Is That X-Ray Necessary?

When Are X-Rays Necessary?

When Are X-Rays Necessary?

I am frequently asked by patients, "Don't I need an X-ray in order to diagnose their condition?" While an X-ray is a useful tool, patients have become very used to their regular use as a diagnostic tool, and this can lead to a couple of problems.

The first is finding something on the X-ray that can lead to more tests, different kinds of tests, only to find there is nothing wrong. These are called “incidental findings” or, as some doctors call them, “incidentalomas.” Sometimes they are a normal variation of a person's anatomy, or they can be an issue with how the X-ray was processed. It is well known that these incidental findings can lead to more tests, and for the patient, more worries. All this to find there isn’t a problem in the end.

The second problem with using an X-ray to diagnose pain like back pain is what you can see and what you can't. An X-ray shows almost nothing other than bones. Most of the pain people experience doesn’t come from their bones, but from muscles, tendons, ligaments or occasionally cartilage… all things you can’t see on X-ray. Often that is what people are told by their doctor… there was nothing seen on the X-ray.

One issue that we have in Canada is the costs unnecessary testing creates for the healthcare system. Unless we want to pay a lot more in taxes, we have limited amounts of money available. I am not saying that no-one should get X-rayed. Just we should have a good reason to do the X-ray, based on what a good physical exam tells us.

A great example of how to avoid unnecessary X-rays are what are called the "Ottawa Ankle Rules". Doctors at the Ottawa General hospital found that many people coming into the ER with ankle sprains were being X-rayed, the result usually being that there was no fracture. The doctors devised a simple screening tool that could be done when they first see someone with an ankle sprain that would determine whether they needed an X-ray or not. The results were that 80% of X-rays were avoided, and of the X-rays done, there were still many that were negative for fractures. In fact they didn’t miss one fracture, and reduced the cost to the health system through a simple, manual test.

Remember, X-rays were invented in 1895, over 120 years ago! They are not the clearest images we can get, and they show the bones and little else. A good, physical and functional exam is the best place to start. If treatment is not going as planned, then an X-ray may show something that can’t be seen any other way.

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