December 2017

General Advice

Do X-rays Lie?

The problem does not lie with the x-rays.  Instead, the potential problem is with the viewer of the x-rays.  I am referring to the reporter, the expert who is interpreting the films.  


There is an old saying that the clinical circumstance cannot be worse than the worst x-ray image.  That is to say, not all radiographs will depict an underlying problem.  Conversely, if a problem is depicted, the problem is real.


Another interesting concept is the folklore that states that patients with exceedingly severe degenerative changes on an x-ray can be completely unaware of the condition at a clinical level.  I sometimes see this with the cervical spine.  Patients can have extremely severe degenerative disease at all levels from the base of the skull down to the upper thorax.  The disc spaces may be almost completely obliterated, large spurs may have formed, the end plates could be extremely sclerotic and osteophytes have protruded out and almost completely obliterated the intervertebral foraminae, the canals through which the exiting nerve roots are obliged to pass.  Despite the severity of these findings, a plaintiff may say that he or she was completely asymptomatic, completely unaware of any problem in the neck prior to the subject accident which forms the basis of the claim.  


In reality, the only time I ever see this circumstance in existence is in the Court room.  I suppose we should never say never in orthopaedics.  In this situation however, I can honestly say that I have never seen a patient with this type of radiographic appearance to be completely asymptomatic.  

normal lumbar spine

It would be worthwhile being wary of this presentation if ever you encounter it.