rays vs. what a chiropractor says about the same images. We go over the reasons why this happens, and why it matters. And we look at what’s different when a medical doctor examines an x-ray and when a chiropractor does their x-ray analysis, using an example of a 12 year old boy who fell off a bike.
Q&A No. 1: Why does my radiology report say normal alignment, while my chiropractor says there’s a problem?
The best way to understand this seeming contradiction is to watch the full length video on this question on YouTube below. There’s also a link to a shorter version hosted on Facebook at the bottom of the post.
If you prefer to read my short summary, plus a few other insights, please keep scrolling.
Chiropractors and medical doctors look at x-rays for different reasons
The biggest mistake you can make when looking at a radiology report of your spine is to assume that the radiologist who read it is looking for chiropractic or biomechanical problems.
Medical radiologists do not read x-rays for chiropractic problems. They read them for medical problems.
Medical doctors examine x-rays looking for signs of a disease process (pathology) or a bone break (fracture.)
If a medical radiologist doesn’t see signs of a disease process or a bone break, they may say that an x-ray is normal. If you have a biochemical problem that is severe (scoliosis curve, or reverse curve in the neck), then a medical radiologist may comment on it. But often they do not.
Chiropractors examine x-rays for biomechanical information.
Yes, it’s important for chiropractors to identify signs of a disease process or a bone break, but our primary purpose in taking an x-ray is to evaluate the shift and position of the vertebrae relative to each other in order to help us understand which area of the spine to adjust/release.
Sometimes chiropractors and medical radiologists notice and comment on the same things
Medical radiologists and chiropractors will comment and talk about the same problems in some cases.
Arthrosis, bone spurs, disc space narrowing, and calcification are some of the words you may read in a radiology report that a chiropractors may discuss with you.
These are words that may be related to a disease process that people generically refer to as “arthritis, arthritic changes, or osteoarthritis.”
It can be more difficult to solve a problem created by a biomechanical breakdown, if you rarely look at biomechanics.
This is a recognized medical disease process (pathology) and it’s also a disease process that is the result of biomechanical problems.
Other words that both medical radiologists and chiropractors may discuss together are spondylosis, spondylolisthesis, and scoliosis.
This shared concern of both medical radiologists and chiropractors doesn’t change the fact that that these are two different professions examining x-rays for two different reasons. Don’t be confused by the same language into assuming that the radiologist is going to comment on all biomechanical problems.
The case of a 12 year old boy who fell from his bike
The short and long-form video version discuss the case of a 12 year-old boy who fell from his bike and had neck pain. The radiologist read his neck x-ray as normal, since there was no obvious disease or fracture. The radiologist may or may not have been commenting on the potential alignment issues.
(If you want to see those images, please watch the video.)
However, when I read the x-ray from a structural chiropractic perspective, I notice three biomechanical problems that the radiologist isn’t going to be concerned with:
- The position of the first neck bone (sagittal plane)
- The loss of the curve at the top of the neck, and the slightly rearward position of one of the vertebra
- The rotated position of the vertebra
The boy developed neck pain after a minor trauma. Now that we know he doesn’t have a fracture or dislocation, the above issues may be an indicator of a malposition of one or more vertebrae that deserves an investigation.
If he has any signs of
- loss of range of motion of the neck
- tight or tender musculature of his neck
- tender joints of his vertebra
- postural distortions such as a head tilt or a raised shoulder, etc
than he may require a chiropractic adjustment to help him “reset” his spine after his injury.
Two different professions, two different sets of eyes, two different concerns lead to different management
The worst assumption a parent in this situation could make is assuming that the medical radiologist is looking for the subtle causes of neck pain, like any of the clinical signs listed above. The radiologist isn’t looking for anything else other than a fracture or a disease process.
This is why two different practitioners can look at the same data and come to different conclusions on what needs to be done.
The 12 year old didn’t need medical management. But he may have needed a chiropractic appointment.
Which brings us to an important ending point.
The unique position of a hands-on practitioner who also reads x-rays and other imaging
Chiropractors have a unique position in that they are one of a few practitioners who can identify problem areas of the spine on imaging they perform, and also clinically investigate that problem in person, often on the same visit.
Said simply, we read x-rays and we touch our patients. This is rare.
This allows us to see and correlate problems that may go unnoticed by other practitioners.
Most diagnosing physicians who work with the spine will not read the imaging studies they order. There is often very little physical examination of the patient. And any hands-on treatment is often referred out to a physical therapist, who often is not trained to consult the original imaging or believes it is necessary.
Here’s a really important example.
Heading to the chiropractor on one hand
Let’s say that a patient has an acute low back pain that radiates into the back of the right thigh.
The patient heads to the chiropractor, who:
- Takes an x-ray, notices a rotational imbalance in the pelvis, and a rearward position with rotation on L4 (4th lumbar vertebra). The chiropractor notes there is no obvious fracture or disease process. There may a thinning of the disc space, and some arthritic changes.
- The chiropractor then palpates the motion of the lumbar spine, and finds a very fixed and painful facet of the right L4 vertebra. The chiropractor feels the skin around the lumbar spine, and notices there is a distinct hot area adjacent to the L4, and even a clammy feel to the skin in general. Because the chiropractor touches a hundred of different people per week, and knows the subtle tissue changes around a fixed joint, the chiropractor even notices that putting slight finger tip pressure on the vertebra seems to help the tissue around the vertebra relax.
- The chiropractor consults the x-ray to correlate the position of the vertebra for its three major planes of motion, and then delivers a light thrust into the vertebra with a hand, or an instrument. It unlocks.
The low back pain and radiating leg pain goes away. This may all happen over the course of just a few hours to a few days.
going the customary primary care route
In another office, a medical physician…
- Would prescribe NSAIDS or a muscle relaxer to the patient after ordering a lumbar x-ray to check for fracture or a disease process. The patient would wait for the radiologist to read the x-ray.
- The radiologist would note the same loss of disc space and same arthritic changes, and may warn that the patient has a disc issue that should be evaluated via MRI.
- The malposition of the L4 vertebra wouldn’t be noted, not because the radiologist doesn’t care, it’s just not part of their evaluation.
- Depending on the practitioner, there would often be very little physical examination of the patient
- The medical physician would refer the patient for physical therapy if the pain did not subside on its own. Often it doesn’t.
- A week or more after the acute back pain, the patient is finally in physical therapy, with the understanding that the x-ray is normal, other an a little bit of arthritis. The physical therapist might read the radiology report, or they might not. They most likely would not consult the x-ray. Physical therapy may include anything and everything from electrical stim, hot packs, cold backs, exercise, massage, to general manipulation.
If the pain doesn’t subside with physical therapy, they the patient may get an MRI.
This is one example of the way that the practitioner involved, and the information their reviewing for the problem at hand can matter.
Neither one of these ways is the more correct way to handle this situation. However, it can be more difficult to solve a problem created by a biomechanical breakdown, if you rarely look at biomechanics.
Here is a shorter version of the above video.
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