X-ray or CT studies of the lumbar spine should not be routinely ordered or rendered for low back pain without suspected or known pathology. 
 

[Commentary:
 1.  The physician requesting the diagnostic services subsequently found not to be medically necessary in accordance with s. 18.2 (1) and 18.2 (2) of the Health Insurance Act will be responsible for repayment.

 2.  Examples of suspected or known pathology include infection, tumour, osteoporosis, ankylosing spondylitis, fracture, inflammatory process, radicular syndrome, and cauda equina syndrome.]

This change to the fee code has resulted in a number of Independent Health Facilities (private x-ray labs) declining to take routine lumbar spine x-rays requested by any health professionals including chiropractors.

The Ministry of Health and Long-Term Care has made a commitment to deliver higher quality evidence-based care to meet the challenges of an evolving health care system. Increasing the usage of clinical practice guidelines by healthcare professionals is an important part of the Ministry's strategy to address these health care challenges.

For a number of years, successive international multi-disciplinary guidelines have advised that in most cases, routine x-rays of the lumbar spine are not necessary in the absence of red flags. These include:

• European Guidelines for the Management of Chronic Non-Specific Low Back Pain; June 2005[i]
• The American College of Physicians and the American Pain Society; Oct. 2007[ii] 
• National institute for Health and Clinical Excellence (NICE); May 2009, and[iii]
• Towards Optimal Practice (Alberta); 2011[iv]

In the publication Diagnostic Imaging Practice Guidelines For Musculoskeletal Complaints In Adults-An Evidence-Based Approach-Part 3: Spinal Disorders (Journal of Manipulative and Physiological Therapeutics, 2008) Andre Bussieres et al present chiropractic specific imaging guidelines.

Where there are potential red flags, i.e. suspicion of serious pathology, imaging is generally recommended. Whether this imaging is x-ray, CT, or MRI depends on the specific case.

Establishing a baseline and monitoring progress, patient education, or screening for pathology are not considered valid reasons for exposing a patient to harmful radiation.

The current funding challenges and focus on quality have resulted in the government using the payment system to encourage adoption of clinical practice guidelines. This is indicative of how important the use of guidelines has become - they are the required norm in health care.

Reviewing the most recent guidelines will help you to critically evaluate your practice and procedures and manage patient expectations around X-rays. A suggested guideline source is Alberta's "Towards Optimal Practice" (TOPS) guideline and its companion documents. Towards Optimized Practice (TOPS) is the Alberta program responsible for provincial clinical practice guidelines, and the Low Back Pain guideline is widely used in Canada.

References: 

1. Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults - An Evidence-Based Approach - Part 3: Spinal Disorders  
2. A Summary of the Guideline for the Evidence-Informed Primary Care Management of Low Back Pain  

[i]  European Guidelines for the Management of Chronic Non-Specific Low Back Pain; June 2005  

 We do not recommend radiographic imaging (plain radiography, CT or MRI), bone scanning, SPECT, discography or facet nerve blocks for the diagnosis of non-specific CLBP unless a specific cause is strongly suspected.  

[ii]  American College of Physicians and the American Pain Society; Oct. 2007 

Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). 
  

[iii]  National institute for Health and Clinical Excellence (NICE); May 2009 

Do not offer X-ray of the lumbar spine for the management of non-specific low back pain. 
 

[iv] Towards Optimal Practice (Alberta); 2011

In the absence of red flags, routine use of X-rays is not justified due to the risk of high doses of radiation and lack of specificity.