Chiropractic Imaging Standards of Care?

Written by: James Demetrious, DC, DABCO

Diplomate, American Board of Chiropractic Orthopedists
Diplomate, International Academy of Neuromusculoskeletal Medicine

When is it Appropriate to Image Patients in Chiropractic Practice?

What is the standard of care for imaging chiropractic patients? When is it appropriate to order advanced imaging? Should the decision to image patients be based on needs dictated by chiropractic assessment and technique? Should the need to image be based upon indications and contraindications of care? How do we negotiate evidence-based recommendations and clinical experience?

An Instructive Case

A 79-year-old woman fell and struck her head. She suffered a head laceration for which she sought local emergency department care. The attending ER physician ordered a CT of the cervical spine that revealed non-union C1 fractures.

One can easily visualize the non-union, corticated bone at the fracture sites that indicates an old fracture. The attending neurosurgeon concluded that the fractures were old, and he sent her home without any further care. No further imaging was recommended.

Interesting Clinical Considerations

In chiropractic practice, we rely upon patients’ histories, our carefully conducted examinations, and the consideration of evidence-based appropriateness criteria. Our standard of care requires careful assessment that may lead to advanced diagnostic studies. Complicated cases require nuanced consideration.

Consensus guidelines are derived from highly powered systematic reviews and provide some insight into patient management and care. The American College of Radiology (ACR) provides their Appropriateness Criteria for spinal trauma. These guidelines offer an evidence-based approach to assessing patients and should be employed in conjunction with the clinician’s clinical experience.

When considering spinal trauma, the ACR provides guidance specific to possible clinical variants. For instance, if a patient has sustained a high-risk spinal injury, as defined by the NEXUS or CCR criteria, CT evaluation is usually appropriate.

This seems straightforward, however, at times, patients’ histories are vague, undisclosed, or unknown. As evidenced in this case, the patient and her family could not recall when the patient previously injured her spine and suffered the fracture. Without that information, how does one proceed?

Chiropractic Imaging Needs Are Unique

In this illustrative case, consider that the neurosurgeon concluded that the fracture was stable and required no additional care.

Now consider the chiropractor who may be unaware of previous trauma, fracture, or ligamentous instability that occurred 1 or 2 years earlier. Despite best efforts, patients and family oftentimes do not report prior injuries, conditions, and potential contraindications to chiropractic care.

Should the chiropractor strictly follow evidence-based guidelines in imaging, or should they recognize that these criteria are intended to guide physicians in making decisions regarding radiologic, imaging, and treatment?

The ACR clearly states, “The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all of the circumstances presented in an individual examination.”

To Image or Not to Image, that is the Question!

I submit that the needs of chiropractors differ from those of other practitioners. The need to image is not black or white. While helpful, guidelines are limited by clinical circumstances and current research. It is based upon the best available research and, ultimately, the clinician’s discretion.


  1. Beckmann et al. ACR Appropriateness Criteria® – Suspected Spinal Trauma. 2018; Accessed on June 26, 2023.


The views and opinions expressed in this presentation are solely those of the author. The information is not offered as a standard of care as research and care evolve. We offer this only to educate and inform. Patients should seek the care of their doctors regarding their conditions.

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