Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 3: Spinal Disorders

Article Outline

• Abstract
• Reporting of Topics Included in the Development of the Diagnostic Imaging Practice Guidelines1
  • Focus
  • Objectives
  • Target Users/Setting
  • Target Population
  • Developers
  • Evidence Collection
• Methods for Synthesizing Evidence
  • Recommendation Grading Criteria
  • Patient Preferences
  • Stakeholders and Editorial Independence
  • Updating/Revision
  • Potential Benefits and Harm
  • Dissemination/Implementation Considerations
  • Definitions, Patient Presentations, Recommendations, and Rationale
• Preliminary Considerations and Disclaimer
  • What Is the Role of These Guidelines?
  • What These Guidelines Do and What They Do Not Do
  • What Is Evidence-Based Health Care?
  • Potential Disagreements
  • Standard Patient Management Activities
  • Duration of Disorders
  • Defining Radicular Pain
• Are There Potential Risks Associated With Conventional Radiographs?
• Acknowledgment
• Appendix A. Supplementary data
• Appendix B. Summary of Recommendations
• Appendix C. Pertinent Clinical Information
• Appendix D. General Indications for Advanced Imaging in Spine Disorders
• Appendix E. Typical Effective Ionized Radiation Dose for Common Imaging Procedures*
• Appendix F. Additional Reading Recommended on Spinal MRI
• Appendix G. Acknowledgments
• References
• Copyright

Abstract 

Purpose

To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for spinal disorders.

Methods

A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research were invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by practicing chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence.

Results

Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed.

Conclusions

The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Key Indexing Terms: Practice Guideline, Guideline, Diagnostic Imaging, Radiology, Diagnostic X-Ray, Radiography, Adult, Musculoskeletal System, Pain, Cervical Spine, Thoracic Spine, Lumbar Spine, Trauma

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Reporting of Topics Included in the Development of the Diagnostic Imaging Practice Guidelines¹ 

An initial literature review considered 10 clinical questions pertaining to imaging of musculoskeletal conditions to evaluate the pertinence of developing diagnostic imaging guidelines. This initial review led to a research project divided into 9 phases: (1) literature search; (2) independent literature assessment; (3) guideline development specific recommendations; (4) first external review; (5) consensus panel (modified Delphi); (6) public website; (7) second external review; (8) final draft and grading of the recommendations; and (9) dissemination and implementation. Details of this study are published elsewhere.²

Focus 

These diagnostic imaging guidelines concern adult musculoskeletal disorders of the spine where conventional radiography and specialized imaging studies are deemed useful for diagnostic purposes. Special consideration for manual therapy intervention is integrated within these guidelines.

Objectives 

Reasons for developing these guidelines include assisting current and future health care providers to make appropriate use of imaging studies, providing indications for the need of imaging studies according to current literature, and expert consensus, and assisting in optimizing the utilization of limited available resources. These proposed guidelines are intended to reduce unnecessary radiation exposure and the use of specialized imaging studies, increase examination precision and decrease health care costs—all without compromising quality of care.

Target Users/Setting 

Intended users of the guidelines are chiropractors and other primary health care providers prescribing diagnostic imaging studies. The setting in which these guidelines may be used include private clinics, outpatient clinics, and hospital emergency rooms.

Target Population 

The patient population eligible for guideline recommendations are adult patients presenting with musculoskeletal disorders of the spine. Children and pregnant patients are excluded from these guideline recommendations.

Developers 

The proposed guidelines are developed from the results of 9 distinct phases overseen by a research team composed of the 3 investigators with postgraduate education from 3 independent teaching institutions. The guidelines were further developed and peer reviewed by more than 60 chiropractic clinicians, academics, and researchers.

Evidence Collection 

Electronic searches in English and French language literature occurred and cross references were repeated on 3 different occasions between 2003 and 2006.

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Methods for Synthesizing Evidence 

Recommendation Grading Criteria 

The evaluation tool used was designed by the Scottish Intercollegiate Guidelines Network (SIGN) and adapted by the Stroke Prevention and Educational Awarenesss Diffusion (SPREAD) group.⁵, ⁷

Patient Preferences 

Condition specific imaging guidelines. Integral to evidence-based health care, decisions regarding the use of imaging studies should be based on the best available evidence, the experience, and judgment of the clinician, while considering the patient preference. A public member reviewed all documents and provided comments and suggestions.

Stakeholders and Editorial Independence 

Updating/Revision 

The literature review and the guidelines should be updated every 2 to 3 years.

Potential Benefits and Harm 

Selection of appropriate radiologic imaging procedures for evaluation of patients with musculoskeletal disorders of the spine; decrease unnecessary ionizing radiation exposure, decrease costs, and improve accessibility.

Dissemination/Implementation Considerations 

Publication; applying to National Guideline Clearinghouse; posting of the electronic document on various websites (malpractice insurance carriers, outpatient teaching clinics); educational intervention strategies (e-learning, community pilot studies); referral guidelines; reinforced by request checking and clinical management algorithms; promotion by national, provincial and state organizations, conferences.

Definitions, Patient Presentations, Recommendations, and Rationale 

These topics are integral parts of each 1 of the 3 diagnostic imaging guidelines: lower extremity disorders, upper extremity disorders, and spine disorders. Results of the 9 phases of the research project are published elsewhere.²

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Preliminary Considerations and Disclaimer 

What Is the Role of These Guidelines? 

These evidence-based diagnostic imaging practice guidelines are intended to assist primary care providers and students in decision making regarding the appropriate use of diagnostic imaging for specific clinical presentations. The guidelines are intended to be used in conjunction with sound clinical judgment and experience. For example, other special circumstances for radiographic imaging studies may include: patient unable to give a reliable history; crippling cancer phobia focused on back pain; need for immediate decision about career or athletic future or legal evaluation; history of significant radiographic abnormalities elsewhere reported to patient but no films or reliable report reasonably available; history of finding from other study (eg, NM or gastrointestinal imaging) that requires spine radiographs for correlation.⁸ Application of these guidelines should help avoid unnecessary radiographs, increase examination precision, and decrease health care costs without compromising the quality of care.

The descriptions of clinical presentations and proposed clinical diagnostic criteria, recommendations for imaging studies, and the comments provided throughout this document are a synthesis of the vast body of literature consulted before and during the various phases of this research project. Where the literature was found to be of poor quality or absent, consensus based on expert opinion was used. Although the investigators and collaborators carefully searched for all relevant articles, it is probable that some have been missed. Furthermore, as many new important studies are published in the near future, these will be incorporated in subsequent revisions of the guidelines and recommendations may change accordingly.

What These Guidelines Do and What They Do Not Do 

It should be emphasized that these guidelines were developed with the intent of being used for diagnostic purposes and not for therapeutic purposes such as evaluating and monitoring functional or structural rehabilitation of the spine.⁹ In addition, these guidelines are intended to address issues faced by first contact professionals only. These guidelines do not address all possible conditions associated with musculoskeletal disorders, only those that account for the majority of initial visits to a practitioner.

Like other diagnostic tests, imaging studies should only be considered if (a) they yield clinically important information beyond that obtained from the history and physical examination; (b) this information can potentially alter patient management and; (c) this altered management has a reasonable probability to improve patient outcomes.¹⁰, ¹¹, ¹²

Investigators and collaborators in the development of these imaging guidelines believe that liability insurance companies, third-party payers, and courts of law should not rely solely on descriptions of patient presentations, proposed recommendations, and/or corresponding comments found throughout the documents, as patient presentations are unique and the application of any guideline always requires clinical judgment and thus needs to be considered in the proper context. In addition, laws and regulations may vary between geographical regions and should be considered when applying the proposed indications for any imaging study.

What Is Evidence-Based Health Care? 

Evidence based is about tools, not about rules.¹³ Evidence-based health care is an approach in which clinicians and health care professionals use the current best evidence in making decisions about the care of patients. It involves continuously and systematically searching, appraising, and incorporating contemporaneous research findings into clinical practice. The overall goal is improving patient care through life-long learning.¹³, ¹⁴

Potential Disagreements 

There are several reasons for disagreement within a guideline development group. These include differences in interpretation of the research literature, differences in personal experience, and different perceptions of the inherent risks and benefits of a procedure.¹⁵ Divergent or competing guidelines on similar topics serve only to further confuse and frustrate practitioners.¹⁶ In addition, the continued lack of unity among chiropractors hinders its growth by limiting integration and cooperation within the greater health care system. Readers of all guidelines are advised to critically evaluate the methods used as well as the content of the recommendations before adopting them for use in practice.¹⁷

Standard Patient Management Activities 

Standard patient management activities, including diagnostic assessment and follow-up, are integral components of every patient encounter.¹⁸ Initial triage of patients with spine disorders is a constant recommendation of various clinical guidelines.¹⁹ Imaging studies are used most practically as confirmation studies once a working diagnosis is determined. The objective is to determine the presence of clinical indicators of serious pathologies (red flags) requiring diagnostic imaging, specialist referral or urgent surgical intervention. When a practitioner recommends that a radiograph or other diagnostic imaging study be performed, and the patient refuses, the patient should be advised of the associated risks and implications and this should be recorded in the patient's records.

Duration of Disorders 

In clinical practice, spine disorders are generally divided into categories according to the duration of the patient complaint on initial presentation. These diagnostic imaging guidelines therefore consider the following categories of clinical presentations: acute spine disorder (<4 weeks' duration); subacute spine disorder (4-12 weeks' duration); and persistent/chronic spine disorder (>12 weeks' duration).

Defining Radicular Pain 

It is generally accepted that patients with neurologic symptoms and signs (pain radiating below the knee or beyond the elbow, as intense as the low back or neck pain, often radiating into the foot or hand with numbness or paresthesia in a dermatomal distribution with positive nerve root tension signs, abnormal motor power, sensation or deep tendon reflexes consistent with a nerve root involvement) have a slower resolution than patients with uncomplicated spine disorders (mechanical pain that varies with time and activity with no neurologic component and a good general health status). Again, clinical presentations are divided accordingly throughout these imaging guidelines.

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Are There Potential Risks Associated With Conventional Radiographs? 

Although somewhat controversial,²⁰, ²¹, ²², ²³ it is important to remember that health hazards of all forms of radiation are cumulative.²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰ The Biological Effects of Ionizing Radiation (BEIR) 2005 report released by the National Academy of Sciences adds further support to the “linear-no-threshold” model of cancer risk from ionizing radiation exposure.³¹ In summary, this report concludes that ionizing radiation is dangerous even at low doses and that there are no safe limits. Given the potential risks associated with conventional radiographs, only appropriate clinical indications can justify its use. In this regard, the need to confirm pathology, to follow the evolution of a pathology possibly affecting therapy, or to identify a clinically suspected contraindication to manipulative therapy is the best-documented reason. The benefits of all diagnostic studies must outweigh the risks and the inherent costs to the patient.¹⁰, ³², ³³, ³⁴, ³⁵, ³⁶, ³⁷, ³⁸, ³⁹, ⁴⁰

Table 1, Table 2, Table 3, Table 4, Table 5 list the patient presentations, recommendations, and comments regarding diagnostic imaging for spine disorders. A list of abbreviations and glossary of terms used in the recommendations is in Appendix A. Appendix B provides a summary of the recommendations. Pertinent information for spinal disorders is presented in Appendix C. General indications for advanced imaging are in Appendix D. Typical effective ionized radiation dose for common imaging procedures is listed in Appendix E. Further recommended reading pertaining to magnetic resonance imaging of the spine is offered in Appendix F.

Table 1. Thoracolumbar, lumbar, and thoracic spine trauma

Patient presentation	Recommendations	Comments
Adult patient with recent (<2 wk) acute thoracolumbar, lumbar or thoracic spine trauma.		In a recent survey, 53% of patients consulting chiropractors reported having an injury. The most common reported source was non–work related (43%); work-related injuries accounted for only 16%, and 21% were classified as nonspecific.41
Absence of pain, normal ROM, and absence of neurologic deficits (normal lower limb motor power, sensation and deep tendon reflexes, and no pathologic reflexes).6	Radiographs not routinely indicated [C]	Physical examination is reliable in this region. When the patient is alert and asymptomatic, injury risk is low and radiographs provide no clinical utility.6, 42
		Increased prevalence of traumatic fractures found in patients >75 yoa. Prevalence of lumbar spine traumatic fracture is <1% but overall prevalence of spine fractures for all age groups is 4%.43, 44
Adult patient with thoracolumbar, lumbar, or thoracic spine blunt trauma or acute injuries (falls, motor vehicle accidents [MVAs], motorcycle, pedestrian, cyclists, etc)	Radiographs indicated [B]	Conventional radiography is highly specific but has a sensitivity of ≈0.70 and a predictive value of 0.9245
	Lumbar AND thoracic spine: AP (or PA), lateral views	Thoracic and lumbar spinal injuries affect 2%-3% of blunt trauma victims with a 40%-50% incidence of neurologic deficits.7
High-risk screening criteria for spinal injuries include any of the following45, 46, 47, 48, 49:	N.B. The high-risk screening criteria for spinal injuries was developed to help determine the need for plain film radiography in the emergency room. The lower prevalence of serious post traumatic injuries in ambulatory care likely influence the sensitivity of such instruments. Nonetheless, it appears reasonable to recommend their use in primary care as well as well.	Major spine traumas are typically seen in hospital settings and mandate immobilization pending radiographic evaluation. Missed spinal injuries resulting in neurologic deficit continue to occur in major trauma centers. Older age (>50), high impact accidents, patients with insufficient imaging, and misread or poor quality radiographs are at highest risk of missed injuries.50
1. Back pain
2. Midline tenderness on palpation
3. Distracting painful injury and other high-risk mechanism of injury*
4. Neurologic deficits**
5. Altered consciousness (caused by head trauma, intoxication/ethanol, or drugs)		The Thoracolumbar Injury Severity Scale (TLISS) may be helpful in the referral decision making process. The scale is based on the mechanism of injury, the integrity of the posterior ligamentous complex, and the neurologic status.51, 52, 53
Sensitivity of 100 % (95% CI, 98%-100%) but low specificity and low positive predictive value for thoracolumbar injuries.
		(See Appendix C(1) for details)
* High-risk mechanism of injury: Severe mechanism of injury (falls ≥10 ft/3 m, ejection from a motor vehicle, and motor vehicle crashes >50 mph/80 km) and the presence of cervical spine fracture are significantly associated with an increase risk of thoracolumbar spine injury.	Special investigations [C]	Advanced imaging and specialist referral recommended:
		a. In presence of a fracture as suggested by history, examination, and/or radiograph. Special attention required in presence of complex lesions and for suspected ligamentous instability or neural injuries;
		b. If conventional radiographs are difficult to interpret;
** Neurologic deficits:		c. In the absence of clinical improvement after 4-6 wk of therapy;
a. Lumbar spine injuries: positive nerve root tension signs decreased motor power, sensation, and/or deep tendon reflexes.		d. Function does not improve or deteriorates;
		e. Patient has persistent S&S.
b. Thoracolumbar and thoracic spine injuries: lower limb spasticity, presence of pathologic reflexes (Babinski sign/clonus), altered sensations below the injury (sensory level), and altered proprioception (vibration/position sense of the feet), loss of anal sphincter tone.		• CT scan (multidetector/multislice CT and spiral CT) highly sensitive (99.3%-100%); specificity of 97%; negative predictive value of 92%47, 48, 54, 55
		• MRI provides the best evaluation for soft tissue pathology, intrinsic or compressive spinal cord damage and multilevel vertebral fractures. MRI needed when conventional radiographs and CT do not explain patient's symptoms, and when there is a possibility of epidural hematoma or traumatic disc herniation56
• Patient with spinal injuries may suffer progressive neurologic deterioration, and imaging again has a role in their diagnosis and management.7
For osteoporotic fracture risk, please see Pain—Osteoporotic Vertebral Collapse section of the Adult Thoracic Disorders Guideline.
Adult patient with posttraumatic chest wall pain
Minor trauma6	Radiographs not routinely indicated [D]	Although difficult to visualize, presence of a rib fracture would alter the treatment plan in manual therapy.
Major trauma6	Radiographs indicated [GPP]	Chest radiographs frequently underestimate the severity and extent of chest trauma, and in some cases, fail to detect the presence of injury. CT is more sensitive than chest radiography in the detection of pulmonary, pleural, and osseous abnormalities.57 Penetrating injuries or clinical findings suggestive of significant air exchange difficulty urgently require more extensive work-up.
	PA, lateral chest radiographs,
	Specific rib radiographs (AP, oblique)
	Additional views:
	PA chest in full expiration,
	Thoracic and /or lumbar spine views
	Special investigations [GPP]	Advanced imaging and specialist referral recommended:
		• CT for sternum injury, pulmonary, pleural, and osseous abnormalities57
Adult patient with pelvis and sacrum trauma (including falls with inability to bear weight)6	Radiographs indicated [D]	Be aware that femoral neck fracture may not be visible on initial radiographs even with a good lateral view of the hip.
	AP Pelvis and lateral hip “frog leg”
The diagnosis of sacral fractures is frequently missed or delayed, and the treatment is controversial, with significant variations in recommendations regarding nonoperative treatment, neural decompression, and internal fixation.58	Additional views:	Factors that may impact treatment outcomes include the level and type of sacral fracture, lumbosacral junction and sacroiliac joint involvement, and associated pelvic ring injury.58
	(1) Lateral lumbar view to better visualize the lateral sacrum
Posterior pelvis physical examination, especially palpation, may accurately detect injuries to the posterior pelvic ring.59 Look for ecchymosis. However; physical examination may not be reliable for other pelvic injuries.	(2) Angulated AP or PA sacrum view (15°-45° tube angulation)	Advanced imaging and specialist referral recommended
		• NM, MRI, or CT may be helpful if radiographs are normal or equivocal.6
	Special investigations [D]	• Imaging measurement parameters used to evaluate sacral injuries may include AP sacral fracture displacement (axial CT of the pelvis), vertical sacral fracture displacement (coronal CT reconstruction), AP translation and kyphotic angulation (sagittal CT reconstruction), and degree of central canal involvement and foraminal encroachment (axial, coronal, and sagittal CT reconstruction)58
Coccyx trauma and coccydynia	Radiographs not routinely indicated [C]	Normal appearance often misleading.63
Consider taking radiographs if unrelieved by initial rest or if manual treatment of this area is contemplated.	(Spot AP, lateral coccyx)6, 63	Look for fractures, dislocations, and hypermobility (coccygeal mobility between 5° and 25° is considered normal).61
• Obesity, a history of trauma, and transient exacerbation of the pain when standing up from sitting may be associated with posterior dislocation.	Additional views:
• Coccyx pain may be referred from a fracture of the distal sacrum. In doubt, consider views of the sacrum if distal sacrum fracture is suspected.60, 61, 62	AP, lateral sacrum
	Dynamic sitting lateral views of the coccyx64

Table 2. Cervical spine trauma

Patient presentation	Recommendations	Comments
Adult patient with acute neck injury and negative CCSR (Canadian Cervical Spine Rule for Radiography in Alert and Stable Trauma Patients)65, 66, 67, 68	Radiographs not routinely indicated [B]	Whiplash incidence is between 70 and 360 cases per 100000.70 Traumatic unstable injuries are rare (<3%). The CCSR65 is superior to physician judgment, more sensitive and specific than the National Emergency X-Radiography Utilization Study criteria/NEXUS66, 67
Conventional radiographs are unlikely to show clinically significant injuries when all Canadian Cervical Spine Rule criteria are fulfilled65, 66, 67, 68, 69	N.B. The CSCR and NEXUS instruments are highly sensitive clinical decision rules developed to help determine the need for plain film radiography in the emergency room. The lower prevalence of serious post traumatic injuries in ambulatory care likely influence the sensitivity of such instruments, nonetheless, it appears reasonable to recommend their use in primary care as well.	In head-turned rear impacts up to 8 g peak acceleration, the alar, transverse, and apical ligaments are not at risk for injury.71
(A) Any high-risk factors in alert and stable patient?		Although patients >65 yoa are more prone to cervical spine fractures, data form NEXUS indicates that being >65 is not, by itself, a risk factor if all criteria are considered.7, 72 (Sensitivity 100% (95% CI.) Cervical spine radiographs are not indicated if patients fulfill all 5 NEXUS low-risk criteria for head and/or cervical spine trauma67:
1. Age >65 (see NEXUS in comment section)
2. Dangerous mechanisms of injury*
3. Paresthesias in extremities
(B) Any low-risk factors that allow ROM assessment?
1. Simple rear end collision**
2. Patient seated in the waiting room		(1) Normal level of consciousness (may be temporally confused, have mild dizziness or headache)
3. Ambulatory at one time since trauma
4. Delayed cervical pain onset		(2) No evidence of intoxication
5. Absence of midline cervical tenderness		(3) Absence of tenderness on palpation of the midline of the neck
(C) ROM assessment: Is patient able to actively turn his/her head to 45° in both directions?		(4) Absence of focal neurologic deficit
		(5) Absence of painful traction injury
* Dangerous injury mechanism:		Rare injuries may be missed, when the CCSR or NEXUS is properly applied, findings are generally considered not clinically significant65, 67: spinous or transverse process fracture, <25% single anterior compression fracture, isolated avulsion injury not associated with ligamentous injury, type I odontoid fracture, end plate fracture, osteophyte fracture excluding teardrop or corner fracture, trabecular bone injury.
• Fall >3 ft/5 stairs
• Axial cranial force (such as diving)
• Road accident >100 km/h, ejected from vehicle or rollover
• Motorized recreational vehicle (ATV, snowmobile, etc)
** Rear end collision excludes:		NB. “Not clinically significant missed injuries” may be relevant to manual therapy practitioners. However, considering soft tissue and bone healing time; recommendations include early activation and a gradual progression from mobilization to SMT. SMT recommended only when patient can tolerate pre-SMT position test.73, 74, 75, 76, 77, 78, 79, 80, 81, 82
• Being pushed into oncoming traffic
• Hit by a bus or large truck
• Rollover
• Being hit by high speed vehicle (≥100 km/h)
Sensitivity 100% (95% CI, 98%-100%) and specificity 42.5% (95% CI, 40%-44%).65, 66		Of interest, the hypothesis that early aggressive conservative care promotes faster recovery was not supported in a recent population-based cohort study83
Adult patient with acute neck injury and positive CCSR (Canadian Cervical Spine Rule for Radiography in Alert and Stable Trauma Patients)65, 66, 67, 68	Radiographs indicated [B]	Conventional radiographs may be difficult to assess; view must clearly include C7-T1 and the odontoid.93
	APOM, AP lower cervical, neutral lateral
Any adult patient not fulfilling all criteria of the CCSR must undergo cervical spine radiographs:	N.B. The CSCR and NEXUS instruments are highly sensitive clinical decision rules developed to help determine the need for plain film radiography in the emergency room. The lower prevalence of serious post traumatic injuries in ambulatory care likely influence the sensitivity of such instruments, Nonetheless, it appears reasonable to recommend their use in primary care as well.	Pertinent 3 view radiological findings:
(A) Age >65; dangerous mechanisms of injury; parethesias in extremities		• ADI >3 mm in adults (>5 mm in children)
(B) Not a simple rear end collision; patient unable to sit in the waiting room; not ambulatory at one time since trauma; immediate cervical pain onset; presence of midline cervical tenderness		• Acute intradiscal vacuum cleft
(C) Patient unable to actively turn his head to 45° in both directions		• Acute angular segmental kyphosis
		• Widened spinous process interspaces
		• Loss of facet parallelism
		• Presence of prevertebral edema without fracture.94
		According to the Yale criteria, a sagittal translation >3.5 mm or >11° of sagittal rotation in adults indicates segmental instability & requires surgical fusion.94
Both physical and psychological factors play a role in recovery or nonrecovery from whiplash injury.84, 85 Finally, an important association exists between a history of whiplash associated disorders (WAD), pain intensity and disability and comorbidity (headache, LBP, digestive, and cardiovascular disorders).86, 87, 88		See Appendix C(2) for a new classification of lower cervical spine injuries (Cervical Spine Injury Severity Score)95
Patient history may include:	Additional views [GPP]	Cervical spine immobilization in awake patient with persistent pain or tenderness and normal initial standard 3-view series (including supplemental CT as necessary) to exclude ligamentous instability may be discontinued after either96:
• Patient age and sex	CT now considered superior to and should replace oblique, pillar, dynamic flexion/extension (F/E) in suspected fracture.
• Pain location/radiation
• Delay in S&S appearance
• Mechanism of injury		(a) normal dynamic flexion/extension (F/E) radiographs as achieved by the patient with no assistance and under proper supervision (consider fluoroscopy)
• Use of relevant psychometric questionnaires: NDI for neck disability, psychological distress (General Health Questionnaire 28, fear of movement/re-injury (TAMPA Scale of Kinesphobia, TSK), acute post-traumatic stress (impact of events scale and general health and well being [Short Form 36, SF-36]).		(b) a normal MRI study is obtained within 48 h of injury
		NB. F/E films may add little value to the acute evaluation of patients with blunt trauma due to muscular spasm. Consider F/E imaging delayed to 14-28 d postinjury when muscular spasm has resolved.97, 98
• a complete system review
Patient physical examination may include:	Special investigations [C]	Specialist referral is highly recommended in blunt trauma and trauma patients with neurologic signs or fractures/dislocations. In moderate- to high-risk trauma, delays in diagnosis of clinically significant C/S injuries range between 5% and 23%, most of which used conventional radiography as initial screening modality. Neurologic deterioration occurs in 10%-50% of these patients.47
• motor function* including cervical ROM and manual spinal palpation	CT is becoming the primary investigation for high risk patients on an emergency basis (more accurate, faster, and need less patient mobilization compared with conventional radiography).54, 90, 91
• a thorough neurologic examination, including cranial nerves, motor power, deep tendon reflexes, and local and general sensory testing.
The above information helps determine the severity of the injury and prognosis. See Appendix C(2) for a modified classification system for acute WADs including physical and psychological impairments.	Harboview CT Screening Criteria (prediction rule):	• Consider MDCT (multidetector/multislice CT) or MRI in blunt trauma or if initial radiographs are difficult to interpret or in presence of complex lesions.
	• High energy trauma	• MRI for suspected ligamentous instability or neural injuries. In the presence of neurologic S&S, examine patient for signs of acute myelopathy. EMG may be useful.6
	• Severe head injury
*Motor system function testing may also include muscle recruitment pattern, joint position error, EMG recording, kinematic analysis of the cervical spine, and quantitative sensory testing/algometry.89	• Focal neurologic deficit
	• Associated injury	• Consider CT for occult fractures.98
	• Age (>50 y)
	• If patient >65 yoa, consider moderate-energy mechanism92	The presence of any one of the following parameters places the patient in the high-risk category (>5% risk of cervical spine fracture) and indicates that the patient should undergo helical CT90:
The reader is referred to Foreman & Croft textbook Whiplash Injuries73and the Quebec Task Force on Whiplash-Associated Disorders74for additional reading on WAD	However, MRI is an acceptable option.	1. High-speed (35 mph [56 km/h] combined impact) MVA
		2. Crash with death at scene of MVA
		3. Fall from height (10 ft [3 m])
		4. Significant closed head injury (or intracranial hemorrhage seen on CT)
		5. Neurologic symptoms or signs referred to the cervical spine
		6. Pelvic or multiple extremity fractures
		See Cervical Artery Dissection section for further details on prior history of major trauma.

Table 3. Nontraumatic lumbar spine disorders

Patient presentation	Recommendations	Comments
General background information		Low back pain on initial presentation is typically classified according to the duration of complaint and type of presentation: uncomplicated/nonspecific LBP, associated with neurologic deficits or to some underlying pathology.101
Standards of care dictate that careful history & physical examination be done routinely for all patients. See Lurie (2005)99 for a comprehensive review of the value of the history & physical examination for LBP.		Duration of complaint:
		Acute LBP: <4 wk of duration
Between 41% and 44% of initial chiropractic visits are for low back–related complaints, of which 45% are acute in origin.41, 100		Subacute LBP: 4-12 wks' duration
		Persistent/chronic LBP: >12 wks' duration
		The cumulative 6-mo incidence of LBP is 18.6% (95% CI, 14.2-23.0) with 17.2% having mild pain (95% CI, 12.9-21.5), 1.0% having intense pain (95% CI, 0.0-2.2), and 0.4% disabling pain (95% CI, 0.0-1.0).102
		Annual course of back pain is as follows102:
		• 27.3 of low back complaints resolve
		• 29% improve
		• 35.4% persist
		• 9.3 get worse
		• 31.3% recur
Adult patient with acute uncomplicated* LBP (<4 wks' duration)	Radiographs not initially indicated42, 101, 108, 109[B]	Routine use of lumbar spine conventional radiography is not indicated because of very low incidence of unexpected findings on radiographs (only 1 in 2500 radiographs), high radiation dose to gonads, high cost/benefit ratio, and poor association between patient findings and LBP (ie, not specific). Anomalies of no proven clinical relevance include block vertebrae, spina bifida occulta, mild scoliosis, and facet tropism; none of which are considered contraindications to SMT.40, 43, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136
* Uncomplicated definition: nontraumatic LBP without neurologic deficits or indicators of potentially serious pathologies)—(see red flag list for details).
Mechanical LBP accounts for the vast majority of LBP seen in primary care setting. Mechanical designates anatomical or functional abnormality without an underlying pathology.44	Special investigations not indicated [B]	Several factors influence the reliability and validity of biomechanical and postural analyses on conventional radiographs: Morphologic asymmetries, geometric and positional distortions, measurement errors, poor correlation with symptoms and lack of convincing clinical usefulness.43, 105, 106, 121, 122, 137, 138, 139, 140, 141, 142, 143, 144, 145
For most young or middle-aged adults, early diagnostic evaluation of low back complaints may focus on 3 basic questions: diagnostic imaging is infrequently required.44	Outside the setting of suspected systemic disease or neurologic compromise, radiography, scintigraphy, computed-tomography (CT), and MRI add very little to the diagnostic evaluation of LBP.42, 99
1. Is there underlying systemic disease?		Acute LBP is generally due to musculoskeletal conditions that respond favorably to SMT.146, 147 A multidisciplinary panel recommended 2 trial courses of 2 wk each, using alternative manipulative procedures.148, 149 Lumbar spine radiography recommended in the absence of expected treatment response or worsening after 4-6 wk.
2. Is there neurologic impairment that might require surgical intervention?
3. Is social or psychological distress amplifying or prolonging the pain?
There is strong evidence that in nonspecific LBP, conventional radiography and MRI findings do not correlate with clinical symptoms or work capacity.103, 104		Serious adverse events are unlikely to occur with chiropractic treatment for LBP.115 Contraindication for lumbar SMT includes progressive neurologic deficits, S&S of cauda equina syndrome, suspicion of abdominal aortic aneurysms or destructive and bone softening diseases such as Paget's disease, and severe osteoporosis. (See LBP with red flag's for details).
In the absence of red flags as revealed by the history and physical exam, radiography in patients with LBP of at least 6 wk duration is not associated with improved physical functioning, severity of pain, disability, or overall health status. Conventional radiography may somewhat improve patient satisfaction. However, minor psychological improvement should be balanced against radiation dose, higher number of doctor visits, and increased disability at 3 mo.105, 106, 107, 108
Adult patient with uncomplicated subacute (4-12 wks' duration) or persistent LBP (>12 wks' duration) AND no previous treatment trial.63, 101	Radiographs not initially indicated [B]	As with all cases, recent previous available radiographs should be reviewed by the clinician. Overall, studies have not shown any significant correlation between posture and LBP. Degenerative processes (disc & facet) are common & usually related to age (prevalence >62% in patients >55 yoa). Degenerative processes may account for 10% of all LBP. Abdominal aortic calcification may be associated with lumbar disc degeneration, back pain. However, even if DJD and DDD are present, clinical management remains essentially unchanged.42, 43, 113, 121, 150, 151, 152, 153, 154, 155, 156
Consider a clinical evaluation of risk factors for chronic LBP (yellow flags). Look for functional disability, significant depression, and risk profile for delayed recovery.
A trial of 4-6 wk of conservative care is appropriate before radiographs.
Adult patient with nontraumatic acute LBP (<4 wks' duration) AND sciatica (no red flags)6, 63, 101	Radiographs not initially indicated [B]	The natural course of acute sciatica caused by lumbar disc herniation (LDH) is benign as most patients improve during the first 4 wk,157 whereas 5%-25% are recurrent or persistent.158, 159
The first clinical clue to neurologic impairment usually is a history of sciatica: sharp pain radiating down the posterior or lateral aspect of the leg, often associated with numbness or paresthesia.		Patient S&S should not increase while in the premanipulative side posture, in which case SMT should not be attempted. Treatment approach should be adapted to further reduce complication risks.160, 161 Ongoing clinical assessment is necessary each visit to detect any early signs of CES.162, 163—(see red flags for details).
Specific clinical diagnoses:
Common causes of sciatica	Radiographs not initially indicated [B]	The natural course of acute sciatica caused by LDH is favorable.157 A trial of conservative care may first be attempted.171, 172 SMT appears to be a safe & effective treatment for nonprogressive S&S of lumbar disc protrusion, especially when compared to common treatments for LDH, such as NSAIDs and surgery.160, 161, 173, 174, 175, 176, 177, 178, 179, 180
Historical and physical findings are the key factors in assessing neurologic compromise.99	Unless patient age >50 or has progressive neurologic deficits
(A) Suspected LDH44, 163, 164, 165, 166, 167, 168, 169, 170:
• Symptomatic LDH represents 4%-5% of causes of LBP	LDH cannot be seen on conventional radiography.	It is estimated only 2% of all patients who have LBP will undergo surgery for disc herniation, representing 5%-10% of all cases of LDH.166, 176
• Risk factors for LDH include: men (1.6 times more likely), middle-aged (35-54 yoa), repetitive heavy lifting, current smoking, obesity (high BMI), and type of occupation.
• Predominantly leg pain, typically involving the foot	Special investigations not initially indicated [C]	MRI within the first 4-6 wk of suspected LDH is necessary only if there is progressive neurologic deficit or intolerable pain levels despite conservative care and surgical referral is planned.99 Disc abnormalities may be classified on MRI according to the following:
• >95% of clinically important LDH involve the L5 or S1 nerve root.	(see Suspected causes of sciatica for details)
• Straight leg raise is sensitive (0.8) but nonspecific (0.5);
• Crossed SLR is highly specific (0.8) but not sensitive (0.3)		Modic classification181:
		4A—herniated disc protrusion with an intact annulus;
• Look for lower limb sensory, motor, and reflex deficits		4B—extrusion with rupture of either the annulus or the posterior longitudinal ligament, or both (extrusion appears to be rare in asymptomatic adults);
See Appendix C(3) for a detailed list of clinical criteria for LDH.		4C—rupture of the annulus and the posterior longitudinal ligament with sequestration of a disc fragment in the spinal canal.
(B) Suspected degenerative spondylolithesis/lateral stenosis	Radiographs indicatedif patient age >50 or has progressive neurologic deficits: PA (or AP), lateral lumbar views [GPP]	If clinical signs suggest instability: please see special investigations in: Re-evaluation of LBP for critical exclusionary diagnoses.
• Back pain with or without leg pain
• Increase pain with activity		• A trial of conservative care may first be attempted
• S&S with or without neurologic deficit
	Special investigations not initially indicated [C] (see Suspected causes of sciatica for details)
(C) Suspected lumbar degenerative spinal stenosis (3% of all LBP)99, 182, 183:	Radiographs indicatedif patient age >50 or has progressive neurologic deficits): PA (or AP), lateral lumbar views [C]	Conventional radiography is of limited value in assessing spinal stenosis. As many as 20% of asymptomatic adults >60 yoa have imaging evidence of spinal stenosis and the prevalence of symptomatic stenosis is unknown.44, 99 Spinal stenosis may be caused by bone (facet hypertrophy, osteophytes, etc), soft tissue (bulging disc or thickened ligamenta flava, etc), or both.
• MC >65 yoa (sensitivity of 0.7; specificity of 0.69)
• Neurogenic claudication: severity of back and leg pain commonly increase with ambulation/standing/walking downhill and improve while seated (flexed spine). Absence of pain when seated, rather than improved pain, has low sensitivity (0.46) but is very specific (0.93);	Special investigations not initially indicated [C]	• A trial of conservative care may be attempted first.
	(see Suspected causes of sciatica for details)
• Variable neurologic deficit (numbness, weakness)
Suspected causes of sciatica:	Special investigations not initially indicated6, 166, 185 [C]	Comanagement or specialist referral recommended even if conventional radiographs are unremarkable:
(A) Lumbar disc herniation
(B) Degenerative spondylolithesis/lateral stenosis		1. After failed conservative therapy (4-6 wk)
(C) Lumbar degenerative spinal stenosis		2. For preoperative planning;
Results from specialized imaging should always be interpreted in light of the clinical findings. Inappropriate utilization of these highly sensitive examinations will produce false-positive results which may result in labeling of patients and contributing to an unfavorable prognosis.99, 101, 184		3. If neurologic status is deteriorating (progressive deficit, disabling leg pain)186, 187;
		• New disc extrusion and nerve root impingement may be the most important findings on MRI135, 188
		• Substituting rapid MRI for radiographic evaluations in the primary care setting may offer little additional benefit to patients, and it may increase the cost of care because of the increased number of spine surgeries that patients are likely to undergo.134, 188, 189
		• MRI sensitivity (0.6-1.0) & specificity (0.72-0.99) for LDH is slightly higher than those for CT (0.62-0.9 & 0.7-0.87) but very similar for the diagnosis of spinal stenosis (0.9 & 0.72-0.99)44
Adult patient re-evaluation in the absence of expected treatment response or worsening after 4 to 6 wk	Radiographs indicated [B]	Probability of encountering disease requiring specialized therapy in patients with LBP using conventional radiography is <0.2 in 100 and the probability of tumors or infection would be <1 in 1000.43, 196, 197
	PA (or AP), lateral lumbar views
Should patient fail to improve as expected or marginally improve within 4-6 wk of initial evaluation, the clinician must review history and physical findings and request appropriate diagnostic imaging studies.42, 44, 99, 101, 108, 109, 189, 190, 191	Additional views not routinely indicated [C]
	a. Lateral lumbosacral spot	a. If poor visualization of lumbosacral junction on lateral view
Adaptation of the plan of management partly relies on the ability to predict patient disability status or long-term return to work status.191, 192, 193, 194, 195 Patient perception of the likelihood of returning to his/her usual activities should be measured after 4 wk of disability or at the time of first consultation if the patient has a history of persistent spinal pain with prolonged disability. Validated questionnaires are available to help clinicians.101	b. Oblique	b. Rarely adds clinical information & doubles radiation exposure to patient.108 Sometimes used to confirm presence of spondylolysis suspected from the AP & lateral films (also for suggestion of malignancy, fracture, etc).
	c. Lateral flexion films may be indicated in scoliosis evaluation	c. Low reliability of lateral flexion film for biomechanical assessment.198 Lateral bending films useful for scoliosis evaluation (see Scoliosis section).
	Special investigations [C]	Comanagement or specialist referral recommended even if conventional radiographs are unremarkable AND anyone of the following:
		1. In presence of a potentially serious pathology as suggested by the patient history, examination and/or radiograph;
		2. After failed conservative therapy (4-6 wk),
		3. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain);
		4. If clinical signs suggest instability. Presumed instability is loosely defined as >10° of angulation or 4 mm of vertebral translation on flexion and extension lateral radiographs. However, diagnostic criteria, natural history, and surgical indications remain controversial.44
		5. For preoperative planning;
		While MRI is excellent for identifying tumor, infection, and nerve compression, it can be overly sensitive with regard to degenerative disease findings and frequently displays pathology that is not responsible for the patient's symptoms.199
		Negative findings (MRI/CT /NM) may be helpful. Structural variables on both MRI and discography have a weak association with back pain episodes and no association with disability or future care.188, 200
		See Carragee and Hannibal (2004)199 and Saal (2002)201 for a review of diagnostic testing in chronic LBP.
Adults with complicated (ie, “red flag”) LBP & indicators of contraindication to SMT (relative/absolute):	Radiographs indicated [B]	**Risks of having a serious pathology may be higher before the age of 20 or over the age of 55. Particular attention to indicators of possible underlying pathology should be given for patients in these age categories.6, 114, 208
	PA (or AP), lateral lumbar views.
Presence of the following indicator(s) should alert the clinician to possible underlying pathology.38, 42, 44, 63, 99, 112, 114, 167, 185, 197	Main purpose of lumbar spine radiographs is to exclude LBP caused by: malignancies (sensitivity of 0.6, specificity of 0.95-0.99); infective spondylitis (sensitivity of 0.82, specificity of 0.57); inflammatory SpA (low sensitivity for AS [0.25-0.45], but highly specific); fractures; and instability (sensitivity of 0.51-0.99, specificity of 0.68-0.99). High false-positive and false-negative rates are reported when assessing segmental instability by radiography99	The major diagnostic task is to distinguish the vast majority of uncomplicated LBP from the 5% with serious underlying diseases or neurologic impairments.44
N.B. Presence of a red flag alone may not necessarily indicate the need for radiology.		Probability of encountering disease requiring specialized therapy in patients with LBP using radiographs is <0.2 in 100 and the probability of tumors or infection would be <1 in 1000.43, 121, 185
• Patient <age 20 and >age 50, particularly with S&S suggesting systemic disease**		Normal radiographs may falsely reassure clinicians as important causes of LBP are not easily identified with conventional radiographs (ie, not sufficiently sensitive)116
Other authors recommend waiting 7 wk in untreated 1st episode of LBP and age over 65 as criteria for radiography203
• Absence of expected treatment response or worsening after 4-6 wk
• Significant activity restriction >4 wk
• Nonmechanical pain (unrelenting pain at rest, constant or progressive S&S)
• Suspected inflammatory—spondyloarthropathies (SpA)(0.3% of all LBP): chronic LBP and asymmetric peripheral arthritis, predominantly of the lower limbs, are the leading symptoms for SpA. Features of inflammatory back pain include significant morning stiffness (>1 h); pain duration ≥3 mo; persisting motion restriction; gradual onset ≤age 40; peripheral joint involvement; UTI, urethral discharge, iritis, skin rash. SI stress tests poorly reproducible.	Additional views [C]	Additional views may be considered in the presence of inflammatory spondyloarthropathy symptoms, although SI joints usually adequately demonstrated on AP lumbar spine.
	Spot AP or PA angled lumbosacral, oblique SI views	The modified New York criteria for AS diagnosis require the presence of radiographic sacroiliitis to classify the patient as having AS. However, plain radiographic abnormalities of the SI joints are a relatively late feature of disease.213 New approaches for an earlier diagnosis of axial and peripheral SpA have been proposed recently. A combination of clinical, laboratory, and imaging parameters is usually necessary.212
AS is regarded as the most severe subgroup.
A new set of criteria for inflammatory back pain has been proposed which gives a sensitivity of 70% and specificity of 81% for the diagnosis of ankylosing spondylitis (AS)204:
Individual features of inflammatory back pain (IBP)	Special investigations in complicated LBP [B]	Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable:
• Morning stiffness for >30 min	Even if conventional radiographs are negative:	1. In the presence of a potentially serious pathology as suggested by the patient history, examination, and/or radiograph;
• Improvement of back pain with exercise but not with rest
• Awakening in the second half of the night due to back pain		2. In the absence of clinical improvement after 4-6 wk of therapy;
• Alternating buttock pain		3. If function does not improve or deteriorates;
Presence of 2 features—positive likelihood ratio for AS is 3.7		4. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain);
Presence of 3 features—positive likelihood ratio for AS is 12.4		5. With painful or progressive structural deformity
** None of the IBP parameters alone are sufficient for a diagnosis of AS.205		6. For unstable segment (spondylolisthesis or pathological process);
		7. When patient has persisting S&S;
• Suspected compression fracture (±4% of all LBP): Recent significant trauma (any age), Hx of repetitive stress of sufficient severity; Hx of high-risk osteoporosis:		8. In complication from treatment (possible fracture, new/progressive neurologic deficit, considerable pain, or disability, etc)
• Severe onset of pain with minor trauma in patients ≥age 50 (higher risk >age 70 with a likelihood ratio of 5.5), Hx of prolonged corticosteroids intake (>7.5 mg/d >3 mo) has a likelihood ratio of 12; structural deformity99, 206—a complaint of LBP in persons at risk may require both thoracic and lumbar radiographs.207See Osteoporotic Vertebral Collapse in the Thoracic Spine section for details.	a. MRI is generally the preferred investigation.	MRI or CT useful in the detection of bone and soft tissue structures. The choice of study depends on the current clinical question, availability of equipment, and costs.214
	b. CT may be needed for bony details. (especially multiplanar reformatted images)
• Suspected neoplasia(0.7% of all LBP): Considerable LBP starting ≥age 50, Hx of cancer/carcinoma in the last 15 y (likelihood ratio of >15), unexplained weight loss (>4.5 kg over 6 mo), failure of conservative care (4 wk). A combination of the above 4 features has a 100% sensitivity for cancer. Other features include no relief with bed rest (sensitivity of 0.90, but low specificity); ESR >50 mm/h, sciatica, systemically unwell; lymphadenopathy; dermopathy (melanoma).6, 99, 203	(especially multiplanar reformatted images)	• Suspected cancer: MRI is especially useful for marrow-based lesions. Sensitivity is highest for MRI (0.83-0.93) and radionuclide scanning (0.75-0.98); specificity was highest for MRI (0.9-0.97) and radiography (0.95-0.99).44
		• Suspected infection: MRI is more accurate than radiography and bone scan (sensitivity of 0.96 & specificity of 0.92) for suspected osteomyelitis, spondylodiscitis, septic disc, paraspinous abscess, epidural abscess.
Suspected infection(0.01% of all LBP): age >50, documented fever (>38.3°C/101°F) for >3 wk and no established diagnosis despite appropriate investigation for 1 week (specificity of 98% with likelihood ratio of ±25, but sensitivity of 50%); elevated ESR >20 mm/h; IV drug abuse; immunosuppression (HIV, transplant patients); UTI, skin infection, diabetes mellitus; alcohol abuse; vertebral tenderness with signs of underlying infection; direct implantation (nail, acupuncture); Hx of spine surgery208, 209		• Suspected acute inflammation in sacroiliac joints and spine: Contrast-enhanced MRI is both sensitive & specific for active sacroiliitis (0.99 & >0.95).99, 212, 213 Although more sensitive than conventional radiography, CT is not deemed useful to detect active joint inflammation. NM has had mixed results for both sensitivity & specificity.99
	c. NM	c. NM: commonly used for detection of possible destructive osseous lesions, skeletal metastatic diseases (known primary tumor-skeletal survey), spinal infection, stress fracture of the pars interarticularis and acute inflammatory sacroiliitis. Bone scan, such as gallium-67 may detect spondylodiscitis as early as 48 h after inoculation.6, 209, 215
•Suspected failed surgical fusion
•Progressive or painful structural deformity(<1% of all LBP): scoliosis, kyphoscoliosis, transitional segments210 & LDH
•Abnormal laboratory examination and positive S&S: ESR >50 mm/h; Rh factor; HLAB27; reduced hematocrit; elevated white blood count; ALP; PSA; serum calcium for example.211, 212		Abnormal laboratory examination: R/O marrow-based malignancies, including metastasis & primary marrow-based pathology (e.g. myeloma); serum gammopathy and possible infection & arthritis
•Suspected cauda equina syndrome (CES)(0.04% of all LBP)	Emergency referral without imaging	It is vital to recognize the S&S of CES as this is a surgical emergency.
The classic syndrome includes LBP, bilateral or unilateral sciatica, saddle anesthesia, motor weakness of the lower extremities that may progress to paraplegia, urinary retention, or bowel and bladder incontinence.	If clinical findings are equivocal, medical referral and specialized imaging recommended [B]	Although several etiologies can cause CES (spinal tumors, epidural abscess, etc), it usually arises from a massive midline posterior disc herniation (represents 1%-2% of all operated LDH). Narrowing of the spinal canal (congenital or degenerative stenosis) is a likely predisposition to CES. To facilitate the early detection of rare but serious complications associated with disc herniations, inquiry should also be made regularly during visits with regard to saddle anesthesia or any changes in bladder or bowel functions which may suggest the development of cauda equina syndrome. The risk of SMT causing a clinically worsened disc herniation or CES in a patient presenting with an LDH has been estimated to be <1 in 3.7 million manipulations, but others have proposed figures as low as 1 in 100 million SMT. The association in some reported cases has been described as temporal rather than causal.44, 149, 161, 182, 220, 221, 222, 223
The most consistent finding of a CES is urinary retention (sensitivity of 0.90, specificity of 0.95, likelihood ratio of 18). Unilateral or bilateral sciatica, sensory and motor deficits, and abnormal SLR are common, all have a sensitivity of >0.80. The most common sensory deficit occurs over the buttocks, posterior-superior thighs, and perineal regions (saddle anesthesia), with a sensitivity of ≈0.75. The saddle anesthesia is characterized by altered sensation in the distribution of sacral dermatomes (S2-S5). Anal sphincter tone is diminished in 60%-80% of cases. Anal wink reflex is absent in the majority of cases.44, 99, 112, 167, 182, 215, 216, 217, 218, 219	Special investigations [C]
	(see previous page for details)
•Suspected abdominal aortic aneurysm (AAA)	Referral or special investigations [B]	Recommendation for AAAs (symptomatic or not): Rate of growth of small AAAs is relatively predictable.236 The sensitivity of ultrasound (US) scanning for AAA is 95%, and the specificity approaches 100%; the examination is safe and reliable.233
Uncommon before age 50, AAA prevalence increases with age (3% in <65 yoa & >8% in >65). About 25% mimic musculoskeletal LBP pain and 75% may be silent (incidental findings on physical examination and/or radiography) until rupture or size draws attention.	In nondissecting AAAs, medical referral and US recommended even if conventional radiographs are negative (calcification, the most reliable radiological sign, is seen in only 50% of AAA)229, 235
		Management42, 226, 227, 230, 231, 232, 233, 236, 237, 238, 239, 240:
Early S&S may include abdominal pain, backache, and feeling of fullness or abdominal pulsation. Patient characteristics which may raise clinical suspicion of AAA include older age, obese males, smokers or with a significant Hx of smoking, Hx of myocardial infarction, claudication, having a first relative with AAA, and presence of hypertension.224, 225, 226, 227		• Ultrasound screening: Recommended in males 65 to 75 yoa (up to 80 in some studies); in females 60 to 85 yoa with cardiovascular risk factors; and in males and females >50 with a first-degree relative with AAA.
		• Ultrasound monitoring: Yearly screening recommended if AAA between 3.0 and 4.4 cm (possibly every 6 mo if AAA is between 4.0 and 4.4 cm).
Physical exam including abdominal inspection, auscultation, percussion, & palpation; and peripheral vascular exam. However, clinical exam cannot be relied upon to exclude AAA, especially in smaller AAAs & if abdominal girth >100 cm.226, 228		• Referral to a vascular specialist: Recommended if AAA >4.4 cm (measures based on US or CT).
		○ Annual rupture rate of small AAA (<4.5 cm) is 1%-3%.
		•Surgical intervention: Recommended if AAA ≥5.5 cm or growth of >0.6 cm to 0.8 cm/y.
Atherosclerosis accounts for 90%-95% of AAA, with the remainder predominantly the inflammatory type. AAAs may be defined as a permanent focal dilation of 1.5 times its normal diameter or an expansion of the aorta measuring >3.8 cm on the lateral view measured between the most distant calcified borders, usually between the renal artery (L2) and the iliac bifurcation (L4). Common iliac arteries are often involved.229		○ Annual rupture rate and death from AAA >5.5 cm is 16%, compared with perioperative mortality of 2%-6% (or lower) for open repair.231
		•SMT: Relative risk of high velocity, low amplitude (HVLA) lumbar spine manipulation currently undetermined.191 However, considering current recommendations on AAA management, it appears reasonable to propose the following with regard to SMT:
		○ Small AAA (3.8-4.0 cm): may be regarded as relative contraindication for SMT. Consider expansion risk factors and the need for yearly ultrasound monitoring.
Risk factors225, 230, 231, 232, 233, 234:		○ AAA between 4.0 and 4.5 cm: consider the need for ultrasound monitoring every 6 mo. May be regarded as absolute contraindication for SMT in the presence of expansion/rupture risk factors.
1. Abdominal aortic aneurysms (AAA): Male sex, cigarette smoking, a first-degree relative with AAA, hypercholesterolemia, and connective-tissue diseases (eg, Marfan, Ehlers-Danlos).		○ Larger AAAs ( ≥ 4.5 cm) may be regarded as absolute contraindication for SMT. Refer patient to a vascular specialist.
2. Aneurysm expansion risk factors: Advanced age (>70 y), cardiac/renal transplant, previous stroke, severe cardiac disease, tobacco use.
3. Risk factors for aneurysm rupture: Increases with age (age >60) and aneurysm size (diameter >5.5cm); current smoking and high mean blood pressure.		As many as 1 in 3 AAAs eventually rupture if left untreated. Most AAA deaths occur in men 65 yoa and older. Rupture of AAA is associated with a risk of death approaching 80%.226, 233, 236
		AAAs confer a risk of spontaneous rupture and death, which is related to the diameter of the aneurysm: a risk of rupture of 0.5%, 1%, 11%, and 26% per year has been associated with a diameter of <4 cm, 4.0-4.9 cm, 5.0-5.9 cm, 6.0-6.9 cm, respectively.230
•Truncal symptoms attributed to presence or worsening of aortic aneurysms including dissection/rupture/occlusion or traumatic aortic injury):	Emergency referral without imaging [GPP]	Evaluation of acute aortic conditions including dissection/rupture/occlusion or traumatic aortic injury224, 243:
Cardiovascular shock and/or syncope, severe, tearing/ripping midabdominal sensation, back, groin, or testicular pain; pressure upon lumbar spine causing excruciating boring pain in the abdomen or back; hypotension; absence of distal lower limb pulses.224, 225, 226, 241, 242	It is vital to recognize the S&S of dissecting AAA as this is a surgical emergency.	• Because of its speed and proximity to emergency department, CT, helical CT, and CTA are imaging of choice to determine the presence and size of the aneurysms, as well as to R/O a ruptured AAA in a clinically stable patient.
		• MRI with MRA also plays an important role, particularly when patient is unable to receive intravenous contrast medium.
At least 25% of AAAs >5 cm will rupture within 5 y, and those <5 cm have a rupture rate of about 5%.229		• Conventional angiography is used as a secondary diagnostic tool to clarify equivocal findings.
		• US is helpful when CT is not readily available or patient is too unstable to undergo MRI

Table 4. Nontraumatic thoracic spine disorders

Patient presentation	Recommendations	Comments
Adult patient with uncomplicated* acute (<4 wk duration) thoracic spine pain6, 38, 42, 63	Radiographs not routinely indicated [B]	Degenerative changes are generally present in the middle-age adult. Radiographs are rarely useful in the absence of neurologic signs or red flags. However, consider osteoporotic vertebral collapse or other forms of destructive bone processes in the presence of acute sudden onset pain, especially in the elderly.6, 42, 63
AND
Adult patient with uncomplicated* subacute (4-12 wk duration) or persistent (>12 wk duration) thoracic spine pain and no previous treatment trial.6, 38, 42, 63
* Uncomplicated definition: nontraumatic thoracic pain without neurologic deficits or indicators of potentially serious pathologies)—(see red flag list for details).	Special investigations not indicated [B]
History and physical examination should exclude causes of thoracic referred pain from nonmusculoskeletal origin (see nontraumatic chest wall pain).
Adult patient: reevaluation in the absence of expected treatment response or worsening after 4 wk.38, 42	Radiographs indicated [B]
	AP, lateral thoracic spine views
Should patient fail to improve as expected or marginally improve within 4 wk of initial evaluation, the clinician must review history and physical findings and request appropriate diagnostic imaging studies.	Additional views:	Symptoms located in cervicothoracic junction or if this area is not well visualized on lateral view.
	Swimmer's view
	Special investigations [C]	Comanagement or specialist referral recommended
	• Consider NM if conventional radiographs are unremarkable.	•MRI or CT scan should be considered:
		1. In suspected pathology as seen on conventional radiography
		2. After failed conservative therapy (4 wk),
		3. If neurologic status is deteriorating (progressive deficit, disabling leg pain);
		Negative findings (MRI/CT /NM) may be reassuring to patients.
Adult patient with nontraumatic chest wall pain.	Emergency referral without imaging in life-threatening conditions [GPP]	Nonmusculoskeletal causes of chest wall pain include disorders of the myocardium and pericardium (infarction, angina pectoris, myocarditis, rheumatic carditis, & pericarditis) of the pleura and lung (pleurisy, empyema, pneumothorax, pulmonary infarction, pneumonia, and neoplasm), disorders of the central structures (mediastinitis, sternal thyroiditis, Hodgkin's disease, oesophagitis, hiatal hernia, aortic aneurysms with or without dissection), intra-abdominal (hepatobiliary), retroperitoneal disorders (pyelonephritis and tumors), and skin disorders such as herpes zoster.244
History and physical exam first need to rule out life-threatening conditions including pathologies of the heart, lungs, and large vessels.
	Special investigations [C]	• CT and MRI245
Musculoskeletal chest wall pain	Radiographs not routinely indicated [D]	Musculoskeletal causes include disorders of the rib, cartilage, and sternum (spondyloarthropathy, costovertebral syndrome, osteochondritis, Tietze's syndrome, slipping rib syndrome); muscles (intercostals, diaphragm, serratus anterior, and pectoral); and intercostal neuralgia.244, 246, 247, 248
Musculoskeletal causes of chest wall pain are a diagnosis of exclusion. Causes are generally identified upon physical examination by reproducing patient complaint (observe for skin lesions, limited and painful movements, positive orthopedic tests such as Schepelmann's sign, and tenderness on palpation).23
Adult patient with complicated (i.e., “red flag”) thoracic pain & indicators of contraindication to SMT (relative/absolute):	Radiographs indicated [B]	Normal radiographs may falsely reassure clinicians as important causes of back pain are not easily identified with conventional radiographs (ie, not sensitive).77
	AP, lateral thoracic spine views.
Presence of any of the following indicators should alert the clinician to possible underlying pathology.8, 38, 44, 63, 112, 114, 167, 185, 197, 203	Main purpose of thoracic spine radiograph is to exclude back pain caused by inflammatory spondyloarthropathy, fracture, malignancy, and infection.
N.B. Presence of a red flag alone may not necessarily indicate the need for radiography.
• Patient <age 20 and >age 50, particularly with S&S suggesting systemic disease**
• No response to care after 4 wk.	Additional views: Spot views. In suspected inflammatory spondyloarthropathy, consider spot angulated AP or PA lumbosacral or oblique SI views.	Additional views may be considered in the presence of inflammatory spondyloarthropathy symptoms, although SI joints usually adequately demonstrated on AP/PA lumbar spine.
•Significant activity restriction >4 wk
•Non mechanical pain (unrelenting pain at rest, constant or progressive S&S)
•Persistent localized pain (>4 wk)
•Progressive or painful structural deformity: scoliosis, kyphoscoliosis210	Special investigations [B]	Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable:
•Symptoms associated with neurologic signs in the lower extremities	* Even if conventional radiographs are negative:
•Suspected inflammatory spondyloarthropathy: significant morning stiffness (>1 h); pain duration ≥3 mo; persisting motion restriction; gradual onset ≤age 40; peripheral joint involvement; UTI, urethral discharge, iritis, skin rash.		1. In the presence of a potentially serious pathology as suggested by the history, examination, and/or radiographs;
	MRI is generally the preferred investigation.	2. In the absence of clinical improvement after 4 wk of therapy;
	CT may be needed for bony details.	3. Function does not improve or deteriorates;
•Suspected neoplasia: considerable pain starting ≥age 50; Hx of cancer/carcinoma (in the last 15 y) and/or unexplained weight loss (>10 lb over 4 wk); or failure of conservative care (4 wk); systemically unwell; lymphadenopathy; dermopathy (melanoma).6, 203		4. If neurologic status is deteriorating (progressive deficit, disabling pain);
	NM commonly used for detection of possible destructive osseous lesions, metastatic diseases, infection, or inflammatory processes6, 215	5. Painful or progressive structural deformity; unstable segment (scoliosis, kyphoscoliosis, pathological process);
		6. Patient has persisting S&S;
•Suspected infection: documented fever (>38.3°C/101°F) for >3 wk and no established diagnosis despite appropriate investigation for 1 week; elevated ESR >20 mm/h; IV drug abuse; immunosuppression (HIV, transplant patients); UTI, skin infection, diabetes mellitus; alcohol abuse; vertebral tenderness with underlying infection; direct implantation (nail, acupuncture); Hx of spine surgery.208, 209		7. Complication from treatment (possible fracture, new/progressive neurologic deficit, considerable pain or disability, etc)
	a. MRI or CT	a. MRI or CT: Suspected primary bone tumor
	b. NM	b. NM: Known primary tumor, skeletal metastases, inflammatory arthritis, or spinal infection
	c. MRI especially for marrow-based lesion and neurologic disorders. MRI (Gadolinium) may increase specificity and detect spondylodiscitis as early as 48 h after inoculation209	c. MRI: More accurate than radiography and bone scan (sensitivity of 0.96 & specificity of 0.92) for suspected osteomyelitis, spondylodiscitis, septic disc, paraspinal abscess, epidural abscess; in suspected myelopathy/long tract signs, spinal cord tumors, inflammation, infection, infarction, etc
•Suspected failed surgical fusion
•Abnormal laboratory examination and positive S&S: ESR >50 mm/h; RA factor; HLA-B27; BCB; ALP; PSA; serum calcium, for example.211, 212		Abnormal laboratory examination: R/O marrow–based malignancies, including metastasis & primary marrow-based pathology (e.g. myeloma); serum gammopathy and possible infection & arthritis
•Suspected acute thoracic aortic aneurysms dissection/rupture/occlusion or traumatic aortic injury: Severe, tearing/ripping chest sensation, back pain; hypotension; absent distal pulse. High index of suspicion in connective tissue disorders and diseases with genetic predisposition for ascending aortic aneurysms such as Marfan or Ehlers-Danlos syndrome.249, 250	Emergency referral without imaging [GPP]
• In recent significant trauma (any age)	See Blunt Trauma/Acute Injuries section.
• Suspected compression fracture(±4% of all back pain)63: specific pathologies and severe trauma account for only 3% and 14%, respectively, of all clinically evident vertebral fractures. The majority in North America are related to osteoporosis.	Radiographs indicated [B]	Although compression fractures can be visualized on conventional radiography, a clear definition for identification of these vertebral “deformities” is still lacking (absence of a true gold standard).253 Furthermore, radiography may be insensitive for revealing osteoporotic fractures254, 276, 277 and there is no consistent relationship between back pain and changes in vertebral shape on radiographs.253
	AP, lateral thoracic
• S&S: Severe onset of pain (with or without appearance of spinal deformity) after trauma in older patients. Patients with thoracic or lumbar spine osteoporotic fractures report pain mainly in the lumbosacro-gluteal area. Look for Hx of repetitive stress of sufficient severity or Hx of high-risk osteoporosis.107, 251	Additional views [D]	Vertebral compression fractures represent a serious public health problem by virtue of the associated disability and cost. Physical function, such as cooking meals, shopping, bending, lifting, and descending stairs, self-esteem, body image, and mood are negatively affected by vertebral fractures.253
• Prevalence of asymptomatic vertebral fracture significantly increases with age and glucocorticoid use in postmenopausal women.252	Supine cross-table lateral view in suspected osteoporotic vertebral pseudoarthrosis (VPA)275
•Only about one third of all affected women in the community have the severe vertebral deformities most likely to produce chronic symptoms including height loss, kyphosis and postural changes, and persistent pain interfering with daily activities.253		Age-adjusted incidence rates for clinically evident vertebral fractures in women are twice those in men, partly due to their greater liability to falls.217 Lifetime risk of clinically evident osteoporotic fracture among postmenopausal North American white women >age 50 has been estimated at 40% (vertebrae 15.5%; wrist 16%; hip 17.5%)254, 278 and at 22% in men.279 The incidence of osteoporotic fractures is increasing and the spectrum of fractures is changing. Fractures of the proximal femur, proximal humerus, pelvic, and many fractures around the knee should also be considered osteoporotic fractures.280
Risk factors for additional vertebral fractures253:
1. History of a previous fracture (4-fold among postmenopausal white women);
2. Greater age;
3. Lower femoral neck bone mass density (BMD);
4. Shorter height.		Vertebral pseudarthrosis, a rare posttraumatic vertebral delayed collapse resulting in bone ischemia, may cause vertebral instability: look for an intravertebral cleft containing gas. These patients tend to have ongoing back pain despite conservative care, severe pain during motion.275
	Special investigations [D]	In suspected fracture:
		• Consider MRI or CT if initial radiographs are positive for fracture, equivocal, in the presence of complex lesions, for suspected ligamentous instability or neural injuries. Small fractures can also go undetected on CT scans.281
		•NM or MRI may be used to determine if fracture is recent or not, as it may impact on treatment. (NM has a 72-hour delay in elderly patients.)63
Suspected osteoporosis	Radiographs are unreliable for assessment of bone mass changes before at least a 30%-50% loss.229 [B]	There is a concern that spinal manipulation (HVLA)282, 283 and spinal mobilization281, 284 could cause fractures in individuals with osteoporosis. Spinal manipulation is generally regarded as a relative contraindication in osteoporotic patients.239, 285, 286, 287 However, in vitro studies and some case reports suggest forces generated in some manual techniques may be lower than the load required for vertebral failure (fracture) in this population.273, 281 A number of control strategies are available that allow treatment to be applied safely and effectively.288
Osteoporosis predisposing risk factors42, 206, 252, 254, 255, 256, 257, 258, 259, 260, 261, 262, 263, 264, 265:
Include nonmodifiable (age, sex, and period of amenorrhea as in anorexia nervosa and female athlete) and modifiable factors (dietary calcium intake, low BMI, smoking, inactivity, parental Hx of fracture, and high alcohol intake). See Appendix C(4) for a list of other important risk factors.
Osteoporosis clinical decision rules:		When DXA results are unavailable, use clinical decision rules to estimate the presence of osteoporosis. See Appendix C(4) for details.
Several highly sensitive clinical decision rules based on weighted indices and major osteoporosis risk factors have been developed to identify women with low bone mineral density in need of DXA.260, 266, 267, 268, 269, 270, 271
	Special investigations [B]	In suspected osteoporosis
1. In healthy peri- and early postmenopausal women (45-64 yoa), consider using the OST score (Osteoporosis Self Assessment Tool). OST score considers only 2 variables: (weight in kg − age)/5. The cut-off for a positive test is <2, indicating this woman should be referred for DXA.	If clinical decision rules are positive	• Bone densitometry or dual-energy x-ray absorptiometry (DXA) recommended in the presence of osteoporotic fractures or with positive osteoporosis clinical decision rules (elevated risk of osteoporosis). DXA is considered the gold standard for bone mass evaluation in the diagnosis and treatment of osteoporosis (DXA >2.5 SD). In postmenopausal females, each SD decrease in lumbar spine BMD increases the risk of any fractures by 1.5-fold and of new vertebral fracture by 2.3-fold. Lateral DXA also accurate for thoracic spine evaluation.253, 284
2. In higher-risk patients, use either the ORAI (Osteoporosis Risk Assessment Instrument), the more complex calculation of SCORE (Simple Calculation of Osteoporosis by Estimation) or the AMMED as all 3 were found to be highly sensitive clinical tools. See Appendix C(4) for details.		Of interest:
a. ORAI considers age, weight and estrogen use;		• Advanced atherosclerosis of the abdominal aorta is associated with lower bone mass density, accelerated bone loss, and increase risk of incident fractures at the proximal femur. Findings in the lumbar spine have been inconsistent.289
b. SCORE considers 6 variables (race, presence of RA, history of fracture, age, estrogen, weight [in pounds]);
c. AMMED considers 5 variables (age, years after menopause, age at menarche, BMI).
Physical examination and osteoporosis:		Physical examination: Vertebral Fracture Index (rising from a chair & bending forward) has a lower predictive value with a lower sensitivity and specificity than axial bone mineral density measured by DXA in assessing vertebral fracture risk.272
When likelihood of significant osteoporosis is low according to clinical decision rules, examination may include asking patient to rise from a chair and to bend forward at the trunk as vertebral fracture risk associated with loading activities increases risk by about 8- and 10-fold respectively compared with upright standing.272
It should be noted, however, that vertebral tolerance to PA thoracic compressive forces is much less than axial loading.273 Simple physical tests that could assist in determining ability to tolerate thoracic spine SMT would be useful.
Quality of life among adults with vertebral osteoporosis may be measured using a self-administered questionnaire such as the one from the European Foundation for Osteoporosis (QUALEFFO).274
Adult patient with nonpainful and nonprogressive scoliosis	Radiographs not routinely indicated [C]	In a skeletally mature patient, scoliosis is defined as a spinal deformity with a Cobb angle of >10° in the coronal plane.292
The prevalence rate in healthy adults is >30% and may be as high as 68% in the elderly.290 Untreated adults with late-onset idiopathic scoliosis (LIS) are productive and functional at a high level at 50-year follow-up. Untreated LIS causes little physical impairment other than back pain (most only have minimal or moderate back pain) and cosmetic concerns.291 Patients with nonpainful and nonprogressive scoliosis are unlikely to benefit from repeat evaluation.
Adult patient with painful or progressive scoliosis	Radiographs indicated [B]	Full spine radiograph for scoliosis to determine other areas of implication
Some patients with known scoliosis may present with significant disability. Back pain is the most common clinical problem presenting as a multiform mosaic of symptoms. Constant & nonspecific back pain has a poor prognosis. Other S&S: Radicular pain & claudication when standing or walking (from nerve traction or compression), neurologic deficit may include sphincter dysfunction. Curve progression needs monitoring.292	Erect sectional radiographs (better detail) or standing full-length PA (14 × 36 in) and lateral sectionals	a. Cobb angle
		b. Nash-Moe method (pedicle rotation)
		NB. Consider ± 5° measurement error
	PA films* significantly reduce breast and thyroid dose. Effective doses to the digestive and respiratory systems are comparable, but are higher in the bone marrow compared to AP views.299, 300	Clinically relevant radiographic parameters in adult scoliosis including lateral vertebral listhesis, L3 and L4 endplate obliquity angles, increased lumbar lordosis and thoracolumbar kyphosis significantly correlated with pain,301 sagittal imbalance & significant coronal imbalance of >4 cm,302 lateral spondylolisthesis (lateral translation & vertebral rotation) may cause radicular pain syndrome.303
Clinical evaluation: Look for spinal deformity, uneven shoulder heights, limb length inequality, pelvic obliquity, hip pathology, and claudication. Neurologic exam includes nerve root tension signs, motor power, sensations, deep tendon reflexes, and pathological reflexes.293, 294, 295	Full spine radiographs not recommended for patients with an AP measurement >28 cm or for older patients due to poor film quality. Consider using sectional radiographic views instead.229	Types of lumbar scoliosis may be classified according to the lordosis and L3 obliquity. Self-reported pain & disability may increase with increasing scoliosis type (from I to III).304
1. Adam's forward bend test is sensitive to detect trunk asymmetry
2. Maximal lateral flexion into convexity to evaluate curve functional aspect.
3. Scoliometer (a trunk angle of 7° indicates a structural curve >20°.)	Additional views:
	a. Right and left lateral bending	a. Most commonly used to determine fusion levels. May help differentiate between structural and nonstructural curves and help assess primary from secondary scoliotic curves.
Spinal deformity has an important impact on the general health status of adults as measured by the Medical Outcomes Study Short-form 36 (SF-36) and the modified Scoliosis research Society Outcome instrument (SRS-22). The SRS-22 is a disease-specific instrument assessing pain, self-image, function, mental health, and satisfaction. It is a valid, reliable, and reproducible outcomes instrument for adult deformity.296, 297
		Adult degenerative scoliosis: pathomechanism includes a viscous cycle of asymmetric degeneration (disc & facet joints) leading to asymmetric loading, leading to asymmetric deformity which in turn triggers asymmetric degeneration and loading and enhancing curve progression.292
There are many causes of spinal deformity in the adult. They may be grouped as follows:	Follow-up evaluation [C]	Follow-up evaluation dictated by clinical progression. Long-term follow-up of adolescent idiopathic scoliosis has revealed little curve progression even 20 y after bracing (7.9°) or surgical treatment (3.5°). Degenerative disc changes are more common in both patient groups compared to a control group.305
(1) Primary degenerative scoliosis (mostly lumbar or thoracolumbar—triggered by disc degeneration).298
(2) Progressive idiopathic adolescent scoliosis of the thoracic, thoracolumbar, and/or lumbar spine.
(3) Secondary degenerative scoliosis	Repeat radiographs [B]	Repeat radiographs, advanced imaging, and specialist referral recommended292
(3a) Scoliosis after idiopathic, neuromuscular, or congenital scoliosis, or occurring in the context of pelvis obliquity, leg length discrepancy, hip pathology, or a lumbosacral transitional anomaly.		1. In the absence of clinical improvement; after 4 to 6 wk of therapy;
		2. If function does not improve or deteriorates;
(3b) Deformity secondary to metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritis and/or vertebral fractures.292		3. In the presence of persisting S&S or considerable pain;
		4. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain);
		5. With painful or progressive structural deformity (scoliosis, kyphoscoliosis);
		6. With suspected segmental instability (this is common in adult scoliosis and should be considered with all manual therapy intervention).
		7. With suspected pathological process;
		8. With new or progressive neurologic deficit including claudication, significant radiculopathy, or suspected syrinx;
		9. To plan surgical intervention.
	Special investigations [C]	• Spiral CT useful in rapid reconstruction of the spine.
		• MRI to evaluate the spinal cord and nerves.
		• Sequential discograms, facet blocks, epidural blocks

Table 5. Nontraumatic cervical spine disorders

Patient presentation		Comments
General background information	Standards of care dictate that careful history and physical examination be done routinely for all patients on the initial visit.	Neck pain on initial presentation is typically classified according to the duration of complaint and type of presentation: uncomplicated/nonspecific neck pain, with or without restriction of activity of daily living, presence of neurologic deficits or to some underlying pathology.
Most neck pain is not the result of serious disease.
Factors associated with neck pain include306:
•Headache
•Low back pain
•Poor psychological health	•Self-reported patient assessment to evaluate perceived pain, function, disability, and psychosocial status are recommended.
•History of whiplash injury	•The validity and utility of the clinical assessment (history and examination) in patients with neck pain without radiculopathy or red flags needs to be confimed.	Duration of complaint:
•Poorer general or self-rated health	•Diagnostic tests such as X-rays, CT or MRI scans are only required in a minority of cases when a thorough physical examination and patient history indicate further investigation is needed. Routine imaging is unlikely to increase understanding of causation.	•Acute neck pain: <4 wks' duration
•Possibly cigarette smoking		•Subacute neck pain: 4-12 wks' duration
		•Persistent/chronic neck pain: >12 wks' duration
•In patients presenting with head and/or neck pain, the physical examination should flow as a natural extension of the information obtained from the chief complaint, history, and system review. (see Honet and Ellenberg307 for a review of history & physical examination for neck pain).		Neck pain affects nearly two third (66.7%) of the adult population over their lifetime representing a significant and costly health problem in terms of care, suffering, and work absenteeism.315, 316, 317 Contrary to prior belief, most individuals with neck pain do not experience complete resolution of their symptoms and disability.
•In complaints of neck and arm pain, peripheral (weakness, dermatomal pattern, and loss of deep tendon reflexes) and central nervous system exam (clonus, Babinski, and pathological reflexes) should be an integral part of initial examination. Findings of long tract signs mandate further evaluation.		The age-standardized 6-month point prevalence is around 22% with nearly 40% having low-intensity and low-disability neck pain, 10% having high-intensity and low-disability neck pain and 4.6% (95% CI, 3.3-5.8) having disabling pain.316
•In headache complaints, vital signs (to R/O severe hypertension or fever) and testing of the cranial nerves (to R/O vascular events, space occupying lesions, etc) should be an integral part of initial examination. Significant positive findings mandate further evaluation.		The age and sex annual incidence of neck pain is 14.6% (95% CI, 11.3-17.9) and each year, 0.6% develop disabling neck pain. Annual course of neck pain is as follows: 36.3% resolve and 32.7% improve. Among neck pain sufferers, 33.3% report persistent problems, 9.9% get worst, and 22.8% recur.317
•In suspected connective tissue disorders, examination should also include inspection of the integument (skin elasticity, discoloration), the back (scoliosis), the thorax (deformity, abnormal respiratory pattern), and extremities (disproportion), auscultation of the heart (valvular defect) and abdominal aorta (bruit), abdominal palpation (organomegaly in fibromuscular dysplasia-kidney, aorta), and musculoskeletal examination including peripheral joint laxity using the 1998 Beighton criteria and examination of chronic joint and limb complaints.308		Between 22% and 25% of initial chiropractic visits are for neck-related complaints. Although most patients seeking chiropractic care experienced their symptoms for <3 wk (45%), over 20% had symptoms for >6 mo.41 In addition, 5%-6% of chiropractic patients consult for headache. Neck pain is slightly more common in females and increases with age, the mean age being in the early 40s.41, 100 Not surprisingly, these figures parallel the most common age range seeking consultation for chiropractic spinal manipulative therapy (61% of females; mean age of 42 years old).
Auscultation of the neck and the use of common premanipulation vascular screening tests (eg, Houles, George, etc) are of no diagnostic value. Functional vascular tests may themselves put patient at risk of a serious complication.308, 309, 310, 311, 312, 313, 314
Adult patient with acute uncomplicated* neck pain (<4 wks' duration)	Radiographs not routinely indicated [C]	The clinical value of conventional radiographs for nontraumatic acute neck pain without red flags or arm pain is not well established. Acute neck pain is generally due to conditions that cannot be seen on conventional radiographs.38, 42, 128 The clinical significance of the cervical spine curvature remains controversial.138, 155, 319, 320, 321, 322, 323
* Definition of “uncomplicated”: nontraumatic neck pain without underlying neurologic deficits or red flag (see red flags list for details).42, 63, 318
	Special investigations not indicated [C]	Consider cervical radiography, advanced imaging studies, and a second opinion in the absence of expected treatment response or worsening after 4 wk.38, 42
Adult patient with nontraumatic neck pain and radicular symptoms	Radiographs indicated [D/consensus]	Disc lesions cannot be visualized on radiographs. IVF narrowing by facet & uncinate process hypertrophy arevery often associated with radicular symptoms.334, 335, 336 Spinal stenosis (sagittal diameter <13 mm) may also be present, in which case special care should be taken if manual therapy is considered. Always examine the patient's lower extremities for upper motor neuron signs indicating cervical radiculo-myelopathy (Hoffman sign, lower limb hyper-reflexia, spasticity, Babinski, and/or Clonus).307, 335, 336
May be caused by HNP, spondylosis, and rarely by other pathological processes (tumor, abscess, etc).318	APOM, AP lower cervical, neutral lateral
(A) Suspected acute cervical disc herniation (CDH)42, 307, 324, 325, 326, 327, 328, 329, 330, 331, 332, 333:
•35-55 yoa
(B) Suspected acute cervical spondylotic radicular syndrome/lateral canal stenosis (LCS)307, 330, 331:		Clinical diagnosis of CDH possible in only 50%-75% of cases of cervical radiculopathy as a wide variation of presentations exists even with only one nerve root involved (C6 more common than C7 which is more common than C8 level). Patients should be monitored as S&S may progress in the first 2-3 wk.38, 337
•45-54 yoa
Common S&S of acute cervicobrachial syndrome (A and B)38, 307, 330, 331, 332, 333:
•Predominant arm & scapular pain		When applied by properly trained and experienced practitioners, SMT is potentially a safe treatment option for patients with nonprogressive cervical radiculopathy secondary to CDH and LCS.338, 339, 340 Premanipulative position test may help determine whether patient can tolerate cervical manipulative procedure. Technique adaptation/mobilization recommended in patients with acute cervicobrachial pain.239
with or without neurologic deficit: Specific weakness and/or hypoesthesia and/or hyporeflexia.
•Provocation tests (Spurling's, axial compression) & possible nerve root tension signs (upper limb tension test, median nerve & medial cord stretch test, shoulder depression, brachial-plexus compression, or arm pain relieved by cervical traction and/or Bakody).
•Possible increased intra-thecal pressure (Valsalva/Dejerine triad)	Additional views:	a. MRI provides more useful information than conventional radiography oblique views. Oblique views may be considered in cervical radiculopathy, spondylotic myelopathy, and extensive degenerative, apophyseal joints, pedicles.229, 341
N.B. Consider past imaging studies for evidence of disc pathology and/or moderate to advanced cervical spondylosis.	a. Oblique views
When consistent with the history and other physical findings, a positive Spurling's, traction/neck distraction, and Valsalva's might be indicative of a cervical radiculopathy, whereas a negative upper limb tension test (contralateral neck rotation and extension of the arms and fingers) might be used to rule out radiculopathy.333	b. Swimmer's view	b. Consider swimmer's view if symptoms located in cervicothoracic (C/T) junction or if this area is not well visualized on lateral view.
See Appendix C(5) for a detailed list of clinical criteria for cervicobrachial syndrome.	Special investigations [C]	Comanagement or specialist referral or MRI recommended even if conventional radiographs are unremarkable38, 42, 63
	Combined with radicular symptoms, specific findings on examination (manual provocation tests), and possibly needle EMG findings, MRI may be helpful in confirming the site and level of root compression.
		1. After failed conservative therapy (4 wk);
		2. Major neurological deficits at onset, disabling radicular pain or progression of deficits;
		3. For preoperative planning
1. Adult patient with uncomplicated* subacute neck pain (4-12 wks' duration) with or without arm pain318	Radiographs not initially indicated [Concensus]	Vertebral degeneration and anterior slippage (anterolisthesis) increases with age. However, there appears to be no correlation between neck pain (with or without prior trauma) and the severity or the number of levels of disc, facet or uncovertebral joint degeneration, or degree of anterior slippage, but for the exception of a weak association between chronic neck pain (>6 month) & the severity of the degenerative disc disease (when present in the lower cervical spine).42, 320, 343, 344, 345, 346, 347
* Definition of “uncomplicated”: nontraumatic neck pain without underlying neurologic deficits or red flags (see red flag list below for details).	NB. This recommendation was modified according to the recent findings of The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and it's Associated Disorders (see articles published in Spine 2008; 33(4S). A majority of Delphi panelists agreed with this change (92% of 50 respondents).	a. Oblique views may be considered in cervical radiculopathy, spondylotic myelopathy, and extensive degenerative disease to evaluate IVFs, uncovertebral joints, apophyseal joints, pedicles.218 However, MRI provides more useful information than conventional radiography oblique views.
AND	APOM, AP lower cervical, neutral lateral	b. Consider swimmer's view if symptoms located in cervicothoracic (C/T) junction or if this area is not well visualized on lateral view.
2. Adult patient with persistent neck pain (>12 wk) with or without arm pain63, 318	Additional views:	c. Flexion/extension views are indicated in suspected segmental instability: high-risk ligament laxity populations (Down's, RA and other inflammatory spondylo-arthropathies), failed surgical fusion, trauma and advanced degenerative disc disease.6, 348 Patients should be supervised during procedure. An ADI interval >3 mm is abnormal.349
Psychological distress/depressive mood, somatization, perceived disability, and passive coping behavior are important predictors of chronicity and poor outcome in persistent neck pain.202, 342 An important association exists between a Hx of a WAD, pain intensity, & disability and co-morbidity (headache, LBP, digestive, & cardiovascular disorders).86, 87, 88 Complete history should therefore include a system review.	a. Oblique views
	b. Swimmer's view
	c. Flexion/extension
Adult patient reevaluation in the absence of expected treatment response or worsening after 4 wk60, 318	Radiography indicated [C]	Comanagement or specialist referral or MRI recommended even if conventional radiographs are unremarkable.38, 42, 63
	APOM, AP lower cervical, neutral lateral
See Appendix C(6) for a list of psychological risk factors (yellow flags) and clinical indicators of significant anxiety or depression in whiplash patients.	Special investigations [B]	1. If conventional radiography reveals suspected pathology;
	(1. subacute neck pain, 2. persistent neck pain, and 3. reevaluation in absence of treatment response or worsening after 4 weeks)	2. After failed conservative therapy (4 wk);
		3. If patient neurologic status is deteriorating (progressive deficit, disabling arm pain);
		4. If clinical signs suggest subaxial cervical spine instability;
		5. For preoperative planning;
		NB. The frequency of all degenerative MRI findings increases linearly with age with disc degeneration being the most frequent ranging from 12% in asymptomatic males & females in their 20s to 89% in those over age 60. Posterior disc protrusion and even slight cord compression are not rare in asymptomatic subjects over age 40 with reduction of the cross-sectional area of the spinal cord not exceeding 16%.350, 351, 352
		Normal radiographs may falsely reassure clinicians as important causes of neck pain are not easily identified with conventional radiographs (i.e., not sensitive)
Adult patient with complicated (ie, “red flag”) neck pain & indicators of contraindication to SMT	Radiographs indicated [B]	APOM useful for trauma, inflammatory arthropathy, high-risk atlantoaxial instability populations, malignancy, known congenital anomaly.
	APOM, AP lower cervical, neutral lateral
Presence of the following indicator (s) should alert the clinician to possible underlying pathology38, 42, 63, 308, 318, 353, 354, 355, 356, 357, 358, 359, 360, 361, 362, 363:		** Risk of having a serious pathology may be higher before age 20 & over age 55. Particular attention to indicators of possible underlying pathology should be given for patients in these age categories.
NB. Presence of a red flag alone may not necessarily indicate the need for radiography.
•Patient <age 20 and >age 50, particularly with S&S suggesting systemic disease**	Additional views:
•No response to care after 4 wk.	a. Flexion/extension	a. Flexion/extension views indicated in suspected segmental instability: high-risk ligament laxity populations (Down's, RA, and other inflammatory spondylo-arthropathies), failed surgical fusion, trauma, and advanced degenerative disc disease.6, 348 Patients should be supervised during procedure. An ADI interval >3 mm is abnormal.349
•Significant activity restriction >4 wk
•Nonmechanical pain (unrelenting pain at rest, constant or progressive S&S)
•Neck rigidity in the sagittal plain in the absence of trauma (discitis, infection, tumor, meningitis, etc);
•Dysphasia;	b. Oblique views	b. Oblique views may be considered in suspected fracture, malignancy, and other equivocal findings on standard AP and lateral radiographs (radiculopathy, spondylotic myelopathy, and extensive degenerative disease).
•Impaired consciousness;
•Central nervous system S&S (cranial nerves, pathological reflexes, long tract signs);
•High risk ligament laxity populations/suspected atlantoaxial instability (see details below);	c. Pillar	c. Pillar views may be considered in severe trauma (CT usually done instead—see Trauma section)
•Arm or leg pain with neck movements;
•Suspected cervical myelopathy and radiculo-myelopathy (see details bellow);
•Sudden onset of acute and unusual neck pain and/or headache (typically occipital) with or without neurologic symptoms, suspected cervical artery dissection (VAD, CAD), TIA (VBI, carotid artery ischemia), stroke (see details bellow);	Special investigations6, 38, 42, 63 [B]	Advanced imaging and specialist referral recommended:
		•MRI for suspected myelopathy (tumors, inflammation, infection, infarction, etc).
•Hx of severe trauma (see Trauma section).		In cases of atlantoaxial instability, MRI (F/E) shows effects on cord compression when radiograph is positive or neurologic signs are present.
In addition, also consider general red flags (relative utility and cost-effective of screening patients for non traumatic neck pain for serious stractural disease (“Red Flags”) need to validate) which may apply to the cervical spine
•Suspected neoplasia: considerable pain starting ≥age 50; Hx of cancer/carcinoma (in the last 15 y) or failure of conservative care (4 wk), lymphadenopathy; dermopathy (melanoma). S&S of cervical spine tumors tend to be variable (slight pain, neck stiffness, scoliosis, presence of a mass and/or severe neurologic deficit). Night pain remains a classic indicator of nonmechanical neck pain and neoplasm. Other systemic symptoms may include unexplained weight loss (>10 lb over 4 wks) and systemically unwell.6, 38, 355, 356
•Suspected infection (discitis, osteomyelitis, tuberculosis): documented fever (>38.3°C/101°F) for >3 wk and no established diagnosis despite appropriate investigation for 1 week; elevated ESR >20 mm/h; IV drug abuse; immunosuppression (HIV, transplant patients); UTI, skin infection, diabetes mellitus; alcohol abuse; vertebral tenderness with underlying infection; direct implantation (nail, acupuncture); Hx of spine surgery.208, 209
•Suspected failed surgical fusion;
•Progressive or painful structural deformity;
•Abnormal laboratory examination and positive S&S: ESR >50 mm/h; RA factor; HLA-B27; BCB; ALP; PSA; serum calcium, for example.211, 212		Abnormal laboratory examination: R/O marrow–based malignancies, including metastasis & primary marrow–based pathology (eg, myeloma); serum gammapathy and possible infection & arthritides
Note: It may be reasonable to consider many of the lumbar spine red flags in complaints of neck pain. However, their level of evidence as such is currently unknown.155
1. Suspected atlantoaxial instability (AAI):	Radiographs indicated [B]	In whites, the prevalence of RA is 0.8%-1%. Cervical spine involvement occurs in over half of patients with RA, and atlantoaxial subluxation (AAS) develops in over 12% of patients with RA. There is a strong correlation between a Larson erosion score for hand & wrist joint damage >50, RA duration of >10 y, disease onset before age 50, number of previous drug modifying disease and RA-related surgery and AAS. It is important to recognize that many patients acquire AAS in the first 3 y of their disease, but neurologic impairments develop after a mean period of 18 y (range, 4-50). RA patients with AAS have a higher mortality rate compared those without AAS.364, 367, 368, 369, 370
High-risk ligament laxity populations/possible atlantoaxial instability include6, 63, 229, 357, 358, 359, 360, 361, 362, 363:	APOM, AP lower cervical, neutral lateral
(a) Active inflammatory arthritis: known rheumatoid arthritis (RA), psoriatic arthropathy, chronic juvenile RA, and less commonly in AS (2% of cases). S&S of presumed inflammatory spondyloarthropathy include significant morning stiffness (>1 h); pain duration ≥3 mo; persisting motion restriction; gradual onset ≤age 40; peripheral joint involvement; UTI, urethral discharge, iritis, skin rash.364
(b) Congenital disorders & hereditary connective tissues disorders such as dysplasia, os odontoideum, Klippel-Feil, Morquios, Down's syndrome (20% are born without a transverse ligament), Ehlers-Danlos syndrome type III, Marfan syndromes.	Additional views [D]	* Flexion/extension views indicated in suspected AAS. However, a single lateral cervical radiograph with the patient in supervised comfortable flexion should reveal any subluxation in patients with rheumatoid arthritis, Down's syndrome, etc.6
	a. Flexion/extension laterals*6
Screening for high-risk ligament laxity populations is important for manual therapists. Little is known about the value of commonly used manual tests. Although agreement and reliability between 2 examiners is difficult to achieve for general cervical spine mobility & intersegmental passive mobility,365 acceptable levels of predictive value, sensitivity, and specificity have been reported for the Sharp-Purser test.320 Cattrysse et al366 were not able to reproduce such results in a small group of children with Down's syndrome, however. Preliminary data support the use of the upper cervical flexion test for those patients.	Special investigations [C]	Monitoring, advanced imaging and specialist referral recommended63, 318, 348, 369, 371, 372:
		1. ADI >3 mm, vertical dislocation, lateral, posterior, or subaxial subluxations
		2. Upward odontoid translocation (pseudobasilar invagination)
		3. In the presence of neurologic S&S
		♦ CT and MRI provide detailed images of the bone and spinal cord lesions.
2. Suspected cervical compressive myelopathy (CCM) and radiculo-myelopathy	Radiographs indicated [C]	For cervical spondylotic myelopathy, patients should be treated conservatively if they have a spinal transverse area >70 mm2, are of older age, and have normal central motor conduction time. Surgery is more suitable for patients with clinically worse status (function expressed as modified Japanese Orthopaedic Association score and slower walk) and a smaller transverse area of spinal cord.376
Causes of cord compression include trauma, tumors, infection, vascular disease, degenerative conditions, demyelinating disorders, spinal stenosis, & central cervical disc herniation.	APOM, AP lower cervical, neutral lateral, and bilateral oblique views.
Cervical spondylotic myelopathy (CSM)63, 372, 373, 374, 375
1. MC >50 y;		Central spinal stenosis, acute cervical myelopathy, and/or radiculo-myelopathy is generally considered a contraindication for manual therapy although some patients with nonacute & nonprogressive S&S have safely received such intervention. Caution is advised in those patients as even minor trauma in patients with preexisting severe spondylosis has potentially serious consequences.318, 336, 339, 340, 377, 378, 379, 380, 381, 382, 383, 384, 385
2. Variable neurologic deficit of upper (hyporeflexia) and lower extremities (hyperreflexia); axial skeleton sensory and motor dysfunction that skip the head & face;
3. Arm or leg pain with neck movements;
4. Long tract signs and pathological reflexes (Clonus, Babinski, Hoffman); Lhermitte's sign (cervical flexion and extension producing electrical shocks down the arm and leg);	Additional views:	Consider Swimmer's view if symptoms are located in cervicothoracic junction or if this area is not well visualized on lateral view.
	Swimmer's view
5. Subtle gait abnormality (loss of balance, spasticity, unsteadiness, loss of leg power, broad base, shuffle and disruption in smooth, rhythmic function);		a. A sagittal diameter <13 mm indicates spinal stenosis and is critical for the development of a cervical radiculo-myelopathy, even in the presence of mild degenerative spondylosis (normal is 17-18 mm between C3-C7). Caution is recommended if AP diameter <11 mm and manual therapy is contemplated.318
6. Bowel & bladder dysfunction (rare).
Neurologic examination in patients with CSM is moderately accurate and reliable for determining the neurologic level of disease. Among the neurologic tests (deep tendon reflex, pinprick response, muscle weakness, and numbness in the hand only), patient-perceived location of numbness in the hands may be the most useful for establishing the affected level.374		b. A Torg' or Pavlov ratio (spinal canal/vertebral body) <0.8 indicates spinal stenosis.334, 383, 386
		NB. It is important to recognize that conventional radiography may not be very reliable to determine central canal stenosis as there is some variation in the size of the spinal cord and stenosis may be due to nonosseous factors (ligamentum flava, cartilage hypertrophy etc).
	Special investigations [C]	Refer patient for investigation and possible surgical intervention:
		1. After failed conservative therapy (4 wk);
		2. If neurologic status is deteriorating (progressive deficit, disabling arm pain);
		3. For preoperative planning;
		•MRI (CT-myelography if MRI not available)
		Electrophysiologic testing such as somatosensory-evoked potentials (SSEP) may be useful.
3. Suspected cervical artery dissection (VAD, CAD), TIA (VBI, carotid artery ischemia), stroke.	Emergency referral without imaging [GPP]	If patient reports active/existing VAD, CAD, TIA/stroke, DO NOT proceed with cervical manipulation
In most cases, there is little that could prospectively alert even the astute practitioner to an impending vascular event. Most patients are young, apparently healthy individuals, suffering from musculoskeletal complaints without any predisposing stroke risk factors.	Urgent referral should be made for appropriate investigation and treatment in patient presenting S&S of cerebrovascular ischemia or when S&S of head/neck pain is suspicious for an acute cervical artery disease.	Emergency care:
		It is vital to recognize the S&S of cerebrovascular ischemia and stroke in which case patient must be referred immediately to emergency facility for early and appropriate treatment.
The most important points in the history and chief complaint, which would warn of a possible cervical artery disease, are308, 318, 354, 387, 388:		Additional information:
a. S&S of VBI—the “5D's and 3 N's”: dizziness, dysphasia, dysarthria (hoarseness), drop attacks, diplopia (or other visual problems), ataxia of gait (hemiparisis), nausea (possibly with vomiting), numbness (hemianesthesia), nystagmus.	Initial investigation often includes CT scan of the brain to R/O hemorrhagic stroke.	a. Sudden onset of acute and unusual headache and/or neck pain is present in 92% of cases of cervical artery dissection and may occur either spontaneously, after a specific activity, a significant neck trauma, or after cervical spine manipulation.
b. S&S of carotid artery ischemia/stenosis: confusion, dysphasia, headache, anterior neck and/or facial pain, hemianesthesia, hemiparesis or monoparesis, visual field disturbances.		b. Immediate or delayed neurologic S&S developing spontaneously, after a specific activity, a significant neck trauma, or after cervical manipulation; including the 5 D's and 3 N's are absolute contraindications to SMT.
c. Neck or occipital pain with sharp quality and severe intensity or severe & persistent headache that is sudden and unlike any previous experienced pain or headache (even when it is suspected the pain is of a musculoskeletal or neuralgic origin)		c. S&S of internal carotid artery dissection: most common presentation: headache and neck pain (90%), ischemic symptoms (50%-95%), Horner's syndrome (<52%), visual scintillation (33%), monocular blindness (6%-30%), subjective bruit (25%-48%), impairment of taste (10%-19%).402
	Special investigations [C]	Should cervical artery problems be suspected, a thorough workup is indicated which may include245:
Any reports consistent with TIAs, prior stroke history (1% risk of recurrence/year), severe hypertension (noted in half of cases of spontaneous/idiopathic vertebral artery dissection), Hx of a major cervical spine trauma (attributed to 10% of vertebrobasilar syndrome), cardiac abnormalities that predispose to thrombus formation or myolytic arteriopathy should prompt close observation for neurologic status.308, 318, 389, 390	Appropriate consultation and/or diagnostic procedures to evaluate the status of the cerebral circulation required in patients presenting with significant risk factors for cervical artery dissection. In such cases, approach the treatment with caution until a specific determination is made.308, 318	• Gold standard diagnostic tests (MRI/MRA) should be performed before implementing any manipulative procedure.308
		• US imaging of the cervical vessels is typically used as a fast, noninvasive screen when pathology is suspected. Color-coded duplex ultrasonography can help diagnose vertebral artery (VA) occlusion and VBI by measuring blood flow velocity & flow volume and diameter of the VAs (including hypoplasia & asymmetry).354, 403, 404, 405, 406 However, US is operator dependant, lacks resolution, and has some limitations associated with vertebral artery evaluation. For these reasons, ultrasound may not be a viable screening tool.407, 408
Although several risk factors have been proposed for cervical artery dissection,308, 318, 387, 388, 389, 390, 391, 392, 393, 394, 395, 396, 397, 397, 398, 399 current literature does not assist in identification of precipitating causes. VBIs may be considered the result of cumulative events over time/multifactorial.400, 401 The patient history should include a system review and family history.		• Catheter digital angiography is an invasive procedure with associated risk of stroke (≈1%). MRI/MRA considered method of choice as initial diagnosis and follow-up of craniocervical artery dissection.
		See Mullins409 and Foerster et al245 or a review on stroke imaging
	Further consideration	Further considerations
		1. External structures such as facet & uncovertebral joint osteophytes and presence of a retroarticular canal may potentially compress the vertebral artery.410, 411, 412 However, no cases were found to be associated with either retroarticular canal or posterior ponticle in young adults.308 Although 1 case of VBI and one stroke have been associated with vertebral artery stenosis from osteophytes, cervical spondylosis does not appear to increase the risk of vertebrobasilar accidents after vertebral manipulation. If such were the case, one would expect older patients (>45 yoa) to be at heightened risk, but they are not.388, 389, 390 There is currently no evidence that in the absence of red flags in the adult patient, routine cervical spine radiographs before initiating manipulative therapy have any value as a mean to reduce rare, random, unpredictable vascular complications associated with neck movement, trivial trauma, or cervical manipulation.308, 318, 390
		2. Limiting neck rotation during SMT and applying the smallest force required to achieve therapeutic objective is advisable.311, 413
		3. Migraine headache is a risk factor for stroke in young patients. When possible, treat all stroke modifiable risk factors aggressively, especially in women over age 35: smoking, oral contraceptives, presence of aura, >12 attacks of migraines/year, >12 y of migraine history.414
		4. Tests and imaging studies that would help screen patients at risk of adverse vascular events before receiving cervical SMT would be of great help. However, such studies are not available presently.308 There is currently no evidence that in the absence of red flags, routine cervical spine radiographs before initiating manipulative therapy have any value as a means to reduce rare, random, unpredictable vascular complications associated with neck movement, trivial trauma, or cervical manipulation.
		5. In patients with past a history of major trauma to the cervical spine*, MRA or angiography recommended before treating the neck as follow-up MRA indicates that these damaged vertebral arteries usually do not recanalize.415, 416, 417, 418, 419, 420, 421
		In a review of 80 cases of traumatic vertebral ischemia, MVA were thought to be responsible for 77.5% of cases, with delays between trauma and the onset of neurologic S&S of up to 5 y. The severity of trauma caused loss of consciousness (LOC) in 70% either at the time of injury or with subsequent episode of vertebrobasilar ischemia and short-term memory deficit in 64%. However, severity of trauma was mild for many, with no LOC, and no blow to the head.422

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Acknowledgment 

We appreciate the efforts of the many people who assisted in this process, listed in Appendix G.

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Appendix A. Supplementary data 

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Appendix B. Summary of Recommendations 

Table 1.Summary of Recommendations—Thoracolumbar, Lumbar, and Thoracic Spine Trauma

Patient Presentation	Recommendations
Adult patient with recent (<2 wk) acute thoracolumbar, lumbar, or thoracic spine trauma
Absence of pain, normal ROM, and absence of neurologic deficits	Radiographs not routinely indicated [C]
Adult patient with thoracolumbar, lumbar or thoracic spine blunt trauma or acute injuries (falls, MVAs, motorcycle, pedestrian, cyclists, etc)	Radiographs indicated [B]
	Lumbar AND thoracic spine: AP, lateral views
High-risk screening criteria for spinal injuries include any of the following:
1. Back pain	Special investigations [C]
2. Midline tenderness on palpation	•CT scan (multidetector [multislice], spiral CT)
3.Distracting painful injury and other high-risk mechanism of injury*	•MRI
4. Neurologic deficits
5. Altered consciousness (caused by head trauma, intoxication/ethanol, or drugs)
Adult patient with posttraumatic chest wall pain
Minor trauma	Radiographs not routinely indicated [D]
Major trauma	Radiographs indicated [GPP]
	PA, lateral chest radiographs,
	Specific rib radiographs (AP, oblique)
	Additional views: PA chest in full expiration,
	Thoracic and /or lumbar spine views
	Special investigations [GPP]
	•CT for sternum injury, pulmonary, pleural, and osseous abnormalities
Adult patient with pelvis and sacrum trauma (including falls with inability to bear weight)	Radiographs indicated [D]
	AP Pelvis and lateral hip “frog leg”
	Additional views: lateral lumbar view,
	Angulated AP sacrum view (15-45° cephalad)
	Special investigations [D]
	•NM, MRI or CT may be helpful if radiographs are normal or equivocal.
Coccyx trauma and coccydynia	Radiographs not routinely indicated: (spot AP, lateral coccyx) [C]
Consider views of the sacrum if distal sacrum fracture is suspected	Additional views: AP, lateral sacrum,
	Dynamic sitting lateral views of the coccyx

Table 2. Summary of Recommendations—Cervical Spine Trauma

Patient Presentation	Recommendations
Adult patient with acute neck injury and negative CCSR (Canadian Cervical Spine Rule for Radiography in Alert and Stable Trauma Patients)	Radiographs not routinely indicated [B]
Adult patient with acute neck injury and positive CCSR (Canadian Cervical Spine Rule for Radiography in Alert and Stable Trauma Patients)	Radiographs indicated [B]
	APOM, AP lower cervical, neutral lateral
Conventional radiographs recommended in the presence of any of the Canadian Cervical Spine Rule criteria are fulfilled:
(A) High-risk factors in alert and stable patient?	If fracture is suspected: 3 views + CT scan recommended
1. Age >65
2. Dangerous mechanisms of injury*	Additional views: CT now replaces oblique, pillar, dynamic flexion/extension (F/E) in suspected fracture [GPP]
3. Parethesias in extremities
	Special investigations [C]
(B) Low-risk factors that allow ROM assessment?	•CT, MRI
1. Simple rear end collision**
2. Patient seated in the waiting room
3. Ambulatory at one time since trauma
4. Delayed cervical pain onset
5. Absence of midline cervical tenderness
(C) ROM assessment: is patient able to actively turn his/her head to 45° in both directions?

Table 3. Summary of Recommendations—Adult Nontraumatic Lumbar Spine Disorders

Patient Presentation	Recommendations
Adult patient with acute uncomplicated* LBP (<4 wks' duration)	Radiographs not initially indicated [B]
* Uncomplicated definition: nontraumatic LBP without neurologic deficits or indicators of potentially serious pathologies)—(see red flag list for details).	Special investigations not indicated [B]
For most young or middle-aged adults, early diagnostic evaluation of low back complaints may focus on 3 basic questions: diagnostic imaging is infrequently required (Jarvik 2002).4
1. Is there underlying systemic disease?
2. Is there neurologic impairment that might require surgical intervention?
3. Is social or psychological distress amplifying or prolonging the pain?
Adult patient with uncomplicated subacute (4-12 wks' duration) or persistent LBP (>12 wks' duration) AND no previous treatment trial.	Radiographs not initially indicated [B]
A trial of up to 4-6 wk of conservative care is appropriate before radiographs
Adult patient with nontraumatic acute LBP AND sciatica (no red flags)	Radiographs not initially indicated [B]
The first clinical clue to neurologic impairment usually is a history of sciatica: sharp pain radiating down the posterior or lateral aspect of the leg, often associated with numbness or paresthesia.
Specific Clinical Diagnoses:
Common causes of sciatica
(A) Suspected LDH:	Radiographs not initially indicated [B]
•Risk factors for LDH include: men (1.6 times more likely), middle age (35-54 y), repetitive/heavy lifting, current smoking, obesity (high BMI), and type of occupation.	unless patient age >50 or has progressive neurologic deficits
•Predominantly leg pain, typically involving the foot
(B) Suspected degenerative spondylolithesis/lateral stenosis	Radiographs indicatedif patient age >50 or has progressive neurologic deficits: PA (or AP), lateral lumbar views [GPP]
•Back pain with or without leg pain
•Increased pain with activity
•S&S with or without neurologic deficit
(C) Suspected lumbar degenerative spinal stenosis	Radiographs indicatedif patient age >50 or has progressive neurologic deficits: PA (or AP), lateral lumbar views [C]
•MC >65 yoa (sensitivity of 0.7; specificity of 0.69)
•Neurogenic claudication
•Variable neurologic deficit (numbness, weakness, etc)
Suspected causes of sciatica:
(A) Lumbar disc herniation	Special investigations
(B) Degenerative spondylolithesis/lateral stenosis	not initially indicated [C]
(C) Lumbar degenerative spinal stenosis
	Co-management or specialist referral recommended even if conventional radiographs are unremarkable:
	1. After failed conservative therapy (4-6 wk)
	2. For preoperative planning;
	3. If patient's neurologic status is deteriorating (progressive deficit, disabling leg pain);
	•MRI, CT
Adult patient reevaluation in the absence of expected treatment response or worsening after 4-6 wk	Radiographs indicated [B]
Should patient fail to improve as expected or marginally improve within 4-6 wk of initial evaluation, the clinician must review history and physical findings and request appropriate diagnostic imaging studies.	PA (or AP), lateral lumbar views
	Additional views not routinely indicated [C]
	Spot lateral, oblique. lateral flexion films may be indicated in scoliosis evaluation
	Comanagement or specialist referral recommended even if conventional radiographs are unremarkable
	1. And if conventional radiography reveals suspected pathology.
	2. After failed conservative therapy (4-6 wk),
	3. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain);
	4. If clinical signs suggest instability. Presumed instability is loosely defined as >10° of angulation or 4 mm of vertebral displacement on flexion and extension lateral radiographs. However, diagnostic criteria, natural history, and surgical indications remain controversial
	5. For preoperative planning;
	Special investigations [C]
	•MRI or CT scan
Adults with complicated (ie, “red flag”) LBP and indicators of contraindication to SMT (relative/absolute):	Radiographs indicated [B] PA (or AP), lateral lumbar views.
Presence of the following indicator(s) should alert the clinician to possible underlying pathology. Presence of a red flag alone may not necessarily indicate the need for radiology.	Additional views: Hibb's,
•Patient <age 20 and >age 50, particularly with S&S suggesting systemic disease**	(Spot angled PA or AP lumbosacral), oblique SI views
•No response to care after 4 wk
•Significant activity restriction >4 wk	Advanced imaging and specialist referral recommended:
•Nonmechanical pain (unrelenting pain at rest, constant or progressive S&S)	1. In the presence of a potentially serious pathology as suggested by the patient history, examination, and/or radiograph;
•Suspected inflammatory—spondyloarthritides	2. In the absence of clinical improvement after 4-6 wk of therapy;
•Suspected compression fracture	3. If function does not improve or deteriorates;
Suspected neoplasia	4. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain);
•Suspected infection	5. With painful or progressive structural deformity
•Suspected failed surgical fusion	6. For unstable segment (spondylolisthesis or pathological process);
•Progressive or painful structural deformity	7. When patient has persisting S&S;
•Elevated laboratory examination and positive S&S	8. In complication from treatment (possible fracture, new/progressive neurologic deficit, considerable pain, or disability, etc)
	Special investigations [B] Even if conventional radiographs are negative
	•MRI, CT, NM
•Suspected CES	Emergency referral without imaging [B]
The classic syndrome includes LBP, bilateral or unilateral sciatica, saddle anesthesia, motor weakness of the lower extremities that may progress to paraplegia, urinary retention, or bowel and bladder incontinence.	Special investigations [B] (see above for details)
•Suspected AAA	Referral for specialized investigations [B]
Early S&S may include abdominal pain, backache, and feeling of fullness or abdominal pulsation.	•Management (ultrasound screening/monitoring and surgical consultation) according to patient history and size of AAA
•Truncal symptoms attributed to the presence or worsening of aortic aneurysms including dissection/rupture/occlusion or traumatic aortic injury	Emergency referral without imaging [GPP]
Cardiovascular shock and/or syncope, severe, tearing/ripping midabdominal sensation, back, groin or testicular pain; pressure upon lumbar spine causing excruciating boring pain in the abdomen or back; hypotension; absence distal lower limb pulses	•It is vital to recognize the S&S of dissecting AAA as this is a surgical emergency.

Table 4. Summary of Recommendations—Nontraumatic Thoracic Spine Disorders

Patient Presentation	Recommendations
Adult patient with uncomplicated* acute thoracic spine pain (<4 wks' duration)
AND	Radiographs not routinely indicated [B]
Adult patient with uncomplicated* subacute (4-12 wks' duration) or persistent (>12 wks' duration) thoracic spine pain and no previous treatment trial.	Special investigations not indicated [B]
* Uncomplicated definition: nontraumatic thoracic pain without neurologic deficits or indicators of potentially serious pathologies
Adult patient: reevaluation in the absence of expected treatment response or worsening after 4 wk.	Radiographs indicated [B]
Should patient fail to improve as expected or marginally improve within 4 wk of initial evaluation, the clinician must review history and physical findings and request appropriate diagnostic imaging studies.	AP, lateral thoracic spine views
	Additional views: swimmer's view
	Co-management or specialist referral recommended
	1. In suspected pathology as seen on conventional radiography
	2. After failed conservative therapy (4 wk),
	3. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain);
	Special investigations []
	•MRI or CT scan
Adult patient with nontraumatic chest wall pain	Emergency referral without imaging in life-threatening conditions [GPP]
History and physical exam first need to rule out life-threatening conditions including pathologies of the heart, lungs and large vessels.
	Special investigations [C]
	•CT and MRI
Musculoskeletal causes of chest wall pain (diagnosis of exclusion).	Radiographs not routinely indicated [D]
Adult patient with complicated (ie, “red flag”) thoracic pain and indicators of contraindication to SMT (relative/absolute)	Radiographs indicated [B]
Presence of the following indicator(s) should alert the clinician to possible underlying pathology.	AP, lateral thoracic spine views.
NB. Presence of a red flag alone may not necessarily indicate the need for cardiography.
Patient <age 20 and >age 50, particularly with S&S suggesting systemic disease**	Additional views: spot view. In suspected inflammatory spondylo-arthropathy, consider: Hibb's (spot angled AP lumbosacral), oblique SI views
•No response to care after 4 wk.
•Significant activity restriction >4 wk	Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable:
•Nonmechanical pain (unrelenting pain at rest, constant or progressive S&S)	1. In presence of a potentially serious pathology as suggested by the patient history, examination and/or radiograph;
•Persistent localized pain (>4 wk)	2. In the absence of clinical improvement after 4 to 6 wk of therapy;
•Progressive or painful structural deformity: scoliosis, kyphoscoliosis (Otani 2001)	3. If function does not improve or deteriorates;
•Symptoms associated with neurologic signs in the lower extremities	4. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain);
•Suspected inflammatory spondyloarthropathy	5. With painful or progressive structural deformity
•Suspected neoplasia	6. For unstable segment (spondylolisthesis or pathological process);
•Suspected infection	7. When patient has persisting S&S;
•Suspect failed surgical fusion	8. In complication from treatment (possible fracture, new/progressive neurologic deficit, considerable pain or disability, etc)
•Elevated laboratory examination and positive S&S
•In recent significant trauma (any age)	Special investigations [B]
	•MRI, CT, NM
•Suspected acute thoracic aortic aneurysms dissection/rupture/occlusion or traumatic aortic injury	Emergency referral without imaging [GPP]
Severe, tearing/ripping chest sensation, back pain; hypotension; absent distal pulse. High index of suspicion in connective tissue disorders and diseases with genetic predisposition for ascending aortic aneurysms.
•Suspected compression fracture	Radiographs indicated [B]: AP, lateral thoracic spine views.
Severe onset of pain (with or without appearance of spinal deformity) after minor trauma in older patients. Patients with thoracic or lumbar spine osteoporotic fractures report pain mainly in the lumbosacro-gluteal area. Look for Hx of repetitive stress of sufficient severity or Hx of high risk osteoporosis
	Additional views [D]: supine cross-table lateral view in suspected osteoporotic vertebral pseudoarthrosis
Risk factors for additional vertebral fractures:
Histories of a previous fracture, greater age, lower femoral neck bone mass density, shorter height.	Special investigations [D]
	•MRI/CT if initial radiographs are positive, difficult to interpret, in presence of complex lesions, for suspected ligamentous instability or neural injuries.
Suspected osteoporosis	Radiographs are unreliable for assessment of bone mass changes before at least a 30%-50% loss
See osteoporosis clinical decision rules
	Special investigations [B]
	if clinical decision rules are positive
	•Bone densitometry or dual-energy x-ray absorptiometry (DXA)
Adult patient with nonpainful and nonprogressive scoliosis	Radiographs not routinely indicated [C]
Adult patient with painful or progressive scoliosis	Radiographs indicated [B]
	Erect sectional radiographs (better detail) or standing full-length PA (14 × 36 in) and lateral sectionals
	Additional views:
	1. Right and left lateral bending
	Follow-up evaluation dictated by clinical progression [C]
	Repeat radiographs, specialist referral and advanced imaging recommended [B]:
	1. In the absence of clinical improvement; after 4 to 6 wk of therapy;
	2. If function does not improve or deteriorates;
	3. In presence of persisting S&S or considerable pain;
	4. If patient neurologic status is deteriorating (progressive deficit, disabling leg pain);
	5. With painful or progressive structural deformity (scoliosis, kyphoscoliosis);
	6. With suspected segmental instability (this is common in adult scoliosis and should be considered with all manual therapy intervention).
	7. With suspected pathological process;
	8. With new or progressive neurologic deficit including claudication, significant radiculopathy or suspected syrinx;
	9. To plan surgical intervention.
	Special investigations [C]
	•Spiral CT, MRI, sequential discograms, facet blocks, epidural blocks, CT-myelogram.

Table 5. Summary of Recommendations—Nontraumatic Cervical Spine Disorders

Patient Presentation	Recommendations
Adult patient with acute uncomplicated* neck pain (<4 wks' duration)	Radiographs not initially indicated [C]
* Uncomplicated definition: nontraumatic neck pain without neurologic deficits or indicators of potentially serious pathologies)—(see red flag list for details).
	Special investigations not indicated [C]
Adult patient with nontraumatic neck pain and radicular symptoms	Radiographs indicated [D/consensus]
	APOM, AP lower cervical, neutral lateral
(A) Suspected acute cervical disc herniation (CDH)
(B) Suspected Acute cervical spondylotic radicular syndrome/lateral canal stenosis	Additional views: oblique views, swimmer's view
	Comanagement or specialist referral recommended even if conventional radiographs are unremarkable
	1. After failed conservative therapy (4 wk)
	2. For preoperative planning;
	3. If patient neurologic status is deteriorating (progressive deficit, disabling arm pain);
	Special investigations [B]
	MRI
1. Adult patient with uncomplicated* subacute (4-12 weeks duration) and persistent neck pain (>12 weeks) with or without arm pain.	Radiographs not initially indicated* [consensus]
	APOM, AP lower cervical, neutral lateral
	N.B. This recommendation was modified according to the recent findings of The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and it's Associated Disorders (see articles published in Spine 2008; 33(4S)). A majority of Delphi panelists agreed with this change (92% of 50 respondents).
	Radiographs indicated [C]
	APOM, AP lower cervical, neutral lateral
Adult patient reevaluation in the absence of expected treatment response or worsening after 4 weeks.	Additional views: Oblique views, Swimmer's view, Flexion/Extension
	Comanagement or specialist referral recommended (even if conventional radiographs are unremarkable)
	1. If conventional radiography reveals suspected pathology.
	2. After failed conservative therapy (4 wk),
	3. If patient neurologic status is deteriorating (progressive deficit, disabling arm pain);
	4. If clinical signs suggest subaxial cervical spine instability. (Moore 2006)
	5. For preoperative planning;
	Special investigations [B]
	•MRI
Adult patient with complicated (ie, “red flag”) neck pain and indicators of contraindication to SMT	Radiographs indicated [B]
Presence of the following indicator(s) should alert the clinician to possible underlying pathology.
N.B. Presence of a red flag alone may not necessarily indicate the need for radiography.
•Patient <age 20 and >age 50, particularly with S&S suggesting systemic disease**	APOM, AP lower cervical, neutral lateral
•No response to care after 4 wk
•Significant activity restriction >4 wk	Additional views: flexion/extension, oblique views, pillar view
•Nonmechanical pain (unrelenting pain at rest, constant or progressive S&S)
•Neck rigidity in the sagittal plain in the absence of trauma (discitis, infection, tumor, meningitis, etc);	Advanced imaging and specialist referral recommended:
•Dysphasia;	Special investigations [B]
•Impaired consciousness;	•MRI
•Central nervous system S&S (cranial nerves, pathological reflexes, long tract signs);
•High risk ligament laxity populations/suspected atlantoaxial instability(see details below);
•Arm or leg pain with neck movements, suspected cervical myelopathy and radiculo-myelopathy (see details bellow);
•Sudden onset of acute and unusual neck pain and/or headache (typically occipital) with or without neurologic symptoms, suspected cervical artery dissection (VAD, CAD), TIA (VBI, carotid artery ischemia), stroke (see details bellow);
•Hx of severe trauma (see Trauma section).
In addition, also consider general red flags (usually applied to LBP) which may apply to the cervical spine
•Suspected neoplasia
•Suspected infection (discitis, osteomyelitis, tuberculosis)
•Suspect failed surgical fusion
•Progressive or painful structural deformity
•Elevated laboratory examination and positive S&S
•Suspected atlantoaxial instability (AAI)	Radiographs indicated [B]
High risk ligament laxity populations/possible atlantoaxial instability include	APOM, AP lower cervical, neutral lateral
(a) Active inflammatory arthritides
(b) Congenital disorders and hereditary connective tissues disorders	Additional views [D]: flexion/extension laterals
	Monitoring, advanced imaging and specialist referral recommended:
	1. ADI >3 mm, vertical dislocation, lateral, posterior or subaxial subluxations
	2. Upward odontoid translocation (pseudobasilar invagination)
	3. In presence of neurologic S&S
	Special investigations [C]
	•CT, MRI
•Suspected cervical compressive myelopathy (CCM) and radiculo-myelopathy	Radiographs indicated [C]
	APOM, AP lower cervical, neutral lateral and bilateral oblique views.
	Additional views: swimmer's view
	Refer patient for investigation and possible surgical intervention:
	1. After failed conservative therapy (4 wk),
	2. If patient's neurologic status is deteriorating (progressive deficit, disabling arm pain);
	3. For preoperative planning;
	Special investigations [C]
	•MRI (CT-myelography if not available). Electrophysiologic testing such as somatosensory evoked potentials (SSEP) may be useful.
•Suspected cervical artery dissection (VAD, CAD), TIA (VBI, carotid artery ischemia), stroke	Emergency referral without imaging [GPP]
The most important points in the history and chief complaint, which would warn of a possible cervical artery disease, are:	Urgent referral should be made for appropriate investigation and treatment in patient presenting S&S of cerebrovascular ischemia or when S&S of head/neck pain is suspicious for an acute cervical artery disease.
a. S&S of VBI—the “5D's And 3 N's”: dizziness, dysphasia, dysarthria (hoarseness), drop attacks, diplopia (or other visual problems), ataxia of gait (hemiparisis), nausea (possibly with vomiting), numbness (hemianesthesia), nystagmus;
b. S&S of carotid artery ischemia/stenosis: confusion, dysphasia, headache, anterior neck and/or facial pain, hemianesthesia, hemiparesis or monoparesis, visual field disturbances.	Special investigations [C]
c. Neck or occipital pain with sharp quality and severe intensity or severe and persistent headache that is sudden and unlike any previous experienced pain or headache (even when it is suspected the pain is of a musculoskeletal or neuralgic origin)	•Initial investigation often includes CT scan to R/O hemorrhagic stroke.
Should cervical artery problems be suspected, a thorough workup is indicated.	Appropriate consultation and/or diagnostic procedures to evaluate the status of the cerebral circulation required in patients presenting with significant risk factors for cervical artery dissection. In such cases, approach the treatment with caution until a specific determination is made.

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Appendix C. Pertinent Clinical Information 

(1) Thoracic spine trauma

The thoracolumbar injury severity scale (TLISS) may be helpful in referral decision-making process. The scale is based on the mechanism of injury, the integrity of the posterior ligamentous complex, and the neurologic status.^i,ii The TLISS has good reliability and compares favorably to other contemporary thoracolumbar fracture classification systems.ⁱⁱⁱ

Description	Points
1. Injury mechanism
a. Compression
•Simple compression	1
•Lateral angulation >15°	1
•Burst	1
b. Translation/rotational	3
c. Distraction	4
2.Posterior ligamentous complex (PLC) disrupted in tension, rotation, or translation
a. Intact	0
b. Suspected/indeterminate	2
c. Injured	3
3. Neurologic status
a. Nerve root involvement	2
b. Cord, conus medullaris involvement
•Incomplete	3
•Complete	2
c. Cauda equine involvement	3

The score is a total of 3 components: injury mechanism, PLC integrity, and neurologic status. A score of ≤3 suggests nonoperative treatment (bracing); 4, operative or nonoperative treatment; and ≥5 suggests operative treatment.

(2) Cervical spine trauma

Risk factors for WAD may include personal, societal, and environmental factors. Both physical and psychological factors are likely to play a role in recovery or non-recovery from whiplash injury. High initial symptom severity (high initial pain level, pain-related limitations, greater number of symptoms and painful body parts), greater psychological distress and passive coping may predict poorer outcome^iv Finally, an important association exists between a Hx of a whiplash associated disorder, pain intensity, and disability and comorbidity (headache, LBP, digestive, and cardiovascular disorders).^vi,vii

a. Adult Patient with Acute Neck Injury and Positive CCSR

Proposed whiplash associated disorders classification included Foreman and Croft (1995), the Quebec Task Force^viii and revised classification on Whiplash Associated Disorders.^ix-x

A biopsychosocial model may improve WAD treatment and help prevent chronic disability.^xi

Classification of patients with chronic WAD may include measures of self-efficacy, disability, and coping such as the NDI, Multidimensional Pain Inventory-Swedish version (MPI-S), The Self-Efficacy Scale, and the Coping Strategies Questionnaire.^xii

b. Cervical Spine Injury Severity Score

The Cervical Spine Injury Severity Score (CSISS), which was developed to measure stability after cervical spine trauma, has excellent intraobserver agreement (ICC, 0.97-0.99) and interobserver agreement (ICC, 0.75-0.98). This classification system is based on morphological descriptions and on quantifiable values of stability and applies to all fractures of the subaxial spine from the caudal aspect of C2 to T1. The score is based on bony and ligamentous disruption of the 4 columns of the cervical spine (anterior, right pillar, left pillar, and posterior osseous ligamentous complex) and correlates to increasing instability, Each column is graded using an analog scale from 0 to 5. Thus, the injury severity score ranges from 0 to 20, with 0 being no injury and 20 the most severe. The CSISS does not take into account neurologic function or deficits. A morphologic description of subaxial cervical fracture is proposed.^xiii

For more information on nonoperative management and treatment of spinal injuries and timing of surgical intervention in spinal cord injuries, see the reviews from Rechtine^xiv and Fhelings.^xv

(3) Clinical Criteria for the Diagnosis of LDH.^{xvi, xvii, xviii, xix}

Nerve root pain due to disc-root conflict should be deemed to be a symptom of multifactorial origin in which the neural and perineural inflammatory reactions and their mediators play a major role that is flanked by venous stasis due to mass effect on the perineural circulation. Nerve compression appears to play an adjuvant role by generating nerve conduction abnormalities due to fiber demylination by a direct or indirect anoxic-ischemic mechanism.^xx

Clinical criteria for the diagnosis of LDH include sciatic pain that originates at the back or buttock and radiates below the knee, either unilaterally or bilaterally, typically involving the foot. Often, a history of recurrent LBP over several months or years, with occupational risk factors, is reported before leg pain onset. The patient often has difficulty rising from a sitting or supine position and typically experiences only partial pain relief while supine. Coughing or sneezing often exacerbates the low back and leg pain (positive Valasalva).

On physical examination, the patient is in acute distress and may manifest an antalgic posture/gait and decreased lumbar lordosis due to marked paraspinal muscle guarding. Lumbar spine ranges of motion may be restricted, especially in forward flexion. Lower extremity neurologic examination^{xxi,xxii,xxiii} may reveal diminished deep tendon reflexes, loss of motor power, and sensory deficit of the involved nerve root (L4, L5, or S1). Reduced ankle reflex (L5-S1), weakness of ankle dorsiflexion (L4-5), foot drop, or weakness of the big toe (L5) requires special attention, as does reduced light touch in the L4, L5, or S1 dermatome. Straight leg raise will typically be restricted on the involved side with a high sensitivity (0.8) but a low specificity (0.4), whereas a crossed SLR (well leg-raise test) has a low sensitivity (0.35) but a high specificity (0.9) for the diagnosis of herniated discs. This may be confirmed by nerve root tension tests such as bowstring and Braggard's.

Wasserman maneuver (Elys test) evokes pain by stimulating the L2-L4 nerve roots when hyperextending the hip with the knee flexed at 90 while the patient is prone. Examination may reveal reduced patellar reflex (L2-L4), weakness of the quadriceps (L2-4), and possibly of ankle dorsiflexion (L4-5), and/or reduced light touch in L2, L3, or L4 dermatome. Bony and soft tissue tenderness may be noted over the lumbar and gluteal region, although not a prominent feature.

(4) Thoracic Spine Osteoporosis

A woman 65 years of age with one vertebral fracture has a 1 in 4 chance of another fracture over 5 years, which can be reduced to 1 in 8 by treatment. Positive treatment decisions are often contingent on identifying a vertebral fracture.^xxiv

Although it may not be possible to restore normal bone structure in women with osteoporosis, antiresorptive agents (eg, bisphosphonates, selective estrogen receptor modulators) can substantially reduce the risk of new vertebral fracture, even without corresponding increase in bone mass density, by reducing excessive bone turnover. Elevated bone turnover can be assessed with a number of biochemical markers such as osteocalcin, bone-specific alkaline phosphatase, C-telopeptides of type I collagen and N-telopeptide cross-links of type I collagen.^xxv

a. Important Osteoporosis Risk Factors:^{xxvi,xxvii,xxviii,xxix,xxx,xxxi,xxxii,xxxiii,xxxiv,xxxv,xxxvi,xxxvii}

b. Osteoporosis Risk Assessment^{xxxviii,xxxix,xl,xli,xlii,xliii,xliv}

In healthy perimenopausal and early postmenopausal women (45-64 years), consider using the Osteoporosis Self Assessment Tool (OST score): the OST considers only 2 variables: (weight in kilograms − age)/5. The cut-off for a positive test is <2, indicating this woman should be referred for DEXA.

In higher-risk patients, use either one of the following 3 clinical tools as they were all found to be highly sensitive:

Table 1. Osteoporosis Risk Assessment Instrument (ORAI).

The cut-off for a positive test is >8; indicating this woman should be referred for DEXA.

Table 2. Simple Calculation of Osteoporosis by Estimation (SCORE).

The cut-off for a positive test is >6, indicating this woman should be referred for DEXA.

Table 3. Age, Years After Menopause, Age at Menarche, BMI (AMMEB).

The cut-off for a positive test is ≥ 10, indicating this woman should be referred for DEXA

(5) Clinical Criteria for the Diagnosis of Cervicobrachial Syndrome

Cervical radiculopathy is a disorder of the cervical spinal nerve root, and most commonly is caused by a CDH or other space-occupying lesion. The annual incidence of cervical spine disc herniation with radiculopathy is approximately 5.5 per 100000 and tends to affect patients aged 35 to 55 years of age. The levels most commonly affected are C5-C6 and C6-C7.^xlv A clinical diagnosis of CDH is possible in only 50% to 75% of cases of cervical radiculopathy as a wide variation of presentations exists even with only 1 nerve root.^xlvi,xlvii Patients should be monitored as signs and symptoms may progress in the first 2 to 3 weeks.

Historical questions with diagnostic accuracy include shoulder/scapular pain, symptoms influenced by neck movement, presence of numbness/tingling, intermittent signs and symptoms, and symptoms that interrupt sleep.^xlviii

On physical examination, the patient is generally in acute distress and may manifest an antalgic posture. The upper limb tension test (ULTT) appears useful as a screening test given its high sensitivity (0.97). If the ULTT is negative, then cervical radiculopathy (CR) can essentially be ruled out, and the need for further work up or treatment for CR is minimized. Findings with useful diagnostic accuracy include cervical spine ranges of motion restriction (ipsilateral rotation less than 60°, and neck flexion less than 55°). Although not very sensitive, the following tests have moderate to high specificity for CR: traction/neck distraction, spurling, Valsalva, and the shoulder abduction test, reduced or absent dermatomal sensation (C5 most accurate), motor power, and deep tendon reflex (biceps most accurate). The probability of the condition increases with several positive findings.^xlix,l

(6) Persistent Neck Pain

(a) Identification of psychological risk factors (yellow flags):^li

(b) Mental status indicators of significant anxiety or depression:^li

Clinicians are encouraged to use validated patient self-administered questionnaires to evaluate perceived neck pain, function, disability, psychosocial status.

(c) Suspected cervical artery dissection (VAD, CAD), TIA (vertebrobasilar ischemia, carotid artery ischemia), stroke.

Acute neck pain is generally due to musculoskeletal conditions that respond well to conservative therapy. Risks of adverse events need to be addressed when considering any form of therapy. Several risk factors have been proposed for cervical artery dissection.^{lii,liii,liv,lv} Cervical artery dissection may be considered multifactorial,^lvi resulting from cumulative events over a period of time. Patient having cervical artery dissections tend to be females under the age of 45: recently, an etiologic model to help explain the pathogenesis of cervical artery dissection has been proposed.^lvii Recent studies and reviews discussing the nature of the association between vertebrobasilar stroke and chiropractic care are available elsewhere.^ix-ixi

It is likely that patients in the early stages of VBA stroke are presenting to a health care professional because of neck pain and headache due to pre-existing vertebral artery dissection which is a risk factor for VBA stroke.

None of the proposed risk factors may be visualized on conventional radiography. Few case reports have linked advanced cervical spondylosis to vertebral artery dissection, suggesting ostophytes off the uncovertebral joint or superior articular process may be associated to a dissection. Advanced cervical spondylosis mostly concerns the older age population which would normally undergo radiographs when presenting with a neck complaint. Major neck trauma is likely an independent risk factor for CAD. Again, imaging studies are indicated in those circumstances.

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li. Haldeman, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999 Apr 15; 24(8):785-94.

lii. Rothwell DM, Bondy S, Williams JI. Chiropractic manipulation and stroke. A population-based case-control study. Stroke 2001; 32:1054-60.

liii. Grau AJ, Brandt T, Forsting M, Winter R, Hacke W. Infection-associated cervical artery dissection. Stroke 1997; 28: 453-5.

liv. Calvet D et al. Increase stiffness of the carotid wall material in patients with spontaneous cervical artery dissection. Stroke 2004;35(9):2078-82.

lv. Rubinstein SM, Peerdeman SM, Van Tulder MW, Riphagen I, Haldeman S. A systematic review of the risk factors for cervical artery dissection. Stroke 2005; 36(7):1575-80.

lvi. Rubinstein SM, Haldeman S, van Tulder MW. An etiologic model to help explain the pathogenesis of cervical artery dissection: implication for cervical manipulation. J Manipulative Physiol Ther 2006; 29(4):336-8.

lvii. Rubinstein SM, Haldeman S, van Tulder MW. An etiologic model to help explain the pathogenesis of cervical artery dissection: implication for cervical manipulation. J Manipulative Physiol Ther 2006; 29(4):336-8.

lviii. Chiripractic clinical practice guideline: evidence-based treatment of adult neck pain due to whiplash. Can Chiropr Assoc 2005;49(3).

lix. Triano J, Kawchuk G, Hall C et al. Current concepts in spinal Manipulation and cervical arterial incidents. NCMIC chiropractic solutions. 2006, p118.

lix. Boyle E, Côté P, Grier AR, Cassidy JD. Examining vertebrobasilar artery stroke in two canadian provinces. Spine 2008;33(4S):S170-S175.

lxi. Cassidy JD, Boyle B, Côté, He H, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of vertebrobasilar stroke and chiropractic care — Results of a population-based case-control and case-crossover study. Spine 2008;33(4S):S176-S183.

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Appendix D. General Indications for Advanced Imaging in Spine Disorders 

++ indicates first choice; +, second choice (must be determined on a case-by-case basis).^a,b

NB. For the estimated accuracy of imaging technique for lumbar spine conditions, please see Jarvik (2002).⁴

a. Adapted with permission from Peterson C. Canadian Guidelines for Imaging, 2002 (unpublished).

b. Taylor JAM. NYCC imaging protocols, 2003 (unpublished).

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Appendix E. Typical Effective Ionized Radiation Dose for Common Imaging Procedures* 

*Classification of the typical effective dose of ionizing radiation from common imaging procedures. Adapted from: European Commission. Radiation Protection 118. Referral guidelines for imaging in conjunction with the UK Royal College of Radiologists; Italy 2001. p 21.

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Appendix F. Additional Reading Recommended on Spinal MRI 

DeVries RM, Manne A. Cervical MRI. Part I: a basic overview. Clin Chiropr 2003;6(3-4):137-43.

Wessely MA. Cervical MRI. Part II: a common disorders affecting the cervical spine. Clin Chiropr 2004;7(1):31-9.

Wessely MA. Magnetic resonance imaging of the thoracic spine. Part 1: normal imaging anatomy. Clin Chiropr 2004;7(4):187-95.

DeVries RM, Wessely MA. Magnetic resonance imaging of the thoracic spine. Part 2: common disorders. Clin Chiropr 2005;8(1):33-40.

Grenier JM, Wessely MA. Hip and pelvis MRI: Part 1. A basic overview. Clin Chiropr 2006;12:92-8.

Grenier JM, Scordilis PJ, Wessely MA. Lumbar MRI: Part 1. Normal imaging appearance. Clin Chiropr 2005;8:205-15.

Grenier JM, Scordilis PJ, Wessely MA. Lumbar MRI: Part 2. Common pathological features. Clin Chiropr 2006;9:39-47.

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Appendix G. Acknowledgments 

The authors express their sincere appreciation to all Delphi panelists (phase 5), external reviewers (phases 4 and 7), and to the quality of literature assessors (phase 2): Jeffrey Cooley, Jonathon Egan, Michael Morgan, Julie O'Shaughnessy, and Jason Napuli, whose significant contributions were essential in the completion of this project. We are grateful to chiropractic college presidents for recommending faculty members for the Delphi panel. We have appreciated the feedback received by colleagues in the field during and after the worldwide consultation on the Web (Phase 6). Many thanks to Dr Andre Cardin of Université du Québec à Trois-Rivières for his significant input in the initial draft (phase 3); Dr Michelle Wessely of the Institut Franco-Europeen de Chiropratique and Dr Julie-Marthe Grenier of Université du Québec à Trois-Rivières for their valuable editorial input; and to Drs Carlo Ammendolia, DC, PhD; Joe Lemire DC, MSc; John Triano, DC, PhD; and Jacques Duranceau, MD, for providing constructive advice. The authors are indebted to those who assisted us during all or part of the project, including Drs Mark Laudadio, DC; Christian Eid, DC; Julie Roy, DC; Nicholas Beaudoin; and Mme Valérie Lambert, academic and technology support, Computer System Development Division at UQTR. Finally, we would like to thank Mrs Vicki Pennick, RN, BScN, MHSc, Senior Clinical Research Project Manager, Managing Editor, Cochrane Back Review Group, Institute for Work and Health for her valuable advice and pertinent comments and suggestions as a public representative. We further apologize, once again, to those who experienced temporary technical difficulties with the evaluation questionnaires at the onset of Website consultations (Delphi, Public and External review).

We wish to acknowledge all Delphi panelists who have dedicated their time to this project. The following is a list of Delphi panelists who have agreed to be acknowledged for their significant contribution to the research project.

Allan Adams, DC, MSEd

Texas, USA, Texas Chiropractic College (Academic and Researcher)

Peter Aker, DC, MSc, FCCS, FCCRS

Ontario, CANADA (Clinician and Researcher)

Thomas F. Bergmann, DC

Minnesota, USA, Professor, Northwestern Health Sciences University (Academic, Clinician)

Douglas G. Brandvold, DC

British Columbia, CANADA (Clinician)

Gert Bronfort, DC, PhD

Minnesota, USA, Professor, Northwestern Health Sciences University (Researcher and Academic)

Peter Bull, DC, MAppSc, FICC

Sydney, AUSTRALIA, Senior Lecturer, Director of Postgraduate Studies, Macquarie University (Academic and Clinician)

Jeanmarie Burke, PhD

New York, USA, Research Director, New York Chiropractic College (Researcher and Academic)

Jane Cook, DC, DACBR

Bournemouth, UK, Anglo European Chiropractic College (Academic)

Jeffrey Cooley, DC, DACBR

Perth, West Australia, Senior Lecturer, Murdoch University (Academic)

Martin Descarreaux, DC, PhD

Quebec, Canada, Université du Québec à Trois-Rivières (Researcher, Academic and Clinician)

Renee DeVries, DC, DACBR

Minnesota, USA, Associate Professor and Consulting Radiologist, Northwestern Health Sciences University (Academic)

Paul Dougherty, DC, FACO

New York, USA, New York Chiropractic College (Academic)

Dennis Enix, DC, MBAc

Missouri, USA, Associate Professor of Research, Logan College of Chiropractic (Researcher and Clinician)

Ronald C. Evans, DC, FACO, FICC

Iowa, USA, Senior Orthopedist, Senior Trustee, Foundation for Chiropractic Education and Research, Senior Member, Chiropractic Healthcare Benefits Advisory Committee, Health Affairs, Department of Defense (Researcher and Clinician)

Roni Evans, DC, MSc

Minnesota, USA, Dean of Research, North Western Health Sciences University (Researcher)

Francis Fontaine, DC, MD

Quebec, Canada, Lecturer, Université du Québec à Trois-Rivières (Clinician)

Simon Forster, DC, DABCO

Texas, USA (Clinician)

Bryan Gatterman, DC, DACBR

California, USA, Life West Chiropractic College (Academic and Clinician)

Claude Gauthier, DC

Quebec, Canada (Clinician)

Kristin L. Grace, DC, DACBR

Pontypridd, Wales, University of Glamorgan, School of Applied Sciences (Academic and Clinician)

Gary Greenstein, DC

Connecticut, USA (Clinician)

Julie-Marthe Grenier, DC, DACBR

Quebec, Canada, Université du Québec à Trois-Rivières (Academic and Research)

Mitchell Haas, DC, MA

Oregon, USA, Dean of Research, Western States Chiropractic College (Academic and Researcher)

François Hains, DC, MSc, FCCS

Quebec, Canada (Clinician)

Michael W. Hall, DC, DABCN

Texas, USA, Associate Professor, Parker College of Chiropractic (Academic and Clinician)

Jan Hartvigsen, DC, PhD

Odense, Denmark, Dean of Research, University of Southern Denmark (Academic and Researcher)

Shawn Henderson, DC, FCCRS(C), FCCO(C)

Ontario, Canada (Clinician)

William Hsu, DC, DACBR

Ontario, Canada, Associate Professor, Canadian Memorial Chiropractic College (Academic)

Eric Jackson, DC, FCCRS

Ontario, Canada (Clinician)

Amanda Kimpton, BAppSc(Chiro), PhD

Victoria, Australia, RMIT University (Academic and Clinician)

Dana J. Lawrence, DC, FICC

Iowa, USA, Associate Professor, Palmer Chiropractic College (Academic and Researcher)

Douglas Lawson, BA, DC

Alberta, Canada (Researcher and Clinician)

Kathleen Linaker, DC, DACBR

Georgia, USA, Assistant Professor, Director Clinic Radiology, Life University College of Chiropractic (Academic, Clinician)

Tracey Littrell, DC, DACBR

Iowa, USA, Associate Professor, Diagnosis and Radiology, Palmer-Davenport Chiropractic College (Academic)

Stephan Mayer, BSc, DC

California, USA, Chair of Diagnostic Sciences and Associate Academic Dean, Cleveland Chiropractic College (Academic)

Peter W. McCarthy, BSc (Jt Hons), PhD

Wales, UK, University of Glamorgan (Researcher and Academic)

Ian D. McLean, DC, DACBR

Iowa, USA, Professor, Clinical Radiologist Professor, Director of Clinical Radiology and Chiropractic Residencies, Palmer-Davenport Chiropractic College (Academic and Clinician)

Michael Mestan, DC, DACBR

New York, USA, Head of Department of Chiropractic Clinical Sciences, New York Chiropractic College (Academic)

Timothy J. Mick, DC, DACBR, FICC

Minnesota, USA (Clinician)

Silvano Mior, DC, FCCS

Ontario, Canada, Canadian Memorial Chiropractic College (Researcher and Clinician)

Tom Molyneux, DipAppsc (H Biology), DipAppSc(Chiro), BAppSc(Chiro), DACBR, FACCR, GradDipTertEd.

Victoria, Australia, RMIT University (Academic)

William E. Morgan, DC

Maryland, USA, Adjunct professor, New York College of Chiropractic, National University of Health Sciences (Clinician)

Elli Morton, DC

British Columbia, Canada (Clinician)

Greg Norton, DC, FACO, FIACN

Iowa, USA (Clinician)

Sandra O’Connor, DC, DACBR, FCCR

Ontario, Canada (Clinician)

Rosemary Pace, RN, DipAppSc(MedRad), MEd (ICT), MBus, GradDipEd, GradDipBus

Victoria, Australia, RMIT University (Academic and Researcher)

Joseph Pfeifer, DC

New York, USA, New York Chiropractic College (Academic)

John Pikula, DC, FCCR(C), FCCS(C), FCCO(C)

Ontario, Canada (Clinician)

Brock Potter, DC

British Columbia, Canada (Clinician)

Tania C. Pringle, BPE, BA, DC, DACBR, FCCR(C)

Ontario, Canada, Assistant Professor, Canadian Memorial Chiropractic College (Academic)

Serge Roux, DC, DABCO

Quebec, Canada (Clinician)

Peter Scordilis, DC

New Jersey, USA (Clinician)

Thomas A. Souza, DC, DACBSP

California, USA, Dean of Academic Affairs, Palmer Chiropractic College West (Academic and Clinician)

John Stites, DC, DACBR

Iowa, USA, Palmer Chiropractic College (Academic)

Rand Swenson, DC, MD, PhD

New Hampshire, USA, Associate Professor of Anatomy and of Medicine, Chairman, Department of Anatomy, Dartmouth Medical School (Academic, Clinician)

John Sweaney, AM, DC

New South Wales, Australia, Chiropractic Education Consultant (Clinician)

Cliff Tao, DC, DACBR

California, USA (Clinician)

Jeffrey Thompson, DC, DACBR

Texas, USA (Clinician and Researcher)

Michelle A. Wessely, BSc, DC, DACBR

Paris, FRANCE, Professor, Head of Radiology and Clinical Research, Institut Franco-Europeen de Chiropratique (Academic and Clinician)

Michael Whitehead, BS, DC, DACBR

Missouri, USA, Chair of Diagnostic Sciences, Cleveland Chiropractic College (Academic and Clinician)

Kenneth J. Young, DC, DACBR, FCC(UK)

Wales, UK, Senior lecturer in radiology, University of Glamorgan (Academic and Clinician)

DELPHI PROCESS ADVISORS

Meridel I. Gatterman, MA, DC, MEd,

Colorado, USA, Chiropractic Educational Consultant

Peter Miller, BSc, MSc, FCC (Orth)

Bournemouth, UK, Anglo-European College of Chiropractic

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