What a Chiropractic X-Ray Shows — and When You Don't Need One

Some chiropractic offices X-ray every new patient. Some never do. Both are wrong as a policy, because the question isn't "do you X-ray?" — it's "what would this X-ray change?" If the answer is nothing, the film is an expense and a radiation dose with no upside. If the answer is "whether it's safe to adjust you," the film is the most important thing that happens at the first visit.

This post explains what a plain X-ray can and can't show, the specific findings that make one necessary, and why the profession's own guidelines say most new back pain shouldn't be imaged at all.

What a plain X-ray actually shows

X-rays image bone well and soft tissue poorly. On a spinal film we can see fractures, the alignment and spacing of the vertebrae, bone spurs and arthritic change, narrowing between vertebrae that implies disc thinning, congenital variations in how the spine formed, and — critically — signs of things that are not ordinary back pain: tumors, infection, and bone loss from osteoporosis.

What an X-ray does not show: the disc itself, the nerve roots, ligaments, muscles, or the inflammation that is usually the actual source of pain. A herniated disc pressing on a nerve is invisible on a plain film. So is a strained muscle, a sprained ligament, and most of what makes a neck hurt after a car crash. Those need an exam, and sometimes an MRI, not an X-ray.

What the guidelines say

The American Chiropractic Association joined the Choosing Wisely campaign — a national effort to identify tests that are commonly ordered but often unnecessary — and its first two recommendations are about X-rays. In the absence of red flags, do not obtain spinal imaging for patients with acute low-back pain during the six weeks after onset. And do not repeat imaging to monitor a patient's progress.

The reasoning, laid out on the Choosing Wisely list itself, is that for uncomplicated back pain, imaging doesn't speed recovery, does cost money, involves radiation, and increases the likelihood of ending up in surgery without improving outcomes. The findings that matter for chiropractic safety are rare, and the ones that show up on X-rays of people with no red flags are rarer still.

Those recommendations shape how the imaging decision is made at Mattia Spinal Care. If you've come in with a week of low back pain after helping a friend move, the question at your first visit isn't whether an X-ray is "included" — it's whether anything in your history or exam raises a flag that a film would help answer. Our earlier post on the whole-person approach to chiropractic X-rays describes what we look at when a film is warranted; this post is about deciding whether it is.

The red flags that change the answer

"Red flags" is the clinical term for findings in your history or exam that raise the possibility of something other than a mechanical problem. The Choosing Wisely list names several, and our exam screens for all of them:

• A history of cancer
• A fall, crash, or other trauma that could have caused a fracture — especially in older adults or anyone with known bone loss
• Neurological symptoms that are progressive: weakness, spreading numbness, changes in reflexes
• Signs suggesting infection: fever, recent infection elsewhere, unexplained weight loss
• Known or suspected osteoporosis, osteopenia, or inflammatory spinal disease
• Pain that doesn't change with position or movement, or that wakes you at night

Any of these earns an X-ray before anyone adjusts you — and depending on what it shows, may earn a referral instead of an adjustment. The guidelines also flag a second category: conditions that don't necessarily indicate disease but may make a thrusting adjustment inappropriate, such as significant bone loss or certain structural findings. In an older patient, that consideration comes up more often.

What about the radiation?

A spinal X-ray is a low dose compared with a CT scan, but it is not zero. The FDA's guidance on medical X-ray imaging puts it plainly: the benefit of a clinically appropriate exam generally far outweighs the risk, and the way to manage that risk is to avoid exams that aren't clinically appropriate. Having digital X-ray in the office means a film can be taken the same visit when the exam calls for one, at the lowest exposure that produces a diagnostic image — and the guidelines' second recommendation, not re-imaging to "check progress," is the reason progress is measured by how you move and feel rather than by a picture.

How we decide, in practice

The decision is made at the end of the history and exam, not the beginning. Dr. Nazario reviews how the pain started, what you've had before, your age and medical background, and the exam findings — range of motion, neurological screen, tenderness pattern, and any signs from the list above. Then one of three things happens: no imaging and we proceed with care; an X-ray in the office before care begins; or a referral for MRI or to another provider because what we found is outside what a chiropractic office should be managing.

If you already have recent imaging — from an ER visit, an orthopedist, or a prior provider — bring it or have it sent. We would rather read an existing film than take a new one.

The film should answer a question

If you've been putting off getting back pain looked at because you don't want to be X-rayed, or because you assume you need one and it sounds like a hassle, either way the answer is the same: come in for the exam and let the exam decide. Schedule an evaluation or call (407) 909-4788. Se habla español.