Tulsa Spine and Rehab

X-rays, they’re such a commonplace thing, you practically expect them when you see a doctor, unless that happens to be Dr. Sean Riley, with Tulsa Spine and Rehab. Sean joins us today to explain why x-rays need to be less common. Why is that Dr. Riley?

Yeah, Charlie. So obviously in my chiropractor training, you learn a great deal about x-rays, how to read x rays, how to shoot x-rays. X-ray is a valuable diagnostic tool. So let me … I just would like to put that disclaimer out there. I obviously believe in x-rays, the importance of x-rays. It gives us a lot of good information. Many times can rule things out. Can tell us what to do, what not to do, more importantly.

But I’ve been practicing 19 years now, and I found it commonplace for most chiropractic offices to sadly, in my opinion, they’re shooting x-rays, for example, on patients before they even evaluate the patient. And I have a problem with that. I have some concern with that in that how are you able to make a determination of what needs to be done diagnostically if you haven’t visited with the patient, you haven’t taken a history with the patient, you haven’t examined the patient because all those types of things are ultimately going to lead you in what needs to be done next. Do we need imaging? Do they need a referral?

So, as I started practicing, I was using a lot of x-rays, using x-rays for diagnostic purposes to rule things out, and I had gotten to the point where my exam was typically leading me in the correct place in that if I felt like my exam indicated or required x-ray, then I would do the x-rays, and if it didn’t, then I would feel comfortable not shooting those x-rays on that patient.

For instance, let’s say, Charlie, you were working in the yard over the weekend, you have no significant history, no red flags so to speak. You developed a nonspecific lower back strain. You present to my office on Monday morning. I do a physical examination. I rule out nasty pathology, a disc herniation. Obviously, I’m not horribly concerned about fracture, dislocation, nothing like that. So, it’s unlikely that I’m going to shoot x-ray. I can make treatment recommendations on that day and hopefully get you feeling a little bit better.

Also, I felt … I bear this burden, if you will, that I was thrown in this stigma of you’re the chiropractor, you’re going to shoot all these x-rays with me on the first visit. I kind of took that somewhat personal because I have a lot of pride in what we do here at Tulsa Spine and Rehab, and hopefully patients understand that I’m making appropriate recommendations. It’s just not a cookie cutter type facility.

And so, that’s why one of the reasons I got rid of my x-ray unit years and years ago, and of course I still, on a daily basis, we’ll refer out. I work with a radiologist here in town that’s able to look at those films with me and give me professional radiological reads. That’s what those guys do for a living to make sure we’re not missing anything, and then from there I’m a big believer in CT and MRI as well. Many times I see a patient, for instance, with radiating pain down into their leg. Once again, I do an evaluation, orthopedic testing, and from that testing it leads me to believe that they might have a disc problem. Plain film x-ray typically doesn’t show us where the disc has gone. It might show me degenerative changes and thinning of a disk space. It will not show me the severity of a disc herniation or a bulge. From there, I would send that patient out for MRI for a proper diagnosis, and from there we can make the appropriate recommendation.

So, although I obviously I think x-ray is a very vital component of the diagnostic process, I don’t think it’s necessary to be shooting x-rays on each patient that walks in my door.

It sounds like it has become a crutch for some doctors or just being done by rote.

Sure. I can’t speak for other physicians, but like I had mentioned, it only makes sense to me. This is our philosophy here in the clinic is that it’s unable … I find it difficult, or I’m unable to make right the appropriate orders and suggestions if I don’t know what their issue is.

So, many times I’ll see a cervical patient or a neck patient that’s having issues in their neck, and throughout my exam and history, we make the determination there’s not an issue with the neck. It’s the upper back, the upper thoracic spine. So, why shoot all those films prior to me examining the patient? I think … I put a lot of emphasis on history and an exam here. That typically leads us where to go.

We’re speaking with Dr. Sean Riley with Tulsa Spine and Rehab. It’s an integrated clinic providing chiropractic and physical therapy, massage therapy, internal medicine and yoga, and Dr. Riley, when you’re talking about your exam and how it helps you hone in on things. I almost wonder if an x-ray can be misleading because you could be taken the wrong way as opposed to, as you’re saying, going by the history of the patient and going for the underlying cause of what is causing some of these problems.

You know, like I had mentioned, x-ray should confirm and then start to rule things out, if you will. So, I think most physicians or practitioners would agree throughout the history and our examination, we have something called a differential diagnosis. And essentially when you present to my office, and I’m looking over your paperwork and go into your history, there might be six things that I’m considering as your diagnosis, what potentially would be your problem.

And throughout the exam process, we’re trying to rule things out to get it down to one or two types of things. And with a proper … Like I’d mentioned, proper diagnosis leads to proper treatment and outcomes. It’s so important that we’re diagnosed properly early on. And then from there, we can use these other tools: Orthopedic testing, neurological testing, range of motion, possibly x-rays, MRI, CT, EMG, other types of diagnostic testing to rule things out and allow us to kind of hone in on one specific diagnosis that will allow us to treat you properly.

I think that the imaging comes from the examination and the history, meaning that those things are going to lead us or tell me what type of further testing to order on a patient.