X-ray protocol

[Dr. Ice]

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I have been asked by my group to try to come up with standardization on ordering spine X-rays. Which views, when and on whom. Do any of you guys use a protocol?

 

[Taus]

I have been asked by my group to try to come up with standardization on ordering spine X-rays. Which views, when and on whom. Do any of you guys use a protocol?

I keep it simple. AP lat flex ex on all.

 

[SSdoc33]

what happens if there is a pars defect? no obliques? why flexion/extension when there is no hint of instability? was there a recent abd CT scan that shows you what you need? or an MRI that was done a couple years ago?

my point is that protocols are for nurse managers and PAs who can't think for themselves. this isnt a cookbook where everything turns out the same. if you have a protocol in place you will invariably take some xrays you don't need or have to retake some that you do. just see the patient yourself and then decide.

a lot of ortho practices have these protocols in place so they can bill every time a patient come in with knee or shoulder pain, and the views are always the standard views. it doesnt really work that way with us. i tried it, and it slowed me down and wasted a lot of time, effort, and $$$

 

[paindoc007]

what happens if there is a pars defect? no obliques? why flexion/extension when there is no hint of instability? was there a recent abd CT scan that shows you what you need? or an MRI that was done a couple years ago?

my point is that protocols are for nurse managers and PAs who can't think for themselves. this isnt a cookbook where everything turns out the same. if you have a protocol in place you will invariably take some xrays you don't need or have to retake some that you do. just see the patient yourself and then decide.

a lot of ortho practices have these protocols in place so they can bill every time a patient come in with knee or shoulder pain, and the views are always the standard views. it doesnt really work that way with us. i tried it, and it slowed me down and wasted a lot of time, effort, and $$$

Ive honestly never ordered obliques in my life. How does an oblique xray in a pars defect help w/management?

 

[pmrmd]

I agree with ssdoc for the most part but for LBP standing AP on everyone to look for curvature or leg length inequality since I do that in house and then appropriate imaging after that to outside radiology.

 

[SSdoc33]

Ive honestly never ordered obliques in my life. How does an oblique xray in a pars defect help w/management?

helps you see a pars defect if you dont know one is there.

you may then order flexion/extension to see if there is any instability

PT is different for a pars defect, including greater focus on hamstring ROM.

you would not fuse for simple DDD, but you might for spondylolysis

 

[Baron Samedi]

No imaging if axial pain, no red flags, and patient doesn't want procedures.

AP/Lateral if I'm contemplating doing a procedure.

Flex/ext if listhesis on above.

 

[mid|ine]

I keep it simple. AP lat flex ex on all.

I agree. KISS. Why make a patient take the time out of their schedule and go back when you see listhesis. Just order it on the front end.

 

[Baron Samedi]

I agree. KISS. Why make a patient take the time out of their schedule and go back when you see listhesis. Just order it on the front end.

Lateral L-spine xrays are a non-trivial amount of radiation.

Also, what's the likelihood that they have an unstable listhesis without radicular symptoms?

 

[painfree23]

Lateral L-spine xrays are a non-trivial amount of radiation.

Also, what's the likelihood that that have an unstable listhesis without radicular symptoms?

lol what about ur stim trials?

 

[NJPAIN]

helps you see a pars defect if you dont know one is there.

you may then order flexion/extension to see if there is any instability

PT is different for a pars defect, including greater focus on hamstring ROM.

you would not fuse for simple DDD, but you might for spondylolysis

Tim Maus at Mayo states that the gonadal dose for lumbar oblique films is very high with low yield.

 

[Baron Samedi]

lol what about ur stim trials?

What about them?

 

[bedrock]

No imaging if axial pain, no red flags, and patient doesn't want procedures.

AP/Lateral if I'm contemplating doing a procedure.

Flex/ext if listhesis on above.

Are you not getting an MRI before most spine procedures?

 

[Baron Samedi]

Are you not getting an MRI before most spine procedures?

Not routinely for SIJ or MBB/RFA

 

[Taus]

what happens if there is a pars defect? no obliques? why flexion/extension when there is no hint of instability? was there a recent abd CT scan that shows you what you need? or an MRI that was done a couple years ago?

my point is that protocols are for nurse managers and PAs who can't think for themselves. this isnt a cookbook where everything turns out the same. if you have a protocol in place you will invariably take some xrays you don't need or have to retake some that you do. just see the patient yourself and then decide.

a lot of ortho practices have these protocols in place so they can bill every time a patient come in with knee or shoulder pain, and the views are always the standard views. it doesnt really work that way with us. i tried it, and it slowed me down and wasted a lot of time, effort, and $$$

Like most things..... blend the science w practically and efficiency. A few thoughts:
-I’d be fine with just standing AP/lat. if a little listhesis on that or fluid in facet on mri, get flex ex.
-It’s time consuming and pita for me and patient to send back for more views.
-I find patients w axial pain feel re-assured and demand mri less when I can tell them immediately no fracture, no instability and no need for surgery. Also no precautions in PT.

-obliques nearly never indicated. It’s much more radiation and If you see fracture line on xray it’s too late..... terminal pars defect unlikely to heal. And if present you’re still getting mri ct or spect. If clinically suspected just get the advanced imaging.

 

[lobelsteve]

But my scotty dog.

 

[manowar rules]

I like obliques to see the facets and plan potential MBBs in people I don’t have an MRI on

I guess I didn’t think that I was frying the gonads lol

 

[Baron Samedi]

I like obliques to see the facets and plan potential MBBs in people I don’t have an MRI on

I guess I didn’t think that I was frying the gonads lol

Plan MBBs?

 

[manowar rules]

Plan MBBs?

Maybe that sounds stupid. I’m talking about trying to see which facets look gnarliest.

 

[Ferrismonk]

Without red flags, axial pain gets an AP/Lateral to satisfy the insurance company. Very rarely will it ever change my management.

Red flags either get AP/Lateral or CT/MRI depending on issue.

 

[Ronin1]

I suspect the incidence of plain films per patient is directly proportional to whether or not you have in office xray.

I rarely send someone for plain films but then I don’t have in office capability....

 

[painfree23]

Without red flags, axial pain gets an AP/Lateral to satisfy the insurance company. Very rarely will it ever change my management.

Red flags either get AP/Lateral or CT/MRI depending on issue.

So no mri/ct before an esi??

 

[Ferrismonk]

So no mri/ct before an esi??

ESI only for radicular pain. This is for axial.