9 Common Questions About Chiropractic X-rays
Here are 9 frequently asked questions regarding the necessity, health effects and validity of X-rays. As a patient or potential patient, these questions are important to answer.
1) What are you looking for by taking X-rays?
Chiropractic care focuses on locating, analyzing and correcting a vertebral subluxation. A vertebral subluxation occurs when the two top bones of the spine lock in a misaligned position. This will imbalance the spine and put tension on surrounding nerves. Tension leads to abnormal sensitivity, perception and behavior of the nerves. This has a negative impact on health expression.
X-rays help me evaluate the integrity of the spine and locate the structural misalignment of a vertebral subluxation.
There are always constants and variables in the determination of a vertebral subluxation. The goal is to reduce the variables and increase the constants. It is impossible to remove all variables. But to tip the scale in the way of constants is vital. The image provided by the X-ray is a constant I rely on.
2) What are the chances that you’ll find it if you take these X-rays?
While not 100% certain, X-rays provide a great opportunity to locate the misaligned bones of a subluxation. Clinically, if a subluxation is what we say it is, then 100% of the time the misalignment will be present in the spine and be found on the X-rays.
The ability to “find” the misalignment will be up to the competency of the Chiropractor to analyze the X-rays to determine the exact nature of the subluxation.
3) Can you find what you are looking for by other means?
Not with the same precision. Non-imaging analysis such as palpation cause too many variables; both from the patient and the doctor.
Palpation uses the bony projections that are closest to the skin. The two most used bony projections in palpation are the spinous and transverse processes. When you run your fingers along your back and feel those “bumps”, those are the spinous processes.
Up to 83% of the population has malformations in these bony projections. This could mean that the left transverse process is longer than the right transverse process. Or that the spinous process is bent to the right when the vertebra is actually lined up to the left.
These naturally occurring malformations can create difficulties in palpation analysis. What is felt to be a misalignment to the right might actually be a misalignment to the left. And vice versa.
Experiments performed early in Chiropractic proved that using palpation alone had serious errors in determining the subluxated vertebra. In non-hyperbolic fashion, the results found 0% reliability when only using palpation to determine the vertebral subluxation.
When it comes to establishing a vertebral subluxation of the upper cervical spine, the point of reference is the foramen magnum. The foramen magnum is the part of the skull where the brainstem exits from the brain. The brainstem resides within the two top bones of the neck, the Atlas and Axis bones. The foramen magnum can’t be visualized without some form of imaging.
4) If you find it, is it something you can correct?
The short answer is ‘Yes’. The correction of the subluxation is in the hands of both the competent chiropractor and the committed patient. Chiropractic is a joint effort between the doctor and the patient.
Chiropractors spend a minimum of 3 ½ years in school learning proper analysis and technique in the adjustment of the subluxation.
As a chiropractic student, a minimum of 250 adjustments are required to graduate; 50 come from students and 200 come from the outpatient clinic. Along with reaching my required adjustment numbers through the curriculum, I also took elective classes to further hone my adjustive skills.
Beyond that, I took part in Chiropractic mission trips to Nicaragua where I had the opportunity to adjust 2,000 children and adults. My educational and clinical experience gives me confidence in obtaining the goal of the adjustment.
5) Does your care plan entail any risks? If not, why can’t you just assume I have the condition, skip the X-ray, give me that care, and see if it works?
Yes, there are risks involved with taking X-rays. Contextually, all healthcare procedures carry risks, no matter what they are. Furthermore, there are also risks involved with not taking X-rays. From a Chiropractic understanding, the risk of negative outcomes increases if we do not know exactly how the bones misalign.
To guess at our adjustment can lead to undesirable consequences. For example, let’s say you have a simple fracture of your femur. A simple fracture is a type of fracture that does not break the skin. And since it does not break the skin, it can be hard to determine the exact direction and degree of the fracture. Would you allow the orthopedic surgeon to set the bone without knowing the specific direction and degree at which the bone fractured? The orthopedic doctor could assume that the bone fractured 20 millimeters to the right and at 10 degrees superior, but should you take their assumption without knowing precisely before they set the bone?
Assumptions should not be the bedrock of any healthcare application. There is an old maxim in Chiropractic that states: “Why Chiropractic X-rays? To see is to know, not to see is to guess, and we won’t guess about your health."
6) When was the last time your X-ray equipment was checked for safety?
In the state of Ohio, the Department of Health checks our X-ray equipment every 3 years through a series of safety protocol inspections. Quality assurance items are reviewed and X-ray equipment is tested. The performance inspection includes the following: Current certificate of registration, Regulations applicable to facility type, Prior violations and corrective action review, Notice-to-Employees postings, Operator training, Personnel monitoring, Radiologic licenses, Preventative maintenance, Quality control tests: daily, monthly, quarterly, Area radiation surveys, X-ray equipment inventory, X-ray equipment safe operating procedures, X-ray equipment receipts, transfers and disposals, Fluoroscopic equipment: tests by the medical physicist, Computed tomography equipment: tests by the medical physicist, Radiation therapy equipment: tests by the medical physicist, Any self-referral approval letters, Any Food & Drug Administration (FDA) X-ray equipment variances, Exposure, kVp and timer reproducibility, kVp and timer accuracy, Half-value layer, Exposure switch position and function, Entrance-skin exposure for examination, Collimator and light field congruency, Collimator beam size an alignment factors, Safety interlocks
7) Will it be operated by a trained technician who knows what he or she is doing and will keep the radiation dosage to a minimum?
Chiropractors, in general, have over 300 hours of radiology education, including diagnosis, equipment use and patient placement. The study of radiology accounts for 12% of our clinical training in college. I pride myself on taking my own X-rays. It is important for me to be with a new patient every step of the way on the initial exam.
In general, medically-trained X-ray technicians do not learn the small intricate details needed to take a proper Chiropractic upper cervical specific X-ray series. Exact placement is integral for upper cervical specific films. Since I will be the one analyzing the films and making the adjustment based on my analysis, it is my job and your right as a patient to demand the highest quality of care.
Based on your age, gender and weight I modify the radiation voltage to prevent needless radiation dosage.
8) What form of shielding or other protection will you furnish me?
Lead aprons are provided and cover areas that are not necessary for the X-ray viewing series. Lead is often used in protection shields because it helps prevent the scattering of radiation. Lead is a heavy metal and is very dense in nature. The density level prevents gamma rays and X-rays from passing through them.
Lead aprons usually cover the reproductive organs of both males and females, especially if an X-ray is taken in the lumbar and/or thoracic region. The majority of my X-rays are taken of the upper cervical spine, so radiation scatter to these regions of the body is very rare. The major concern with taking cervical X-rays is the proximity of the thyroid gland to this area.
The thyroid gland is involved in many metabolic and hormonal processes; a malfunctioning thyroid can lead to a variety of ill-conditions. The major difference between an upper cervical specific X-ray series and a regular cervical series is the location of the central ray. The central ray is the point of the tube where the radiation is created. From this point, the X-rays diverge out from the tube in a cone-shaped projection. The central ray also has the greatest concentration of radiation, lessening as it diverges out.
With a regular cervical series, the central ray is located at the C5 vertebra, just posterior to the thyroid gland. With an upper cervical series, the central ray is located at the C1 vertebra. This means there is a higher concentration of radiation to the thyroid gland with a regular cervical series than with an upper cervical series. Although the radiation risk is low in either series, exposure is less in the upper cervical series.
9) What dose of radiation will I receive?
Radiation exposure is a warranted health concern of the public and should not be glossed over by healthcare professionals as something inert. I do think it is important though to put perspective into the conversation when it comes to dosage. When talking with my patients, they are always surprised to find out that the general population receives natural radiation all the time, and usually from sources not advertised as producing radiation.
The average person in the United States receives an effective dose of about 3.1 mSV per year coming from natural radiation and cosmic radiation. The predominant source of natural radiation is found in the air we breathe, inhaled as radon. The other main sources are found in our food and water, ingested as uranium, thorium, and radium.
Radiation exposure has increased over the last 20 years though, with the majority of the increase coming from healthcare sources. The major healthcare source of exposure comes from X-rays. With all the negative press that standard X-ray imaging receives, other imaging procedures seem to skid by unnoticed with regard to radiation dosage.
One imaging procedure that seems to get a “hall pass” in the radiation debate is CT Scans. CT Scans are a series of X-ray images that are taken from different angles to create cross-sectional sections of the body. One CT scan can total an average of 6 mSv, double the normal amount of radiation a person is exposed to in an entire year.
As an Upper Cervical Chiropractor, I normally take a 3 View Cervical Series. With this series of X-rays, the total dose of radiation averages out to be around 0.6 millisievert (mSv). This is using an 18-year-old person as a point of reference.
These 9 questions and answers are not exhaustive when it comes to X-ray validity and patient concerns. I hope though that they at least answer some inquiries when it comes to X-rays. This is a place to start in the conversation and hopefully eases the patient’s reservations about starting Chiropractic care.
- Jarek Esarco, DC, CACCP
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