A spinal x-ray is an imaging technique that uses electromagnetic radiation to provide a general overview of the spine. Spinal x-rays are used for the evaluation of the bony structures, such as the vertebrate and joints, in diagnosing and guiding medical treatment for conditions that cause neck or back pain.

Also called a plain or conventional radiograph, the x-ray is one of the first tests ordered when a back or neck problem is suspected.

Spinal Conditions That May Be Identified on an X-ray

The conventional x-ray typically has five views of the spine: one anteroposterior (or front-to-back) view, two lateral (or side) views, two (left and right) oblique views, and one odontoid view (taken from the front, to view the neck, with the mouth open). One or more of these views may be used in aiding the diagnosis of 1 Hackett BA. The role of imaging in diagnosis of low back pain. Journal of Radiology Nursing. 2020;39(3):154-155. , 2 Oakley PA, Cuttler JM, Harrison DE. X-Ray Imaging is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation: Radiography Increases Benefits and Reduces Risks. Dose Response. 2018;16(2):1559325818781437. Published 2018 Jun 19. doi:10.1177/1559325818781437 :

  • Compression fractures
  • Spinal arthritis and bone spurs
  • Spinal tumors
  • Spinal alignment disorders (abnormal curves of the spine), such as scoliosis or kyphosis
  • Stress fracture or spondylolysis
  • Foraminal stenosis (narrowing of the bony openings in the spine through which the spinal nerves pass)
  • Spinal osteopenia (thinning of the spinal bones)
  • Birth defects (such as a cervical rib, lumbar sacralization or fusion of the L5 vertebra with the pelvic bone, spina bifida occulta, and other abnormal fusions in the spine)

A full-length spinal x-ray series, also known as a “scoliosis series,” is taken while standing. The series provides important postural data, such as segmental and total angles of curvature between the vertebrae, balance, and degenerative processes. 2 Oakley PA, Cuttler JM, Harrison DE. X-Ray Imaging is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation: Radiography Increases Benefits and Reduces Risks. Dose Response. 2018;16(2):1559325818781437. Published 2018 Jun 19. doi:10.1177/1559325818781437

See Cobb Angle Used to Measure Scoliosis Curves

The visualization of soft tissue structures is not well defined in a conventional spinal x-ray. For example, the details of the spinal canal that houses the spinal cord or the severity of a disc herniation may not be clear in an x-ray and may need a more detailed imaging study. 1 Hackett BA. The role of imaging in diagnosis of low back pain. Journal of Radiology Nursing. 2020;39(3):154-155.

How Spinal X-ray Works

X-rays are high-frequency energy waves that can penetrate through the body and are either absorbed, reflected, or traversed through the target tissue(s). 3 Nakashima J, Duong H. Radiology, Image Production and Evaluation. [Updated 2021 Aug 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553145/?report=classic When they pass through the tissues, x-rays have the ability to create two-dimensional black-and-white images of the structure(s) that they’ve traversed on a photographic film placed on the opposite side of the body. Spinal x-rays can be captured to specifically focus on the 3 main parts of the spine–cervical spine (neck), thoracic spine (mid-back), and lumbar spine (lower back) as well as the pelvis, which includes the sacroiliac joint.

X-ray of spinal bones

Dense tissues with high calcium content, such as bone, absorb less x-ray and create a white-colored image on the photographic film. Bones are the best and most clearly visualized structures on an x-ray. The structure, shape, and alignment of the spinal vertebrae and facet joints can be well-documented in spinal x-rays.

X-ray of spinal soft tissues

Soft tissues allow more x-ray to pass through them, creating a black impression on the photographic plate. Muscles, ligaments, and tendons, which are often a source of back and neck pain, are not very well-visualized on a conventional x-ray. Similarly, neural tissues, like the spinal cord and spinal nerves, that may cause back or neck pain are usually not well defined in conventional x-rays. A tumor, which is also a mass of tissue, can be visualized on an x-ray due to its bulk and position.

Fluoroscopy and Live X-ray of the Spine

Physicians may use x-rays for live guidance while evaluating internal spinal structures, such as the spinal joints or nerves. This process is called fluoroscopy and includes the injection of a contrast agent or dye into the target tissue. The dye highlights the tissues to be evaluated and shows a continuous x-ray movie on a computer screen. Through these live visuals, physicians can precisely guide injection needles for administering diagnostic or therapeutic spinal injection treatments into the epidural space, facet joints, intervertebral foramen, and other target areas of the neck or back.

Preparing for a Spinal X-ray

It is essential to remove all jewelry and any clothing or accessories that contain metal, as metals can interfere with x-ray beams and cause impressions on the film that affect the test results. It is also important to alert the radiology technician about insulin pumps or glucose monitors, which should be removed before taking the x-ray to prevent damage by radiation exposure.

Several clinics and laboratories ask patients to wear a hospital gown after removing personal clothing to avoid metals or other objects on the clothing (eg, zippers or buttons) from obstructing the x-ray.

Spinal X-ray Procedure

An x-ray is taken relatively quickly, in a few seconds, and is a painless procedure. The patient does not feel any radiation passing in or out of their body. Movements are not allowed while taking an x-ray because any movement can blur the final image.

Back x-ray

X-rays of the upper and/or lower back may be taken in a standing or lying down posture, depending on the part that needs to be analyzed in the film. If the physician suspects abnormal curves or wants to assess the posture or tilt, a standing pose may be favorable. For specific pathologies, such as fractures or congenital defects, a lying-down pose may be appropriate. The radiology technician may also ask the patient to move the arms out to the side or upward in some cases.

Neck x-ray

X-rays of the neck taken from the front may need an open-mouth position to move the teeth out of view and get a clear view of the cervical vertebrae on the x-ray film.

Protection from scattered beams

During an x-ray, the radiology technician covers the patient’s body parts around the target tissue with a scatter drape made of a radiation-absorbing material, such as lead or bismuth. This drape minimizes the risk of excessive radiation exposure through scattered beams.


Spinal X-ray During Pregnancy

Spinal x-rays are in general not recommended for pregnant women. A high risk of fetal exposure to radiation occurs during lower back and pelvic x-rays, making radiographic images of these specific regions inappropriate for pregnant women. A growing fetus is sensitive to the effects of radiation, which may cause damage to the rapidly growing and dividing cells within its body, increasing the risk of birth defects or specific types of illnesses, such as leukemia, later in life. 4 X-Rays, Pregnancy and You. US Food and Drug Administration. Accessed May 10, 2022. https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/x-rays-pregnancy-and-you

It is advisable to talk to the treating physician if pregnancy is confirmed or suspected, even in the very early stages, so that other diagnostic methods can be determined.

With newer technology, spinal x-rays are precise, informative, and capture useful details of the spine to help physicians and medical professionals diagnose and treat back pain and neck pain. Patients can always request a copy of the x-ray(s) and keep it for reference. If a second opinion is needed, there is generally no need to repeat the x-ray right away; the same copy can be used.

Read more about Getting an Accurate Back Pain Diagnosis

Dr. Adaku Nwachuku is a physiatrist with Privium Consultants, where she specializes in treating musculoskeletal and spine pain. Dr. Nwachuku has been published in the Oxford Handbook of Physical Medicine & Rehabilitation as well as in several medical journals. She also coordinates and participates in medical missions to Nigeria.