Question: Do I really need x-rays before treatment?
Almost daily we get a phone call from a prospective patient. Understandably, they want to know if we can treat the condition they have or think they have, and they want immediate relief (I do, too!). Right after the discussion of cost, in which they often discover we are more reasonable than the provider in their insurance network, there is usually a question about necessity of x-rays.
My rule of thumb is guided by patient safety. The risk-benefit scale may tip in favor or imaging or not, but when it tips in balance of imaging, I do not hesitate. There are several factors I will weigh on that scale, including the nature of the complaint, patient history, age, gender, presence of trauma, physical signs, and "instinct."
X-ray, discovered by Madame Curie in 1895, are composed of electromagnetic radiation that pass through the body to cast shadows. Bone shows as white, air shows as black, and soft tissues and organs show in varying shades of gray. Believe it or not, we can look at these cryptic images and discover interesting things about your anatomy.
After trauma, I will do a careful exam to see if you appear to have any fractures. If I am suspicious from either the history or exam, I will x-ray right then. If there is a fracture, we will consider appropriate referral if warranted.
Among seniors, it is very possible that we will need x-rays prior to treatment to look for arthritic joints, osteoporosis, structural issues, and pathology. I am likely to x-ray seniors when there is a pain complaint, either chronic or acute. If there is a cancer history a recent fall (very common in those over 65), I am likely to x-ray.
In a patient of any age, I am likely to x-ray when there is radiating pain, especially when it appears in both sides, as that is unusual. The appearance of numbness, tingling, or muscle weakness on one or both sides is likely to trigger films, possibly as a precursor to other imaging, such as MRI.
I am very hesitant to expose children or teens to x-ray. There must be a clear benefit to obtaining the information to offset the potential negatives of irradiating bone growth plates or gonadal tissues, for example. Trauma, of course, weighs heavily on the pro side, as does the possibility of congenital anomalies in the spine or hips. These decisions are made with the parents after considering all the data and options.
There are also conditions of the extremities that I do not tend to x-ray. Uncomplicated shoulder pain without trauma, for example, is one that I do not tend to x-ray prior to treating. The best research does not support imaging hard tissue when the problem is like soft tissue that will not show on x-ray.
I mentioned "instinct" above. As a doctor, I sometimes look at the subjective and objective data in front of me, including the patient's history, family history, physical exam, etc., and feel there is a missing piece. Call it curiosity, experience, "gut feeling," or even "white hair." Sometimes this leads us to a completely new and sometimes unexpected conclusion as to the nature and cause of a condition.
No matter what the circumstances, when I x-ray, I will develop the films immediately and view them with you, the patient, and discuss the findings in full context of the history and physical exam. At that point we can decide on a treatment plan, further imaging, or referral or co-management when appropriate. You will not wait for answers in my clinic.
It is a complex decision: to x-ray, or not to x-ray, to misquote Shakespeare. It is based on a combination of scientific literature, clinical presentation, demographic factors, patient desires, "instinct," and above all, patient safety. As complicated as it might sound, I hope this helps make the process more transparent.