557- What Cervical X-rays Really Reveal About Pain, Degeneration, and Alignment in Practice

Welcome to The Evidence-Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to The Evidence-Based Chiropractor. I am your host, Dr. Jeff Langmaid. This week we are back with more brand new research and an awesome study from a doc I recently met, Dr. Tyler over at Palmer, Florida. Reached out to me, said, hey, I'm a listener of the show. I was involved and published a research study. If it makes sense, I'd love for you to highlight it on the podcast. And I was absolutely floored and super happy to do so. So that's what we're going to talk about today. And this is all about What cervical X-rays really tell us about pain, degeneration, and alignment. We're going to dive into this and much more. Big shout out to Dr. Tyler. Thanks for reaching out. Thanks for sharing the study, and I'm honored to share it here. We'll drop a link down in the show notes, of course. As we get started, a few shout outs to some of our partners. Leander Tables, $750 off their Series 950 using the code EBC2026, or Shockwave Centers of America, $500 off and a free cart. Massive savings for being a listener on this podcast. Thank you so much for tuning in, and thank you to our partners as well. So as you can imagine on the title of this study, we're going to get into one of those topics that can get chiropractors of all ilks fired up pretty quickly: cervical X-rays, degenerative changes, cervical curves. And more specifically, the question we're going to look to answer is, when you see degeneration, hypolordosis, or even cervical kyphosis on an X-ray, How much does that actually tell you about what your patient is feeling? Because there's 2 mistakes that chiropractors can make. Both are kind of throwing the baby out with the bathwater. On one side, you could look at imaging and say, well, none of this really matters. Degenerative process is just part of aging, and alignment and curvature don't really mean anything. That's probably too simplistic. On the other side, you could look at every structural finding that's not abjectly perfect even if it might be normal due to aging, and say, well, that's the reason why there's pain. We got big issues here. And I think this study gives us a really nice opportunity to live somewhere in the truth, which is, you know, there's 3 sides to every story, right?

Yeah.

One person's side, the other person's side, and the truth. And I think this study does a really good job living in the truth. So the paper is titled Associations Among Cervical Radiographic Morphology, Degenerative Severity, and Clinical Presentation. It's a retrospective cross-sectional study of 250 outpatient examinations. So this isn't like an abstract discussion about imaging. It's really practical. What relationships actually showed up between cervical X-ray findings and the patients sitting in front of this doc in practice, in clinic? And the headline's pretty straightforward. Age and degeneration, pretty strong relationship. Degeneration and pain, much weaker. Cervical curve and pain, relationship to be determined. And There's a lot to unpack with those statements, and that's what we're going to do today. So if we set the stage, neck pain, as you know, incredibly common. And anybody who's really looked at more than a few X-rays in their career know that degenerative findings are really, really common too. Disc space narrowing, osteophytes, facet degenerative changes, changes in alignment and curvature, loss of lordosis, sometimes kyphosis, straight, all of those things, right?

Yeah.

So the challenge is that structural abnormalities, as you know, don't automatically equate to symptomatology. So the authors point out that degenerative findings are frequently present in people without symptoms, as we all know, and can become increasingly common with age. So that immediately limits our ability to look at an image alone and say, that's why you hurt. I think that's actually really good news because it's us as docs, as I always used to say in practice, My job is to sort out the not perfects from the problems, or the problems from the not perfects. You're gonna have a ton of not perfects on a picture. I don't care about not perfects. What I care about are problems. And getting down to that often takes more than the image alone, which is why it comes down to you being the doctor doctor and saying, let me take a look at what you're telling me in the intake. What's the history here? What is the symptomatology? What does the imaging, if I have it, look like? What does the assessment and examination, how does this all combine to tell the story? So the researchers wanted to put several pieces together in one cohort. A lot of what we just described, looking at things like age, sex, degenerative severity, morphology, clinical presentation, pain intensity, patient-reported outcomes. And their hypothesis was specific. They expected age to have a stronger relationship with degenerative changes. than static cervical morphology would have with pain or clinical presentation. And that's basically what they found. So the study was a retrospective cross-sectional review of cervical X-ray and clinical records. So they went back 250 patients from 2021 to 2024, and there were no duplicate patients, you know, in there. The average age, 38 years old. Age range, 17 to 81. 132 women, 118 men. So pretty equally divided. And let's start breaking it down, what they actually measured on those films. So lateral cervical morphology was placed into one of 3 categories, normal cervical lordosis, hypolordosis, or kyphosis. AP morphology categorized as neutral alignment or lateral deviation or combined abnormality. Degeneration was graded as none, mild, moderate, severe. So these classifications came from finalized clinical reports issued by the board-certified chiropractic radiologist rather than, you know, the study author rereading themselves. So it was kind of a third party. Pain was measured on a standard 0 to 10, you know, numeric rating scale as far as that's concerned. And there were also several patient-reported outcome studies that kind of came in and out. So the Bournemouth Questionnaire Neck, Neck Disability Index, Headache Disability Index, and the Quadruple Visual Analog Scale. These instruments, of course, measure different things, have different scoring. So the research chose not to lump them all together. They stressed and emphasized that the Neck-Bornemouth Questionnaire, or NBQ, because it was the most commonly completed measure in this study. So hopefully that gives you kind of a basic framework as we start to dive in. So the key finding was age and degeneration were very strongly related, and that was the clearest finding. The correlation was 0.783, and that's a super strong relationship, 95% confidence interval. So in plain English, as age went up, degeneration on the X-rays went up substantially. And the raw numbers made this even easier to appreciate. The median age of patients with no degenerative changes, 25. The median age among patients with severe degenerative changes, 63. So gigantic separation right there. And it showed us that as you move from none to mild to moderate to severe, the age distribution shifted upwards appropriately. So that does not mean that degenerative changes are meaningless by any stretch of the imagination. So calling something age— and this is important— calling something age-related is not saying it's clinically irrelevant. Those are 2 totally different statements. And I think often they can be combined. It's like, ah, it's just age-related changes on one hand, or on the other hand, people are overemphasizing it. And it's— the bottom line is it's part of the clinical picture. The presence of degenerative changes by themselves don't prove that degeneration is the primary pain generator, but it could be, which is why you are the doctor to determine that. So this behaves differently in different conversations. So your neck is degenerating, the bones are wearing down, that's why you hurt. That's one conversation. Another maybe more nuanced way would be to say, hey, we see some degenerative changes. Those changes become common as you get older, My job is to interpret them in the context of what's going on with your symptoms and what we see on the exam so that we can make the best plan of action. So slight differences, but meaningful. Like the words I said were generally in the same ballpark, but man, the outcome and expectations of those words and the expectation setting that I'm doing as a clinical provider, as a clinician, massively different based upon the words that I choose, which is, again, something I think all of us should be auditing all of the time. So the second key finding was degeneration and pain were related, But they were weakly related. So this might be the most important clinical distinction on the paper. Degeneration severity did have a clinically significant association with pain. The correlation was 0.232. So as degeneration increased, pain tended to increase somewhat. And this is where you want to be careful with things. So technically, Degeneration is associated with pain, but that's clinically incomplete because statistical significance and the strength of the relationship are 2 totally different things. So the degeneration category explained only a small amount of the variability in pain. So degeneration matters. It does matter, but it's not the whole story. So, you know, there's clearly a lot of information that you can get from the imaging, and you should use that. But you should always pair it with the exam. You're gonna hear me say that time and time again. So here's what the author said. Degenerative findings may occur without substantial symptoms, and pain and function are influenced by factors not represented on radiographs. Probably not telling you anything you don't know, but it's just reinforcing what we do know, which is nice. And it's clinically intuitive. You probably have had a 70-year-old patient whose cervical X-rays look like, you know, this person's been through like 10 demolition derbies, osteophytes everywhere, disc spaces, nonexistent, and they say, yeah, my neck gets a little stiff sometimes. And then you see a patient and they're 30 years old, their X-rays look pretty good, and they're barely able to move their head because their neck hurts so bad. So that's not weird. That's exactly why structural imaging and pain can't be treated as interchangeable concepts. So if we take that one step further and say, well, what about function and disability? The same general pattern showed up. And that's with the Neck-Bournemouth Questionnaire. Among the 90 patients who had an NBQ score, degeneration severity was correlated at 0.230, statistically significant but weak. Age itself had a similarly weak association, 0.238. So pain and NBQ score, weakly correlated, 0.253. You can see where that's going. So there were relationships there, but they weren't overwhelming.

Right.

And cervical curvature in this study did not explain pain. So only 9.6% were classified as having normal cervical lordosis. So 57% of the patients in this study had hypolordosis, 33% were kyphotic. So 9 out of 10 patients in this study had something other than a normal lordosis, which is pretty interesting amongst itself. But the pain intensity did not differ across those categories. So the effect size was almost zero. So there really wasn't much there.

Yeah.

As far as that went. So if we go one step farther, we say radiculopathy. Radiculopathy was the primary presentation in about 25% of these patients. If you look at radiculopathy rates based on cervical curvature among patients with normal lordosis, 12% had radiculopathy, hypolordosis 27%, kyphosis 24%. So at first glance, you kind of look at it and say 12% to 27%, whoa, hypolordosis doubles the risk. Well, the unadjusted relationship was not statistically significant. So again, this is where the devil is in the details, so to speak, with a lot of this literature and research to say, okay, great, I see the numbers, but what does that really mean? So one of the most useful things in this study, in my opinion, were what the authors argued for, which is what we talked about on this podcast, which is imaging should be interpreted as one component of the broader clinical assessment.

Yeah.

Age matters. Symptom behavior matters. Trauma matters. Neurological findings matter. Functional limitation matter. Patient-reported outcomes matter. And the imaging belongs within that. And that is part of having sound clinical reasoning. So when we look at imaging, is imaging worthless? Absolutely not. Is imaging necessary? In some techniques, absolutely yes. In other techniques, it's going to be based upon how the patient presents. Clinically, what you see in your exam, what their health goals are, all of those things matter. And then if that's not complicated enough, of course, when we go one step farther, you know, nobody said being a chiropractor was easy. When we go one step farther, interpreting that imaging needs to be looked at within the entirety of things. So of the 250 patients in this study, 24— excuse me, 42% had no degeneration, 33% mild, 15% moderate, 10% severe. And the most common presenting complaint was neck pain, almost 50% of the people, 25% radiculopathy, 11% headache, and 10% previous trauma. So this paper is really cool because it showcases what's going on in a real practice with real patients. And in my mind, it continues just to move the ball down the court to say, continue to really value The entirety of your clinical exam. If somebody comes in with images, don't just read the report, take a peek at them yourself. There's value there. And additionally, if somebody's coming in, you know, and they don't have images, really weigh with yourself, do I need to take those images? Sometimes the answer will be yes, sometimes the answer will be no. And again, this is technique-specific, this is patient-specific. This is what are their health goals? This is how are they presenting? What's their age? What's their trauma history? Yeah. What are you seeing in your movement assessments or exams? All of this really matters. And imaging is and continues to be an important part of what we do. But that is the critical component. It's a part of what we do and always needs to be looked through the lens of the broader picture of the patient themselves. And then combine that with your clinical expertise, your clinical reasoning. That's ultimately, how you produce the best outcomes in your practice time and time again. So thank you so much, Doc, for sharing this study with me. I hope I did it justice. You can send me an email and let me know. Additionally, big shout out to NovoPulse and their OA Recovery Program. They have a managed service option where you use no capital expense. Yes, you heard that correctly, no capital expense. You can visit a link down below, connect with their team. In addition to that, Dr. Grant Elliott, his RehabFix Hybrid Program. If you wanna make more money, help more people beyond the 4 walls of your practice, but including those individuals, you don't have to just have an online practice. This is about creating opportunities beyond the 4 walls of your practice. You'll— if you want to go totally digital, he'll help you do that. If you want to extend, like most docs, you want to just extend beyond the 4 walls, he is probably the world's leading expert in that. The Rehab Fix Hybrid Program, uh, you can talk with Grant, see if it's a great fit for you, your practice, and your goals within your business as well. Thank you so much for tuning in. If you've not left a rating or review, I'd love it if you would take a moment and Do so. Have a fantastic week in practice, and I will talk to you soon.

Thank you for joining us on this episode of The Evidence-Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit theevidencebasedchiropractor.com and join our MD marketing membership today.