Digital imaging is rapidly replacing photographic film as the standard for capturing and storing x-ray images. The advantages for today's chiropractor are many, such as image quality, amount of information from a single exposure, image manipulation, storage and transportability, not to mention patient safety from less x-ray exposure. Superior results, efficiency, and convenience are also benefits to consider. And while the initial cost of new digital equipment may be prohibitive for some, the cumulative savings from the elimination of ongoing film, processor, and chemical costs associated with traditional x-ray systems can compensate for the extra start-up expense.

Digital Quality

For Tony Lane, DC, Silverdale, Wash, the biggest reason for going to digital radiography was image quality and information. "We can see a lot more than we could ever see on film, and with just a single exposure," Lane says.

Lane uses the iCR 2600 digital x-ray imaging system from iCR Co. It's a cassette-based system, which Lane switched to after first entering digital with a direct view system imported from Japan. He much prefers the cassette system because of the shorter waiting time. "The work flows much faster," he says, "because you can interchange cassettes without having to wait for each image to download from the sensor." Lane gives an example: "Let's say I'm taking a lateral cervical and a flexion extension, a common combination. I can shoot the lateral cervical, then just change the cassette, have the patient tuck their chin forward, and take the flexion. It can happen in a matter of seconds, whereas with the direct system you have to download each image and wait 1 to 3 minutes before you can take another image."

Since making the change from direct to cassette, Lane also has upgraded the system hardware, including ramping up to a 600-milliamp generator, which he says has provided "even better detail."

"Now we can get instant results to determine if there's a fracture, so we know if it's safe to move ahead with treatment," he says. "Let's say someone has injured their shoulder badly, and you need to check for soft tissue swelling and injury as well as bone problems. You can adjust the window and level, and look at all levels of the target, from the most superficial, such as the clothing, deep into the bone, and all with just one exposure."

To illustrate, Lane cites the case of a recent patient who injured his hand while working on a construction site. The man worked near Lane's office, so rather than going to a hospital emergency department and waiting 4 to 5 hours to be seen, he came right over for an x-ray, which revealed a fracture. Lane put the digital image on a CD and sent it along with the patient to an orthopedist with whom he has a working relationship. Within an hour from the time of his injury, the patient "had his hand reduced, cast, and was on his way home."

The iCR 2600 digital x-ray imaging system; the cassettes seen at left are used for acquiring images.

The iCR 2600 system consists of a large scanner that's about 4 feet wide, 2 feet high, and 1 foot deep. A computer and software come bundled with the system, along with the rewritable cassettes. Cost is about $60,000 for "a good system" (you can spend a lot more, Lane says), and about another $20,000 for the hardware upgrade. Because of the savings realized from not having the recurring expenses of the old x-ray system, "you can break even in about two and a half years."

Lane, a graduate of the Los Angeles College of Chiropractic and for a time a practitioner at a Huntington Beach, Calif, facility, is enjoying the practice he shares with another chiropractor in Washington State. "Our practices are very similar, wellness-based with diversified techniques. We treat whole families, including children and the elderly."

Lane believes that digital imaging, with its data integrity, reproducibility, and transportability (in the past, he says, you had a 10% chance of ever seeing your x-ray films again), has contributed significantly to the success of his practice. "We even receive referrals from local physicians to do spot photos."

Digital in Motion

"It's the future!" That's the way Allan German, DC, Craig, Colo, sums up the growth in digital imaging. "Not just in chiropractic, but in any discipline related to muscular/skeletal/soft tissue injuries. When you can take 2,700 pictures in 2 or 3 minutes, instead of five or six per session like it used to be, it's night and day in terms of ease of diagnosis and better patient care."

Nearly 3,000 images in a couple of minutes? Yes, it can be done, but for that you need to go to the next level: digital motion x-ray. German claims he likes to "stay ahead of the curve," so when, in November 2007, he decided to bring digital imaging to his practice, he went directly to the DMX (Digital Motion X-Ray) developed by John Postlethwaite, DC, Palm Arbor, Fla (DMXworks.com). "We went right to motion because we knew that's where the future was going."

DMX is basically for people who experience pain in conjunction with bodily movement, whether it's during walking, turning the neck or shoulder, bending—any motion at all that brings pain. For MRI, CT, and regular x-ray, the patient has to be perfectly still. "But most people have pain when moving," German says. "With the DMX, you can locate the pain when it's happening."

As German explains, "For detecting whiplash injuries, for example, the gold standard has been the MRI. But there are no disks in the upper third of the neck between the occipital and the atlas, only muscles and ligaments." It's the same, he says, with the lower back—no disks. "So the injury in the upper neck and lower back most likely involves ligaments and muscles, and to diagnose this we need a motion study such as you get with the DMX."

Tony Lane, DC, positions a patient in preparation for digital x-ray using the iCR 2600 digital x-ray imaging system from iCR Co.

In this connection, German cites the case of a 22-year-old woman whose vehicle was rear-ended in a traffic accident. "All the MRIs and static (nonmotion) x-rays were negative, showing no problem. But a DMX study revealed that her C3 vertebra was moving too far forward and back, which had resulted in partial tears in all the ligaments holding it in place."

German likes to stay in motion, so he installed his DMX in a van. The cost is high—$180,000 versus about $85,000 if installed in an office—but German has a satellite clinic in Colorado Springs, so he is able to make good use of the portability, taking the DMX there for about 2 weeks after each 3-week stay in Craig.

Wherever he practices, German is finding things in his patients that he might not have been able to diagnose previously. "In December alone of last year, the first 50 studies showed 12 broken necks that the patients were previously unaware of, had never been diagnosed." For German and his patients, that kind of diagnostic accuracy, needless to say, is extremely significant in providing effective treatment.

Digital Offerings

Some of the companies in the digital imaging arena include ALLPRO Imaging, Melville, NY; HCMI, Springfield, Mo; and DMX Works, Palm Harbor, Fla.

ALLPRO Imaging features the ScanX14 computer radiography system. It utilizes a reusable phosphor storage plate that comes in three sizes, the largest measuring 14 x 17 inches and the smallest, 8 x 10 inches. Even the largest plate can be processed in the ScanX and sent to the computer for viewing in as few as 55 seconds. The plate also can be simultaneously erased while being scanned so it's ready immediately for the next exposure, and can be reused thousands of times. ALLPRO emphasizes that digital imaging is much more forgiving of exposure errors than traditional film because if the image is underexposed or overexposed, the computer adjusts the error and provides a useable image. This also eliminates the need for a repeat of the x-ray, thus sparing the patient additional irradiation.

The DMX System from DMX Works offers a digital solution for people who experience pain in conjunction with bodily movement.

At HCMI, the lead product is the Bennett DCX Direct Digital X-Ray. As pointed out by national sales rep Matt Grippi, DC, the Bennett DCX receptor uses a cesium iodide scintillator with a carbon fiber grid that allows for close to 400 speed, thus providing high-quality imaging as well as excellent grid cleanup. Grippi says the Bennett DCX system, on the market for 2 to 3 years, "has the largest installation base with over 200 units in US chiropractic offices." He also says that the software has undergone several revisions that "allow the doctor to do linear and angular measurements to accommodate a variety of techniques." Grippi believes that direct radiography is especially well suited to spinal imaging because of the rapid image acquisition time of 5 to 8 seconds, which allows for greater patient throughput.

At DMX Works, it's all about x-rays in motion, as the company manufactures two versions of its Digital Motion system: a portable configuration for convenient use in a clinical setting, and a mobile version for traveling to distant locations for on-site motion x-ray studies. In either setup, the Digital Motion X-Ray can be captured in real time and instantly recorded to DVD and digital video. The images can then be sent via e-mail. As noted earlier, the DMX system provides the means to identify problems with ligaments that can be seen only when the patient moves through specific ranges of motion, revealing irregularities that are often undetected by static x-rays and MRI. DMX Works provides initial training at the doctor's clinic following installation, and advanced training seminars are held monthly at the corporate office in Palm Harbor, Fla.

The Future Is Here

Whether the choice is computed radiography, direct radiography, or digital motion radiography, there is no question that digital imaging is here to stay and is quickly ushering out x-rays as we used to know them. With costs likely to come down, this new technology should be more readily available in the near future.

Alan Ruskin is staff writer for Chiropractic Products. For more information, please contact .