What Imaging Should I do?

A very good question that I am asked frequently. As I’m sure you are aware, technology changes every day; the advances in medical imaging technology are no different. The main ones DCs are concerned with are MRI, MR arthrography, CT, fluoroscopy, ultrasound, bone scan, X-ray.

Just a few of the headlines from a well-known radiology website AuntMinnie.com—Holography beckons as alternative to 3D printing, ISCT: The road to full automation in abdominal CT, photoacoustic imaging could guide breast CA removal, CT detects frailty and predicts survival in elderly—and June 21, 2017 — Brigham and Women’s Hospital (BWH) in Boston is making a considerable investment in the future of radiology and patient care with its recent installation of an investigational 7-tesla MRI scanner.
Granted these are out of reality for chiropractors but I think you get the idea. So let’s focus on musculoskeletal imaging since that’s the bailiwick for most DCs.

So do I go to MR or maybe MSKUS? Well first let’s go back to basics: a patient comes in with a common musculoskeletal complaint of _________

  • Initially, musculoskeletal issues should be simply imaged FIRST WITH X-RAY. It should be remembered that plain films remain a reliable method to assess biological activity and probable diagnosis of an osseous lesion. X-ray equipment is relatively inexpensive and widely available. [S5]
  • Plain X-ray therefore is used to arrive at a reasonable differential diagnosis or at least to categorize the lesion as to degree of aggressiveness.
  • To visualize structures, natural contrast is used between the five radiographic densities—air, fat, water, bone, and metal.
  • You can visualize the area as a whole with relation to surrounding osseous and soft tissue structures.

Advantage — fast, readily available, inexpensive, and noninvasive.

Disadvantage — lack of soft tissue discrimination; ionizing radiation.

  • It is an absolute necessity to have a minimum of two views perpendicular to each other. [S1]

In summary, X-RAY first:

  • Provide initial investigation of abnormalities [S5]
  • Provide information on what additional imaging may be indicated or contraindicated [S5]
  • Diagnosis is frequently possible or provide short differential

So what’s the downside? Ionizing radiation used in the production of X-ray images is dangerous; continuous exposure to these rays over time may cause damage to the body. However, with the advances of modern digital technology and microsecond imaging exposure times, the benefits of an accurate diagnosis and treatment far outweigh the comparatively small risk involved in X-ray imaging.

As mentioned above, always take at minimum two views, so here is a case example of why always a minimum of two images: A 35-year-old woman complains of neck pain.

For purposes of this discussion only look at the AP, please DON’T CHEAT! The referring doctor was very concerned with what he saw on the AP—what do you see?

Strange-looking area to right of the spine? Potentially aggressive-looking? Possible soft tissue lesion? Well, as I mentioned above, always, always take at least two views. Now let’s look at the lateral — I hope you didn’t cheat.

So what do you think now? What was the dastardly looking possible soft tissue lesion? Yep, you got it — hair artifact. [S3]

Lesson — always take at minimum two views; more views is not a bad thing. [S1]