Chapter 4 - Diagnostic Imaging

Chapter Outline

Overview
Definitions
List of Subtopics
Literature Review
Assessment Criteria
Recommendations (Guidelines)
Comments, Summary or Conclusions
References
Minority Opinions

Overview [Top]

The chiropractic profession recognizes that diagnostic x-ray examinations, while offering inestimable benefits, have risks which must be weighed against those benefits. There should always be clinical evidence of need for diagnostic x-ray examinations before such are performed.

Because a chiropractor's responsibility to diagnose is broader than scope of treatments, she/he must have the ability to perform or prescribe all imaging procedures needed to formulate a diagnosis and treatment plan.
Definitions [Top]

For definitions see the Glossary at the end of this publication.
Film/speed Screen Systems
Quality Assurance

Radiologic services:

Technical component: that portion of radiology services that includes providing the facilities, equipment, resources, personnel, supplies and support needed to perform and produce the diagnostic study.

Professional component: represents the services performed by the chiropractor/radiologist to interpret each study and to document the diagnostic conclusions of the study in a formal written radiology report.

List of Subtopics [Top]

A.	Quality Assurance
i.	Equipment
ii.	Technical
iii.	Film Quality
iv.	Processing
B.	Radiation Health and Safety
i.	Occupational Exposure
ii.	Patient Entrance Exposures
iii.	"Ten day" Guideline
iv.	Free Examinations
C.	Operator Qualifications
D.	Compliance/Peer Review
i.	Continuing Education
ii.	Peer Review of Film Quality
iii.	X-Ray Records
iv.	Interpretation and Reporting
v.	Professional Responsibility and Informed Consent
vi.	Billing Practices
E.	Clinical Parameters (Indications, Contra-Indications)
F.	Spinal videofluoroscopy

Literature Review [Top]

Diagnostic imaging, including plain film radiography, is not unique to chiropractic. Because of the potentially harmful biologic effects of ionizing radiation, this area of practice has long been the subject of well-developed and universally accepted guidelines. In Canada there are federal and provincial government guidelines and regulations addressing every aspect of radiography applying to all user groups.

A literature review in the field is largely a study of the existing government regulations and professional guidelines. There is little controversy over what constitutes minimum standards as most are regulated. Any unique application of radiography within chiropractic must first meet the legal and professional standards. The following review presents a compendium of existing laws and widely published and accepted guidelines.

A. QUALITY ASSURANCE

The fundamental objective in performing an x-ray examination is to obtain optimum diagnostic information with minimum patient exposure. A functional quality assurance program should be in place in all facilities. Achievement of the objective requires (E.P.A. (USA) 1976):

assurance that equipment is functioning properly and is calibrated as required;
operation of equipment by qualified personnel;
appropriate preparation of the patient; and
technique factors which will minimize exposure.

The frequency of procedures for preventative maintenance and calibration is dependent on the radiographic workload. Equipment with radiographic workloads below 150 mA-minutes per week requires preventative maintenance and calibration every twelve months. Equipment with radiographic workloads of 150 mA-minutes per week and above must be serviced every six months.

Preventative maintenance must include quality control procedures to monitor the following areas (Alberta 1992):

radiation safety;
electrical safety; and
mechanical safety.

(i) Equipment

All owners of an x-ray machine must register their equipment with the appropriate statutory authority in their jurisdiction. Approval of plans and registration must take place prior to new facilities becoming operational. The following radiation safety areas must also be addressed:

1.	Patient exposure:
(a)	use of gonadal shielding;
(b)	the need for repeat examinations;
(c)	examination of pregnant patients;
(d)	radiography of women of reproductive capacity; and
(e)	collimation.
2.	Worker exposure:
(a)	holding of patients;
(b)	protection of pregnant workers;
(c)	protective devices and clothing; and
(d)	dosimetry.

Staff members may be trained to perform the quality assurance tests. The registered owner, however, remains responsible for the program. X-ray equipment and facilities should meet current standards of technology as generally recommended by published or regulatory standards. (Alberta 1990, Harp Act Ontario, 1981).

Generators

All new installations should have generators with a minimum capacity of 300 mA at 125 kVp. (Alberta 1990, CCR 1990, Hildebrand 1981). Existing facilities that have generators of no less capacity than 200 mA at 100 kVp may meet regulatory standards by virtue of additional accessories.

Tubes

All tubes should be rotating anode with dual focal spot.

Collimators

A properly centered and focused square-leaf collimator with light defining beam must be employed. All collimators are expected to meet the standards of federal and provincial legislation. Cones alone, whether they be rectangular or circular, are not unacceptable.

Buckies and Grids

All facilities should have reciprocating buckies, oscillating buckies, or stationary grids. The bucky grid should have a minimum of 60 lines to the inch. The minimum grid ratio should be 10:1, 60 line. A 12:1 grid ratio is more appropriate for kVp. at 100. Stationary grids should be 103 line, 10:1 ratio.

Film/Screen Combination

Screens should be ultra high speed (e.g. rare earth) for spinal radiography. Slower systems produce better detail but require more radiation. Faster systems reduce radiation but with commensurate loss of detail. A balance of adequate detail and radiation reduction is achieved with the selection of film and rare earth screens that together yield a 400 speed system.

All spine radiographs should be taken at a minimum of 400 speed. Extremity radiographs, distal to the knee and elbow should generally be taken with detail screens. If detail screens are not used, peripheral studies should be done on film/screen combinations not in excess of 200 speed. Film speed consistency and uniform film density can be checked using a step wedge test. (Alberta 1990, CCR 1990, Bushong 1984, Sherman 1982, Curry et al. 1990, Vear 1991, Aikenhead 1989, Yochum 1987).

(ii) Technical factors

Minimum Studies and Film Size

An authoritative text/manual containing the minimum number of views to be obtained and correct patient placement for each requested examination should be available.

Appendix A gives recommended minimum requirements for radiographic studies of the areas listed. Additional or special views may be necessary. However, additional views must be supplemental to, and not instead of, the required views.

When two or more views are taken on the same film, lead sheeting or its equivalent must be used to protect the film from scatter during the exposures (Alberta 1990). Motion studies and structural analysis studies may be taken alone when previous routine sectional films of diagnostic quality have been reviewed. The sectional studies should have been taken within a three month period (Alberta 1990).

The number, sequence and types of standard views for an examination should be problem-oriented and kept to a minimum. Diagnosticians should closely monitor the performance of x-ray examinations, and, where practicable, direct examinations to obtain diagnostic objectives stated by clinicians by appropriate addition, substitution or deletion of prescribed views. Technique protocols for performing x-ray examinations should detail the operational procedures for all standard radiographic projections, patient preparation requirements, use of technique charts, and image receptor specifications (E.P.A. (USA) 1976).

A functional quality assurance program should be in place in all facilities. The quality performance of equipment and material is determined by such factors as:
Collimation: Collimation is the procedure whereby the x-ray beam is restricted to the area under study. The International Commission on Radiological Protection has identified the technique of collimation as the most important aspect of efficient patient protection (ICRP Publication, Protection of Patient in X-ray Diagnosis, 1965).

Where possible, collimation should be used to exclude radiosensitive and other tissues not germane to the diagnostic purpose of the study. Evidence of collimation should be present on all films. Both horizontal and vertical collimation lines will be present (three sides on angulated views).

Protection of the Eyes: Due to the radiosensitivity of the eyes, the patient's eyes should be specifically excluded from the field of radiation unless this area is required for the study in question.

Corresponding A-P and Lateral Studies: A-P and lateral radiographs should cover the same area. An A-P 14 x 17 and a lateral 7 x 17 are acceptable. An 8 x 10 is not acceptable. Two views of the same anatomical region at right angles is the minimum requirement.

Photo-identification: Films should be marked with the patient's name or identification, date, facility city location, and facility name. Date of birth and sex may also be included. This is done with lead markers at the time of exposure or with photo-imprinting.

Right and Left Markers: Films should be marked at the time of exposure with right and/or left markers. Lateral exposures should be marked with the side of the patient closest to the film. Special markers that indicate recumbent vs. upright studies may be employed (Yochum 1987).

Gonadal Shields: All facilities must have suitable gonadal shielding available for use on both male and female patients with reproductive capacity. All facilities should have lead aprons for shielding the abdomen on all studies that are not exposing the abdominal area of patients. Gonadal shielding should be used on all pelvic radiographs of patients with reproductive capacity unless the shielding will specifically interfere with the diagnostic requirements of the study (DHEW 1975, NCRP #39 1974, Aikenhead 1989, Bushong 1984, Curry et al. 1990, Hildebrandt 1981, Jaeger 1988).

Focal Film Distance: The focal film distance should be as great as is consistent with grid focus and power of the generator. Grid focus is the recommended focal film distance for the angulation of the grid strips, and can be read off the identification plate on the grid. For full spine radiography, there should be a minimum focal film distance of 72" (159 cm) and ideally it should be 84" (210 cm).

Filtration: Fixed, in-beam filtration must be a minimum of 2.5 mm. A1. equivalent, ideally 4-6 mm. Selective in-beam compensating filtration must be used to reduce the amount of radiation that is received by the thinner body parts when radiographing body areas with a range of densities (Aikenhead 1989, Buehler 1985, Gatterman 1985, Merkin 1982, NCRP #33 1975, #39 1987).

Full Spine: In full spine radiography collimation must be used to exclude the eyes, and should not be wider than is necessary. Ideally it should be no wider than the mamilliary line, and should include not more than the lateral margins of the acetabuli. Collimation lines will be visible on all sides of the film. Special breast shields should be employed (FDA 1985, HARPC 1987, CCR 1990, Hardman 1981, Aikenhead 1989, Gutterman 1985, Hildebrandt 1980, Merkin 1982, Butler et al. 1986, Hellstrom et al. 1983, Fearon et al. 1988, Nykoliation et al. 1986, Alberta 1990).

P-A Scoliosis Studies: Radiation to the gonads and breasts is significantly reduced by using P-A procedures. In scoliosis studies, where repeat radiographs are usually required, P-A positioning is recommended (Frank 1983, Vear 1991).

Patient Clothing Restrictions: To avoid unacceptable artifacts, remove necklaces, earrings, dentures, hairpins, eyeglasses, and all clothing except underwear that does not have thick elastic. Female patients will put on a patient gown (CCR 1990, Alberta 1990).

Radiographic Factors: Radiographic factors consistent with minimum patient exposure will be employed. mAs selection utilizing shortest possible time and an optimum k.V.p. technique should be used. (For recommendations, see Appendix B). In facilities with adequate capacity, the longest possible FFD, consistent with grid focus, is recommended (Bushong 1984).

Relevant Sectional Views: There are times when a single exposure A-P full spine radiograph accompanied by related sectional films may be desired in the assessment of interdependent spinal disrelationships, scoliosis, and multiple site symptom complexes (Alberta 1990). The A-P full spine radiograph will be accompanied by relevant lateral radiographs. A single A-P film is not acceptable (Alberta 1990, CCR 1990). Single A-P or P-A scoliosis studies are acceptable for re-examination purposes.

Patient Immobilization: Many chiropractors take weight-bearing (standing) radiographs which have the dual advantage of providing diagnostic as well as postural or biomechanical information. These procedures are prone to motion unsharpness, and precautions should be taken to reduce movement during exposure. Compression devices may be used (Sherman 1982).

Patient Size Restriction: If a patient measures more than 27 cm, A-P, consideration should be given to radiographing the patient sectionally as opposed to full spine, and recumbent rather than upright (Vear 1991, CCR 1990, Alberta 1990).

Split Screens: The use of split-screen or graded screen techniques used in the production of a 14 x 36 radiograph is unacceptable.
Lateral Full-Spine Studies: Because of the inherent difficulties in obtaining a lateral full spine single exposure of good quality, sectional lateral spinal studies are preferable (CCR 1990, Sowby 1985).

(iii) Film/Equipment Quality Assurance

In Ontario chiropractors participated in the development of quality assurance regulations for the Healing Arts Radiation Protection Act (HARP Act). Four tests adopted for the continuing quality assurance programs under the regulations relate to:

Photographic quality control;
half value;
collimation; and
patient entrance exposure.

Photographic Quality Control: a daily check to ensure that the radiographic imaging system is functioning optimally. A pre-exposed film test strip is processed each operational day and compared to an initial standard. In some jurisdictions the pre-exposed test strip is replaced with daily sensitometry and densitometry. Regardless of the method used, the processor must be checked each day films are to be processed. Variances from optimal processing should be detected and corrected.

Half Value Layer: a test is performed semiannually to determine the thickness of aluminum or equivalent that will reduce the beam to one half its strength. Reference to a chart of known half value layers will confirm the strength of the un-attenuated beam. The test demonstrates the consistency of the kVp output of the tube at given machine settings.

Collimation: a semiannual test is performed to ensure the accuracy and competence of the beam limiting device. This test will also be performed each time a collimator bulb is adjusted or replaced. Light field to x-ray field incongruence should not exceed 2% of the x-ray source-image distance.

Patient Entrance Exposure: Semiannual tests using a calibrated dosimeter determines the doses delivered for standard exposures as per the chart in Appendix C.

All facilities must establish a quality assurance manual which includes:

1.	Written policies regarding radiation protection that address the following:
(a)	use of gonadal shielding;
(b)	the need for repeat examination;
(c)	examination of pregnant patients;
(d)	holding of patients;
(e)	radiography of women of reproductive capacity;
(f)	protection of pregnant workers; and
(g)	dosimetry.
2.	Quality procedures to be performed, including:
(a)	description of each test procedure;
(b)	frequency for each test;
(c)	control limits for each test; and
(d)	samples of forms used.
3.	Records for each piece of x-ray equipment, including:
(a)	a copy of the completed Application for Registration form;
(b)	initial equipment acceptance testing results;
(c)	scatter radiation survey of the area;
(d)	records of semi-annual/annual testing
(e)	results of preventative maintenance for the past two years; and
(f)	results of calibration for the past two years.
4.	Records of photographic quality control for the past two years including:
(a)	control charts of film processing sensitometry;
(b)	maintenance logs for automatic processors; and
(c)	cleaning and chemical changes.
5.	Results of repeat/reject analysis conducted every month including:
(a)	results of the first analysis to serve as a baseline;
(b)	results of monthly analyses for the past two years; and
(c)	results of corrective actions taken.

All facilities with radiographic, fluoroscopic and mammographic equipment must have the following photographic quality control equipment:

(a)	thermometer (non-mercury);
(b)	alarmed timer (for manual processing);
(c)	sensitometer;
(d)	densitometer;
(e)	film/screen contact mesh; and
(f)	technique chart for each piece of equipment.

DAILY REQUIREMENTS

Photographic Quality Control - All Facilities

Photographic quality control procedures must be performed every day of operation before the first patient examination. Corrective action must be taken if results are not within control limits. The following procedures must be performed:

(a)	developer temperature;
(b)	speed index;
(c)	contrast index;
(d)	base plus fog; and
(e)	replenish solutions.

Equipment Quality Control - All Facilities

Each day of operation, operators must check x-ray equipment for proper function. If an x-ray unit is not in optimum operating condition, it must not be used until it has been repaired. The following functions must be assessed:

1.	Generator indicators:
(a)	kVp meter;
(b)	mA meter;
(c)	mAs meter;
(d)	exposure time indicator; and
(e)	exposure indicators (visual and audible).
2.	Mechanical safety:
(a)	table movement and locks;
(b)	tube movement and locks;
(c)	exposure termination; and
(d)	tube warm up.

WEEKLY REQUIREMENTS

Photographic Quality Control - All Facilities

The following quality control procedures must be performed each week in all facilities with automatic processing:

(a)	check automatic processing solution replenishment rates;
(b)	clean automatic processor cross-over racks.

MONTHLY REQUIREMENTS

Photographic Quality Control - All Facilities

The following procedures must be performed in all facilities every month:

(a)	repeat/reject analysis;
(b)	change processing solutions; and
(c)	clean processor solution tanks.

ANNUAL REQUIREMENTS

Photographic Quality Control - All Facilities

The following photographic quality control procedures must be performed annually, or every six months for equipment with radiographic workloads of 50 mA-minutes per week or more:

(a)	film/screen contact;
(b)	clean intensifying screens and cassettes.

Equipment Quality Control - All Facilities

The following equipment quality control procedures must be performed annually, or every six months for equipment with radiographic workloads of 50 mA-minutes per week or more:

1.	Preventative Maintenance:
(a)	check mechanical operation of all moving parts;
(b)	check integrity of all electrical cables;
(c)	clean and lubricate high tension cable terminals;
(d)	clean and lubricate bearings and ropes;
(e)	check operation of interlocks; and
(f)	other procedures recommended by the manufacturer.
2.	Calibration:
(a)	kVp reproducibility;
(b)	kVp accuracy;
(c)	radiation output reproducibility;
(d)	radiation output linearity;
(e)	timer accuracy;
(f)	radiation field size indicator;
(g)	SID indicator;
(h)	light/radiation field alignment;
(i)	AEC reproducibility;
(j)	AEC density control; and
(k)	filtration (beam quality). (Alberta 1992).

(iv) Film Processing

Three principles govern proper processing: consistency, cleanliness and quality assurance. Processing may be manual or automatic. For both, the equipment must be kept clean and maintained in the optimal working order. Manual processing is prone to great fluctuations in quality unless rigid adherence to the Time/Temperature method (based on a mean of 5 minutes at 68 degrees) is practised. Automatic processing by machine is more reliable.

In both methods chemistry must be monitored, replenished, stirred and maintained at a correct temperature. Chemistry strength and temperature are critical factors. They can be maximized by following manufacturers product guidelines.

Chemistry silver reclamation and environmentally safe disposal of spent chemistry are regulated responsibilities in most jurisdictions. The use of a silver reclaimer plus the mixing of chemicals and wash water renders the effluent safe for disposal by drain. Regulations governing hazardous chemicals require a description of chemicals to be available while they are being transported and to be posted where they are used or stored. Chemical reservoirs should be labelled appropriately (Ontario Reg. 309, HARP Act 1987, Sherman 1982, Bushong 1984, Kodak 1980, Curry et al. 1990, Vear 1991).

B. RADIATION HEALTH AND SAFETY

(i) Occupational Exposure.

Occupational exposure of staff to x-ray facilities is governed by regulation as to maximum permissible dose (MPD) and is monitored by thermo-luminescent dosimeter badge (TLD). Compliance with regulations regarding working conditions is the responsibility of the radiation protection officer (RPO). This is the owner or his designate and, in chiropractic practice, usually the chiropractor. Proper shielding during X-ray room construction protects non-radiation staff and public (RPB-SC4,NCRP #33 1975, #39 1987, Maurer 1989).

(ii) Patient Entrance Exposures.

For reducing unnecessary doses to the individual patient three principles apply:

Time - as short as possible.
Distance - as great as possible.
Shielding - gonad, in-beam, selective filtration and collimation.

(Bushong 1984, Juhl 1987)

Proper measures of patient radiological protection should always be utilized and include adequate collimation, filtration, and gonadal shielding. Doctors of chiropractic should use all standard radiation health and safety measures, including proper selection of patients with due reference to age, reproductive capacity and clinical need (CCR 1990).

Clinical need implies that the examination, tests and treatment procedures used are generally accepted by the profession as being necessary and appropriate to properly diagnose and treat the patient (Baddley 1984, Lusted 1977).

Diagnostic radiology utilizing the aforementioned measures will minimize patient entrance exposures. Techniques producing doses over the limits set by national or provincial regulatory bodies require modification.

(iii) The Ten Day Guideline.

All women with reproductive potential (ages 12-50) should be radiographed only when clinically necessary and, preferably, during the first ten days following the onset of menses. Radiographic investigation is generally contraindicated during pregnancy (CCR 1990, Alberta 1990).

(iv) Free Examinations.

The practice of advertising free spinal x-ray examinations is not condoned (CCR 1990).

C. OPERATOR QUALIFICATIONS

Radiographic or fluoroscopic examinations should generally be prescribed only by doctors of chiropractic, not assisting staff. Specialized studies should be prescribed only by those chiropractors with advanced training and experience.

Radiologic Technologist or Radiographer: a radiologic technologist or radiographer is educated and trained to perform appropriate diagnostic studies on the requisition of a duly licensed practitioner. The technologist has limited licence or certification and does not practice independently.
Doctor of Chiropractic: A doctor of chiropractic is trained and regulated in radiation protection, standards of quality, clinical indications for radiography and radiographic interpretation. He/she may perform all components of radiographic services including the technical and professional components. The general practitioner may delegate the technical component to, and is a recognized employer group of, radiologic technologists.
Chiropractic radiologist: The chiropractic radiologist is a doctor of chiropractic who has continued post-professional education in a CCE accredited institution and received a formal specialty qualification. He/she is trained in advanced interpretive skills encompassing all aspects of radiology but with particular emphasis on musculoskeletal and spinal imaging. Individual practices may vary by licensure and scope of practice laws.

D. COMPLIANCE/PEER REVIEW

Licensing boards are responsible for quality assurance and are in a position to enforce standards and to discipline for non-compliance. Boards develop and modify quality assurance, peer review, and continuing education programs in consultation with these specialist groups and professional associations.

(i) Continuing Education.

A number of provinces have mandates of continuing education requirements with respect to diagnostic radiology that are a prerequisite to renewal of license to practice. Some require a minimum number of hours of attendance each year at approved seminars, workshops and courses (B.C. and Alberta). Quebec requires
a separate X-ray licence to be renewed on the basis of continuing educational requirements.

(ii) Film Review.

All chiropractors who operate an x-ray facility must participate in the Film Reviews when requested by their licensing board. The review typically consists of requests for certain studies, and the log sheets and quality assurance sensitometry or wedge strips for the period in which the radiographs requested were taken. (See Appendix D.)

(iii) X-Ray Records.

A record, sufficiently detailed for audit, shall be maintained on each patient and, in addition to information identifying the patient, must contain:

(a)	a recent history including record of onset of last menstrual period in the case of a female who is of child-bearing age;
(b)	results of chiropractic, neurologic or orthopaedic examination performed by a chiropractor;
(c)	clinical indicators for radiographic diagnosis;
(d)	the specific reason for which the radiodiagnostic examination is being conducted, e.g. differential diagnosis, treatment planning indicators, etc., the interpretation and the action recommended and/or taken as a consequence of the examination.

A patient's health record need not contain a history of the patient if the patient came for and received imaging services only (Ontario - Regulation #57/92, Independent Health Facilities Act 1992).

Each radiographic facility shall maintain an x-ray log book with the patient's name, sex, thickness for each view, factors used, date, and a description of radiographs taken. Each radiographic facility should also have current and accurate technique charts available in the control booth.
Provincial law provides a period during which radiographs must be kept. It is wise to retain them for the lifetime of the patient. If radiographs are destroyed following the period prescribed by law, a written record of findings should be retained (CCPA Newsletter 1992).

(iv) Interpretation and Formal Reporting.

A written interpretation of each imaging study should be included as part of the patient's permanent health care record. Reports must be signed and dated by the individual performing the interpretation. Components of the formal written report include patient identification; location where studies were performed; study dates; types of studies; radiographic findings; diagnostic impressions; and a signature including professional qualifications. A report may contain recommendations for further studies (Taylor 1990, Yochum 1987).

Professional Responsibility and Consent

Individuals or institutions are responsible to the level of service provided. Adequate performance of the technical component is the responsibility of the technologist and the facility providing the services. The professional component may be performed by a chiropractor or a chiropractic or medical radiologist. Practitioners performing this professional service are held responsible to the appropriate level - either general practitioner or specialist.
Each patient must be informed in advance of the need for and nature of the radiographic examinations to be performed. Information may be conveyed in part through the use of standardized forms to be signed by the patient or, in the case of minors and others not competent to give consent, by the parent or guardian (Carey, 1988).

(vii) Billing Practices

Invoicing may be for the technical service, the professional service, or both combined. Sub-dividing basic service or maintaining a two-tier system for the purpose of billing third party payers is inappropriate.

E. CLINICAL PARAMETERS FOR PATIENT SELECTION (INDICATIONS/ CONTRAINDICATIONS)

(i) General Indications and Contraindications for Plain Film Radiography (CCR 1990)

0 - 10 Years
With this age group the overall justification is considered low. However, in the presence of developing or idiopathic scoliosis, developmental or congenital defects producing aberrant spinal curvatures, marked locomotor disturbances of the spine and pelvis, suspicion of pathology and significant trauma, the justification may be high.

10 - 18 Years
Marked spinal pelvic locomotor defects, idiopathic or developmental scoliosis, marked inter-related spinal lesions or developmental defects, suspicion of pathology and significant trauma are the criteria for justification. Justification is decreased in the absence of these conditions.

18 - 40 Years
The frequent incidence of inter-related biomechanical spinal/pelvic lesions, multiple symptom complexes, altered spinal curvatures, suspicion of pathology and significant trauma results in an increased justification. Due consideration must be given to females of reproductive capacity.

40 + Years
Multiple site spinal articular degenerative states, multiple site symptom complexes related to the spine and pelvis, altered vertebral motor unit dynamics, inter-related mechanical lesions, spinal curvatures, suspicion of pathology and significant trauma are indications for a higher justification and usefulness.

Contra-Indications

Pregnancy or possible pregnancy: There are few conditions that would warrant the use of spinal irradiation during the early months of pregnancy. To avoid irradiation during early pregnancy, elective radiographic examinations should not be done in the second half of the menstrual cycle of women who are capable of reproduction (Howe 1985).

Obesity: Body type and/or size may preclude good radiographic resolution.

Infants: Spinal radiography is usually not justified in infants and small children due to the high radiosensitivity of many body tissues. The indication is also low because of the juvenile appearance of the ossification centres in the spine.

Radiation Exposure: Recent exposure to high radiation doses, therapeutic or occupational.

Positioning Difficulty: A final contra-indication for some patients, because of a physical or mental state that prevents proper immobilization or positioning for good radiographic detail.

(ii) Patient Selection: Decision Making

The number, sequence and type of standard views for an examination should be problem-oriented and have clinical efficacy in terms of impact on diagnosis, treatment or prognosis (Meeker 1985, Wyatt 1987).
A proper history and clinical evaluation of each patient must be performed to established the necessity for a radiographic examination (Lusted 1977, Baddley 1984).
The history and clinical evaluation is a guide to not only which portion of the body should be x-rayed but also how many different views should be taken.
In using radiograms as a diagnostic aid all necessary views should be taken, but unnecessary projections and exposure should be excluded (Schultz 1990).
It is vital to take at least two views of an affected osseous area, preferably at right angles to each other in order to have minimum radiological impression. Frequently, it is advisable to make multiple projections - for example when there is an indication of possible fracture, significant pathology, congenital defect, or when an initial study is insufficient to make a comprehensive diagnosis (Vear 1991, CCR 1990, Yochum 1987).
Repeat or serial examinations should be performed only to help confirm clinical suspicions of change which need to be known for the benefit of the patient. If the patient makes an adequate clinical recovery, serial x-rays would not normally be indicated. Exceptions are to check progress of fracture repair, infectious processes, scoliosis. If the patient does not make an adequate response, then serial x-rays may be indicated, but this must be based upon a full clinical re-evaluation of the patient (CCR 1990).
A patient should never be exposed to unnecessary radiation. Areas of exposure as well as the number of exposures should be kept to a minimum. Routine and/or repetitive radiographic examinations for demonstration of subluxations or as a screening procedure (e.g. pre-employment) are not appropriate (Wyatt 1987, Joseph et al. 1986, Frymoyer 1984, Morris 1985, Sinclair 1988, Maurer 1988, HARP Commission, 1987, Mootz 1989, Kovach 1983, Deyo 1986, Hall 1983).

Stress Views of the Spine

These views are used to visualize joint structures at the limits of motion and demonstrate the integrity of the periarticular holding elements. (Grice 1979, Phillips 1990, CCR 1990, Weitz 1981) They:

(a)	are reserved additional views, not generally considered as part of the initial routine radiographic examination; unless specific trauma or biomechanical dysfunction disclosed by history or clinical evaluation and suggests findings unobtainable by other means; and
(b)	are performed on the cervical and lumbar spines only. Studies should be segmental, unless used to demonstrate fixation in scoliosis.

Repeated stress views are rarely indicated save in those cases where appropriate response to treatment is lacking or where re-injury or exacerbation has been clinically documented.

While stress views evaluate total excursion, videofluoroscopy is valuable for assessing segmental function throughout the full range of motion.

F. Spinal Videofluoroscopy Protocol for the Use of Spinal Videofluoroscopy

(From Statements of Policy, CCR 1990)
Videofluoroscopy is a useful imaging modality for the demonstration of spinal intersegmental joint dysfunction.
The following recommendations presuppose that an appropriate patient history, clinical examination, plain film radiographs and additional diagnostic modalities have been performed to exclude pathology and there has been a reasonable period of conservative management.

Indications.

Acute/Subacute

Videofluoroscopy is rarely indicated for the acute patient. Unusual circumstances may exist wherein there is inconclusive or equivocal evidence of intersegmental joint dysfunction from plain film radiography, CT, MRI or other appropriate imaging procedures. In those instances spinal videofluoroscopy may be appropriate. The study should not be performed until cessation of restrictive muscle spasm which prohibits evaluation of joint function.

Chronic

Videofluoroscopy may be indicated for chronic patients. There should be persistent signs and symptoms and/or unsatisfactory response to chiropractic care in excess of 12 weeks, suspected persistent intersegmental joint dysfunction, and inconclusive or equivocal evidence of this dysfunction from plain film radiography, CT, MRI or other appropriate imaging procedures.

Radiographic Signs of Intersegmental Joint Dysfunction
The following signs may be helpful in the selection of patients for spinal videofluoroscopy following persistent signs and symptoms and appropriate conservative management:

(a)	hypermobility
(b)	hypomobility
(c)	aberrant motion
(d)	instability
(e)	aberrant coupling
(f)	paradoxical motion
(g)	evaluation of spinal arthrodesis

Indications for Spinal Videofluoroscopy Re-evaluation

Spinal videofluoroscopy re-evaluation may be performed at a 12 week interval following the initial study if the patient has failed to respond to clinical management, or if there has been exacerbation. The examination should be limited to the area in question, using only those positions and manoeuvres which previously demonstrated the abnormality. For technical protocols see Appendix E.

Contra-indications

Contraindications include sufficient information regarding intersegmental joint dysfunction obtained by other diagnostic procedures, pregnancy, risk of detriment to the patient's well-being (e.g. recent fractures; dislocations; pathological processes that may weaken restraining structures or osseous architecture; severe neurological deficit or restrictive muscle spasm).

Assessment Criteria [Top]

Rating Systems 1 and 2 assessment criteria are used in this chapter. For an explanation of these systems see the Introduction and Guide to Use (p. ...).
Recommendations (Guidelines) [Top]

Quality assurance

4.1 X-ray facilities shall have quality assurance programs designed to produce radiographs that satisfy diagnostic requirements with minimal patient exposure. Such programs should contain materials and equipment specifications, equipment calibration and preventive maintenance requirements, and quality control of image processing through daily sensitometry and densitometry and operational procedures.

Chiropractors should follow recognized procedures to assure quality in radiology. This includes regular monitoring and recording of proper function and accuracy of equipment, appropriate technique of exposure utilizing proper collimation, filtration, gonadal shielding when applicable, and optimum number of views with minimum exposure. Retake examinations should be performed if diagnostic quality has not been achieved.

Rating: Established
Evidence: Class II, III
Consensus level: 1

Operator qualifications

4.2 Operators of radiographic facilities may be registered radiologic technologists, chiropractors and chiropractic radiologists. Each is accountable to their level of expertise.

Chiropractors are trained in imaging technology, radiation protection, quality assurance, clinical indications and radiographic interpretation. A chiropractor who employs diagnostic radiology in practice has an obligation to maintain competency and incorporate new concepts by participating in continuing education programs.

Rating: Established
Evidence: Class II, III
Consensus level: 1

Radiographic services

4.3 Technical service (image production) - is the set of protocols and procedures to produce finished radiographs, including equipment, positioning, exposure selection, patient protection and processing exposed film.

Professional service (interpretation) - is the study of and report of findings from the finished radiographs. This service may be performed by a chiropractor, who will review the series and enter a report in the patient's case file; and/or by a radiologist who will produce a detailed, written and signed report.

Rating: Established
Evidence: Class II, III
Consensus level: 1

Billing guidelines

4.5 Billing procedures are for the technical and professional components whether rendered separately or as full service.

A chiropractor should establish a fee schedule and may divide the fee structure into technical (production) and professional (interpretive) components. This division of fees should not increase the fee for the full service. There should not be a two tier fee schedule with different charges to third party payers. However, appropriate professional bodies may negotiate fee schedules with different paying agencies.

Rating: Necessary
Evidence: Class II, III
Consensus level: 1

Consent

4.6 The reasons for the x-ray examination and the type of radiological exam required should be explained in advance and consent received. Parental or guardian consent should be obtained for minors and the mentally incompetent.

Rating: Necessary
Evidence: Class II, III
Consensus level: 1

Owner responsibility

4.7 Appropriate technological consideration is the responsibility of the registered owner and must be in compliance with federal and provincial regulations governing the protection of patients, staff and others from ionizing radiation.

Rating: Necessary
Evidence: Class II, III
Consensus level: 1

Pregnancy

4.8 The possibility of pregnancy should be determined before radiographic studies are performed. There is seldom a clinical necessity to irradiate the abdomen of a pregnant woman. When it is essential to radiograph other areas, the patient's abdomen should be shielded.

Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1

Full spine radiography

4.9 The standing AP or PA full spine film can be an important diagnostic tool for selected patients. Except in the case of scoliosis reassessment, it should be utilized in conjunction with the appropriate regional views. Techniques consistent with radiation health and safety should be used to reduce patient radiation exposure and optimize film quality. Lateral full spine views are inappropriate.

(a) Rating: Established for scoliosis
Evidence: Class I, II, III
Consensus level: 1

(b) Rating: Promising for complex biomechanical or postural disorders and the evaluation of multi-level spinal complaints.
Evidence: Class II, III
Consensus level: 1

(c) Rating: Inappropriate for lateral full spine views
Evidence: Class II, III
Consensus level: 1

Patient selection

4.10 Chiropractors shall use proper patient selection protocols with reference to age, child-bearing status, and clinical indications of need. In the acquisition of radiologic studies, chiropractors should consider the risk/benefit ratio and the A.L.A.R.A. (As low as reasonably achievable) principle as to dosage.

The number of views and when they are taken should be based upon the clinical indications. The minimum number of views to reach a diagnostic conclusion should be the prime objective. Generally, two views at right angles are the minimum number of projections for diagnosis of osseous structures.

Rating: Established
Evidence: Class II, III
Consensus level: 1

Stress views

4.11 Stress views may be an important diagnostic tool for selected patients. These are additional views, not considered as part of the initial routine radiographic examination. They are utilized for the purpose of visualizing joint structures at the limits of motion to demonstrate the integrity of the periarticular holding elements.

Cervical spine:

(a) Rating: Established for flexion and extension views for assessment of post traumatic or post surgical instabilities.
Evidence: Class II, III
Consensus level: 1

(b) Rating: Promising for flexion and extension studies for assessment of dyskinesia/aberrant motion.

Evidence: Class II, III
Consensus level: 1

(c) Rating: Established for lateral bending views for assessment of (anatomical) subluxation/partial dislocation of the atlantoaxial articulations.
Evidence: Class II, III
Consensus level: 1

(d) Rating: Doubtful for lateral bending views for the assessment of dyskinesia/aberrant motion.
Evidence: Class II, III
Consensus level: 1

Thoracic spine:

(e) Rating: Established for assessment of flexibility of a scoliosis.
Evidence: Class II, III
Consensus level: 1

Lumbar spine:

(f) Rating: Established for flexion and extension views for assessment of traumatic or post surgical instabilities and spondylolisthesis.
Evidence: Class II, III
Consensus level: 1

(g) Rating: Investigational/Equivocal for flexion and extension studies for assessment of dyskinesia/aberrant motion.
Evidence: Class II, III
Consensus level: 1

(h) Rating: Investigational/Equivocal for lateral bending for assessment of dyskinesia/aberrant motion.
Evidence: Class II, III
Consensus level: 2

Extremities:

(i) Rating: Established for assessment of frank instability of the extremities.
Evidence: Class II, III
Consensus level: 1

Videofluoroscopy

4.12 Videofluoroscopy may be a useful imaging modality for the demonstration of spinal intersegmental joint dysfunction. Spinal videofluoroscopy may be performed following appropriate history, clinical examination, and other diagnostic studies, and a reasonable period of conservative management.
Videofluoroscopy may be used to assess traumatic or post surgical instability.

Rating: Established
Evidence: Class II, III
Consensus level: 1

4.13 Videofluoroscopy may be used to assess dyskinesia/aberrant motion in the cervical spine.
Rating: Equivocal
Evidence: Class II, III
Consensus level: 1

4.14 Videofluoroscopy has been used to assess lumbar motion.
Rating: Investigational
Evidence: Class II, III
Consensus level: 1

4.15 Spinal videofluoroscopy has been used as a screening device.
Rating: Inappropriate
evidence: Class III
Consensus level: 1

Serial examinations

4.16 A patient should never be exposed to unnecessary ionizing radiation. When the patient makes an adequate clinical recovery, serial x-rays are not usually indicated (exceptions include monitoring the progress of fracture repair, infectious processes, and scoliosis).

Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1

Repeat radiography

4.17 Routine repeat radiography (pre & post adjustment) has been used to demonstrate changes in vertebral position. Its use may be inappropriate.
Rating: Investigational
Evidence: Class I, II, III
Consensus level: 1

4.18 Radiography has been used as a pre-employment screening procedure.
Rating: Doubtful
Evidence: Class I, II, III
Consensus level: 1
Comments, Summary or Conclusions [Top]

Imaging has been and continues to be essential in the evaluation of chiropractic patients. It is important to consider the deleterious effects and cost of imaging prior to acquiring a study. The critical issue is need for the study. The practitioner considering imaging, from plain film to MRI, must consider this question: "Will the results of this study have an impact on the treatment I propose to deliver?" If this question is asked and answered objectively in every case, there will be proper acquisition of imaging studies. This is particularly true of plain films.

The recommendations or guidelines presented in this chapter must be read subject to provincial government regulations, guidelines, safety codes and technical recommendations that vary from province to province and govern radiographic practice by all health providers in Canada today.
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Minority Opinions [Top]

None

Chapter Appendix A:

Recommended Minimum Views Per Area

Central ray alignment should be consistent with standardized texts on radiographic positioning. All film studies should be collimated to less than the film size being use.

Shoulders: Minimum two views, internal and external rotation. Minimum film size of 8 x 10.

Upper arm, elbow, forearm, hand, fingers, knee, foot, calcaneus, toes: Minimum two views at right angles to each other. Film size as required.

Wrist, ankle: minimum three views, A-P, lateral, oblique.

Acromio-clavicular: Two views, both A-P, one without weights, one weight bearing.

Clavicle: Two views, one A-P, and one oblique.

Hip: Minimum two views, A-P and Frog leg. Minimum film size of 8 x 10.

Cervical Spine: Minimum, three views, A-P open mouth, A-P lower cervical, and lateral cervical. Minimum film size of 8 x 10.

Cervico-thoracic combination: This is not a recommended series. If it is taken, the chiropractor is responsible for insuring that the study is diagnostic throughout all areas. It is recommended that this area be exposed as a cervical and as a thoracic study. If it is to be exposed as a combination study, then density equalizing filters must be used. Minimum two views at right angles to each other. One A-P open mouth cervico-thoracic combination. One lateral cervico-thoracic combination (Swimmers' View). Minimum film size 7 x 17. As an alternative to a lateral cervico-thoracic combination view, two views may be taken, a lateral cervical 8 x 10 and a lateral thoracic 10 x 12.

Thoracic spine: Minimum two views (an A-P and Lateral) at right angles to each other. Minimum film size 7 x 17.

Lumbar spine: Minimum of two views at right angles to each other. Minimum film size of 7 x 17. On those patients over 55 years of age, the minimum film size is 14 x 17 with the collimated image to be 12 x 17.

Lumbo-pelvic combination: Minimum two views at right angles to each other. Minimum film size 14 x 17 A-P, and 7 x 17 lateral. Minimum lateral to be a 14 x 17

on the lateral if the patient is over 55 years of age, with the collimated image to be 12 x 17.

Sacroiliac: Minimum three views; right and left anterior obliques and A-P (cephalic angulated). Minimum film size to be 8 x 10.

Ribs, A-P, Lateral and Obliques: Minimum two views at right angles to each other. Minimum film size 11 x 14.

Skull: Minimum two views at right angles to each other. Minimum film size 10 x 12..

Chest: Minimum two views at right angles to each other. Minimum film size is 14 x 17.

(Block et al. 1988, Clark 1979, CCR 1990, Alberta 1990, Jaeger 1987)

Chapter Appendix B:

OPTIMUM kVp TECHNIQUES

Radiographs will be exposed at the highest kVp that is consistent with high quality radiographs. As a guide, the following are considered optimum by the Chiropractic College of Radiologists (Canada).

CERVICAL:	A-P OPEN MOUTH A-P LOWER CERVICAL LATERAL CERVICAL	80 k.V.p. 70 k.V.p. 70 k.V.p.
THORACIC:	A-P LATERAL	85 k.V.p. 90 k.V.p.
LUMBAR:	A-P LATERAL	85 k.V.p. 90 k.V.p.
EXTREMITIES:		55 k.V.p.
SKULL:	A-P AND LATERAL	80 - 90 k.V.p.
KNEE:	ALL VIEWS	55 - 65 k.V.p.
SHOULDER:	ALL VIEWS	70 - 80 k.V.p.

Practitioners should not vary from the above by more than 5%.
(Yochum 1987, Alberta 1990, CCR 1990)

Chapter Appendix C:

SKIN ENTRANCE EXPOSURE
(all measurements with no scatter - lead backing)

PATIENT		(mR) PROV.
PROJECTION	THICKNESS	F.F.D.	K.V.P.	M.A.	TIME	P.E.E.	LIMIT
A-P LOWER CERVICAL	13 CM.	100cm.	_____	_____	_____	_____	60mR
A-P THORACIC	23 CM.	100cm.	_____	_____	_____	_____	200mR
A-P LUMBAR	23 CM.	100cm.	_____	_____	_____	_____	250mR
LATERAL LUMBAR	32 CM.	100cm.	_____	_____	_____	_____	1000mR
FULL SPINE	23 CM.	100cm.	_____	_____	_____	_____	250mR

(HARP Act, Ontario, Table 6, 1987)

Chapter Appendix D:

Peer Review/Film Critique

A mail-in film review could follow this suggested format. These three forms were developed by The Board of Directors of Chiropractic, Ontario and used in their X-Ray Peer Review Program.

FORM #1

Doctor:	Address:
Please forward two (2) sets of x-rays of your choice and complete the following for each set.
1. Processing: (Please circle)	Automatic Manual
2. Quality Assurance Program: (Please circle)	Yes No
3. Source of Films:	1. Your facility 2. Other Chiropractor 3. Medical Facility

FILM SET #1
TECHNICAL FACTORS

VIEW	KVP	MA	CM'S	TIME
______	______	______	______	______
______	______	______	______	______
______	______	______	______	______
______	______	______	______	______

Sex of patient:__________
Age of patient:__________

FULL SPINE VIEWS SHOULD
BE ROLLED IN A TUBE

FILM SET #2
TECHNICAL FACTORS

VIEW	KVP	MA	CM'S	TIME
______	______	______	______	______
______	______	______	______	______
______	______	______	______	______
______	______	______	______	______

Sex of patient:__________
Age of patient:__________

FULL SPINE VIEWS SHOULD
BE ROLLED IN A TUBE

FORM #2

Name: Date:

Your x-rays have been evaluated and for your information we are providing you with the results. Where correction is indicated please refer to the accompanying guide. The highlighted areas are suggestions for improving your film quality and reducing patient exposure.

CONTRAST	1. Acceptable	2. High	3. Low
DENSITY	1. Acceptable	2. High	3. Low
FILM FOGGED	1. Acceptable	2. Needs correction
ARTIFACTS
1. Acceptable 4. Film Streaks	2. Stains 5. Screens	3. Foreign Objects 6. Other
>FILM DETAIL
1. Acceptable 4. Distance 7. Exposure Factors	2. Motion 5. Collimation	3. Positioning 6. Identification

OVERALL RATING OF FILMS

Set #1

Excellent
Good
acceptable
Poor
Unacceptable

Set #2

Excellent
Good
acceptable
Poor
Unacceptable

IF THERE ARE ANY CORRECTIONS NECESSARY, PLEASE SEE THE ACCOMPANYING GUIDE. THE HIGHLIGHTED AREAS ARE SPECIFIC RECOMMENDATIONS BASED ON THE EVALUATION OF YOUR FILMS.

COMMENT:

FORM #3

RADIOGRAPHIC FACTORS AFFECTING FILM QUALITY
This guide may be used as a starting point for correcting problems with film quality and exposure. The highlighted areas are specific recommendations that you may use as a starting point. If you experience other problems, consult a chiropractic radiologist.

CONTRAST

exposure too short
exposure too long
underpenetrated (KVP too low)
underdeveloped
processing temperature too low
exhausted, contaminated, diluted, or incorrectly mixed developer
bucky not used or inoperable
insufficient collimation

DENSITY

temperature too high*
temperature too low*
KV too high
MAS too high
MAS too low
processing temp. too high
light fog
aged or improper chemistry preparation exhausted, contaminated, diluted or incorrectly mixed developer
grid cutoff
tube not centered

FILM FOG

improper safelight or filter
light leaking into darkroom
light on prior to completion of fixing

ARTIFACTS

fixer residue from insufficient rinse
old or exhausted developer
screen artifacts
scratches, nail marks, etc.
particulate matter
patient artifacts, jewellery
poor film screen contact

FILM DETAIL

positioning
motion due to excessive exposure time
inadequate patient immobilization
tube to film distance too long
improper film identification
marker absent

* = Automatic processing (Quality Assurance Program)

Chapter Appendix E:

Technical Protocol For Spinal Videofluoroscopy
CERVICAL SPINE EXAMINATIONS

A. Minimum Examination

Includes the following but must be preceded and supported by clinical and radiographic findings.

A minimum of three repetitions should be performed and all fluoroscopic exposure must be video-taped. The patient should be examined standing when possible.

1. Lateral Projection
(a) nodding
(b) full range "forced" flexion and extension
(c) relaxed flexion and extension

2. Oblique right and left
(a) full range "forced" flexion and extension

B. Additional Examination (As Indicated)
Right and left lateral flexion (open mouth and lower cervical)

C. Optional Examination
Unsupported cross table lateral flexion/extension

D. Check Ligament (Alar) Examination

Lateral view, nodding
Right and left lateral flexion open mouth
Passive stress views. Cases of incomplete tear can only be demonstrated by a passively forced lateral flexion manoeuvre.

LUMBAR SPINE EXAMINATIONS

Videofluoroscopy of the lumbar spine is discouraged due to patient dosage and decreased image quality.

Patient selection is limited by size. The examination should not be performed on individuals exceeding 24 cm. in the A-P position and 32 cm. in the lateral position.

A minimum of two repetitions should be performed and all fluoroscopic exposure must be video-taped. The patient should be examined with the pelvis stabilized to prevent other than spinal motion.

Lateral projection in flexion and extension
A-P right and left lateral bending

Thoracic Spine and Sacroiliac Articulations

Videofluoroscopy of the thoracic spine or sacroiliac articulations is presently considered to be of little diagnostic value and is discouraged.
MINIMUM EQUIPMENT RECOMMENDATIONS

125 kVp 1-3Ma
Image intensifier with a minimum 12000:1 gain
4.5 mm. of total filtration A1 equivalenc
6" minimum FOV with a freely moving gantry
9" minimum FOV without a freely moving gantry (3 planes of movement)
Automatic Brightness Control must be utilized
Video recording equipment should have:

(a) slow motion playback

(b) pause mode

Certain avoidances must be observed with the use of videofluoroscopy. Among these are those ill-advised practices which include but are not limited to the following:

Spinal videofluoroscopy is never appropriate in clinical practice to visualize the spinal adjustment or manipulation, nor is it efficacious to employ videofluoroscopy as a "pre and post" evaluation procedure in conjunction with an adjustment or joint manipulation.
Spinal videofluoroscopy must never be performed without videotaping of the procedure. This ensures accurate recording of pertinent information and time of exposure.
Spinal videofluoroscopy serves only as an ancillary diagnostic imaging procedure.
Spinal videofluoroscopy shall never be utilized as a replacement for static radiographic procedures.
Spinal videofluoroscopy shall never be employed as a screening or cursory imaging device.

Laboratories as well as referring practitioners are responsible for the necessary documentation and protocols as stated above, regardless of the source of referral for the examination.

Practitioners utilizing spinal videofluoroscopy will adapt rigorous measures to ensure the radiation health and safety of both patient and operator. This includes limiting the examination to the area of clinical complaint, along with the application of appropriate radiation protective devices inclusive of, but not limited to lead gowning and filtration.

Prior to the individual or institutional utilization of spinal videofluoroscopy, the operator(s) of the spinal videofluoroscopy equipment shall be adequately prepared by didactic training and practical experience to assure competency of application, and interpretation of both the technical and professional component of spinal videofluoroscopy.