X-ray has been a very important diagnostic tool since its discovery by W.C. Röntgen in 1895. It provided a non-invasive means to peer inside the body, which opened the doors to better diagnostic and treatment decisions by clinicians. Over 100 years later, x-rays are still in common use in healthcare settings, including chiropractic offices, to assess the cervical spine in patients with whiplash associated disorders (WAD) and neck pain in general. But should x-rays always be used or are there instances when taking films should be avoided?

In a study published in 2002 that looked at data from Canada’s healthcare system, researchers reported that 200,000 cervical spine x-rays are taken of individuals injured by blunt or secondary trauma to the neck each year.  Avoiding radiographs for patients who are likely to have results that are normal would reduce the financial burden on the healthcare system and at the same time reduce the patient’s exposure to ionizing radiation.

The obvious reason for taking x-rays for a patient with WAD is to rule out a fracture that could result in a devastating or life-threatening injury, such as spinal cord trauma when cervical instability is present. One common guideline recommendation supporting the use of plain film x-ray has been trauma resulting in midline posterior neck tenderness if there’s the possibility of fracture.

Clinical decision rules have been published in both Canada and the United States to help identify sub-groups of patients that may not require x-rays such as WAD I (symptoms without exam findings) and some WAD II (symptoms with non-neurological exam findings) injuries where the history and physical examination can quite clearly exclude significant pathology.

The Canadian C-Spine Study, which included over 14,000 patients, identified the following risk factors to warrant supervised cervical range of motion x-rays: age over 65 years; a defined dangerous mechanism of injury (evident head/neck trauma); any sensory abnormality or focal neurologic deficit in the extremities; altered level of consciousness, intoxication, or evidence of facial or external head injury when examination of the neck is unreliable, such as other distracting painful injuries; when active rotation ROM cannot be performed by the patient in a defined manner;  and if fracture or instability is suspect.

As you can see, x-rays are not always necessary when it comes to patients with neck pain, whether from whiplash or not, so if your doctor of chiropractor does not take films as part of your initial examination, there may be good reason.