The short version
- For new low back pain without red flags, the ACR rates all imaging as usually not appropriate.
- The American Chiropractic Association's Choosing Wisely list advises against routine imaging for acute low back pain of less than six weeks without clear clinical indicators.
- Red flags such as trauma, osteoporosis, older age, steroid use, cancer or infection can make imaging appropriate.
- A lumbar spine X-ray delivers about 1.4 mSv, roughly six months of natural background radiation.
- Chiropractic BioPhysics uses X-rays to measure spinal curves; whether that should be routine is debated.
Why do chiropractors take X-rays?
Chiropractors use X-rays for two main reasons. The first is safety: to look for fractures, bone weakening, instability or other problems that change whether and how the spine should be adjusted. The second, for some techniques, is measurement: to see the shape of your spinal curves and how your posture is aligned.
An X-ray shows bones and joint spaces well. It does not show discs, nerves or muscles clearly. That is a job for MRI.
When are X-rays recommended for back pain?
Imaging helps when your history or exam points to something more than a simple strain. The American College of Radiology (ACR) Appropriateness Criteria, a widely used guideline for choosing imaging tests, rates imaging as usually appropriate in these situations:
| Situation | Imaging the ACR rates as usually appropriate |
|---|---|
| New or ongoing low back pain, no red flags, no prior treatment | None; all imaging is usually not appropriate |
| Persistent or worsening symptoms after 6 weeks of care, when surgery or injection is being considered | MRI |
| Suspected cauda equina syndrome | MRI, urgently |
| Prior back surgery with new or worsening symptoms | X-ray or MRI |
| Low-energy trauma, osteoporosis, older age or long-term steroid use | X-ray, MRI or CT |
| Suspected cancer, infection or a weakened immune system | MRI |
A car accident or fall is a common reason for an X-ray in a chiropractic office. Our guide on what to do after a car accident covers the steps after a crash.
When are X-rays not needed?
For a new episode of low back pain without red flags, imaging usually does not help. The American Chiropractic Association's Choosing Wisely list advises clinicians to avoid routine spinal imaging for acute low back pain of less than six weeks without clear clinical indicators. The same list advises against repeat imaging just to monitor progress.
Several medical groups give the same advice. Early imaging often finds age-related changes, such as disc wear, that are common in people without pain. Those findings can cause worry and lead to more tests without improving recovery.
How much radiation does a spine X-ray use?
A spine X-ray uses a small dose of radiation. RadiologyInfo estimates a lumbar spine X-ray at about 1.4 millisieverts (mSv), which is similar to about six months of natural background radiation. People in the United States receive about 3 mSv a year from natural sources. A CT scan of the spine is much higher, at about 8.8 mSv.
The dose is low, but no imaging test should be taken without a reason. Tell the clinic if you are or might be pregnant before any X-ray.
Why does Chiropractic BioPhysics use X-ray analysis?
Chiropractic BioPhysics, often called CBP, is a technique that aims to restore the spine's natural curves. To do that, CBP practitioners measure the spine on X-rays, using angles and lines to describe the neck and low back curves and any sideways shift. Those measurements guide the adjustments, exercises and traction positions used, and they give a baseline to compare with later.
Researchers who developed and teach CBP have argued in published papers that X-rays are essential to this kind of structural rehab and that the radiation risk is very low. Other researchers have disagreed, pointing out that no evidence-based guideline supports routine spinal X-rays and that imaging is mainly indicated when serious disease is suspected. Both views are published, and you deserve to know the debate exists.
What should you ask before getting an X-ray?
You can ask any clinician these questions:
- What are you looking for, and how would the result change my care?
- Do I have any red flags that make imaging important?
- Can you use X-rays or reports I already have?
- Will I need follow-up X-rays, and why?
Good answers connect the X-ray to a decision. If you are working on posture and tech neck or a curve problem, measurement may be the reason. If you have a simple new back strain, the honest answer may be that you do not need one yet. You can read more about what to expect on our new patients page.
Frequently asked questions
Not always. For a new episode of low back pain without warning signs, guidelines say imaging usually does not change care. An X-ray is more likely to be useful after a fall or car accident, if you have osteoporosis, are older, take long-term steroids, have a history of cancer, or have symptoms that are not improving. Some chiropractic techniques, such as Chiropractic BioPhysics, also use X-rays to measure alignment.
RadiologyInfo, run by the American College of Radiology and the Radiological Society of North America, estimates a lumbar spine X-ray at about 1.4 millisieverts. That is similar to about six months of the natural background radiation people receive from their surroundings. People in the United States receive about 3 millisieverts a year from background sources. A spine CT scan is much higher, at about 8.8 millisieverts.
X-rays and MRI show different things. X-rays show bones, alignment and posture well, and they are quick and widely available. MRI shows discs, nerves and soft tissue, and it is the preferred test when cauda equina syndrome, infection or cancer is suspected, or when surgery or injections are being considered after six weeks of care. Neither is needed for most new back pain without red flags.
The American Chiropractic Association's Choosing Wisely list advises against repeat imaging just to monitor progress. Practitioners who focus on structural or postural correction sometimes take a follow-up X-ray to measure change in spinal curves. If a repeat X-ray is suggested, it is fair to ask what decision the result will change before you agree to it.
Yes, and it is a good idea. Recent X-rays or MRI reports from another provider can help your chiropractor understand your spine and may avoid repeat imaging. Bring the images on a disc or the written report, along with the date they were taken.
Sources
- American College of Radiology: ACR Appropriateness Criteria, Low back pain (opens in a new tab)
- American Chiropractic Association: Choosing Wisely recommendations (opens in a new tab)
- RadiologyInfo.org: Radiation dose in X-ray and CT exams (opens in a new tab)
- Oakley PA, Cuttler JM, Harrison DE. X-ray imaging is essential for contemporary chiropractic and manual therapy spinal rehabilitation, Dose Response, 2018 (opens in a new tab)
- Letter to the editor responding to Oakley et al., Dose Response, 2018 (opens in a new tab)
This page is general education, not medical advice. It cannot replace an exam. Results from any treatment vary from person to person.
