Diagnostic Imaging


A 2018 meta analysis1 evaluating appropriateness of imaging confirmed previous findings that primary contact clinicians (e.g., general medical providers, physiotherapists and chiropractors) frequently overuse imaging in the management of low back pain and do not follow best evidence recommendations. The study also found that underuse may need to be addressed, again highlighting the need for improved approaches to promote appropriate imaging decisions.


Low Back Pain (LBP)

The most current evidence-based diagnostic imaging practice guidelines for chiropractors/primary care physicians do not recommend the routine use of imaging for patients seeking an evaluation of their LBP. A 2015 review2 was performed to assess the effectiveness of interventions aimed at reducing imaging rates and found:

  • Clinical decision support that involved a modified referral form allowing only 3 indications from guidelines for appropriate imaging reduced the imaging rate by 36.8%.
  • Targeted reminders involving educational messages that promoted appropriate imaging practices were sent with lumbar spine imaging reports to primary care doctors and reduced the rate by 22.5%.

A systematic review and meta-analysis were conducted by a working group for the Danish Health Authority in 2018.3 Based on the evidence, the authors developed national clinical guidelines that aligned with recommendations from international guidelines. In patients with lumbar radiculopathy or recent onset LBP without indications of serious underlying conditions, routine imaging is not recommended and does not improve outcomes; in fact, the potential for harms (e.g., iatrogenic effects, overtreatment, and increased surgical rates) outweighs the potential for positive effects.

Adolescent Idiopathic Scoliosis4

For the diagnosis and management of curves, x-ray is the current gold standard for use limited to only the region of interest and in as few views as reasonably possible. During the treatment period, the number of films taken varies necessarily. Patients should not be radiographed more than 1x/year if there is no progression evident as increased radiography (ionizing radiation) has been associated with an increased risk of malignancy.


  1. Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine J. 2018;18(12):2266-2277.
  2. Jenkins HJ, Hancock MJ, French SD, Maher CG, Engel RM, Magnussen JS. Effectiveness of interventions designed to reduce the use of imaging for low-back pain: A systematic review. CMAJ. 2015;187:401-408. FREE FULL TEXT
  3. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60-75.
  4. Ng S-Y, Bettany-Saltikov J. Imaging in the Diagnosis and Monitoring of Children with Idiopathic Scoliosis. Open Orthop J. 2017;11:1500-1520. FREE FULL TEXT