Should I get an MRI?

“RELAX. Don’t do it… when you want to go to it!” What I plead to the majority of people who tell me that they are scheduled for an X-ray or MRI.

 

More often than not, your spine, knees and hips are a scary site on imaging. It is like looking at yourself in the mirror when you first get out of bed. Don’t get me wrong; having sophisticated equipment to screen for more serious acute injury and disease is a blessing. It guides medical providers in determining when surgery is a necessity. But, it is important to understand that these red flag findings on imaging are a rarity in low back pain complaints (cancer .07%, spinal infection .01% and cauda equina syndrome .04%)(16).

 

The problem we run into is overuse of this medical imaging in situations when it is not warranted. I understand that fear or uncertainty related to your pain can cause a great deal of stress. I know that having certainty provides relief. Unfortunately, seeking that certainty from medical imaging can lead you down a path you did not sign up for.

 

What scenarios currently warrant imaging for lower back pain following medical evaluation? (17)

  • Severe or progressive neurological deficit (numbness in genital region, changes in bowel/bladder function, sudden or progressive weakness)
  • Serious underlying pathology (cancer or infection)
  • Fracture (associated with trauma, steroid use or osteoporosis)
  • Non-spinal causes of back pain (i.e. pyelonephritis, pancreatitis, penetrating ulcer disease or other gastrointestinal causes, and pelvic disease).

 

If you are concerned, click here for more red flag symptoms.

 

Low back pain is a 100-billion dollar problem that has progressively gotten worse despite medical advances in imaging (16). A study that looked at adherence to current treatment guidelines from 1999 through 2010 found a 56.9% increase in the use of CT and MRI. “Six randomized controlled trials have found that imaging in the acute care setting provides neither clinical nor psychological benefit to patients with routine back pain, and multiple prospective studies have found lack of serious disease in the absence of red flag symptoms.”

 

When you are the one with pain you question these guidelines, but PLEASE trust the process. Routine low back pain will often resolve itself in three months in the absence of any scary red flag symptoms (16). I applaud most insurance companies as of late because they’re making an effort to hold medical providers to the guidelines that are in place. As medical providers, we fail to stick to the guidelines in place. Even worse, we provide contradictory information. Here is a great example – wait for it… bending and twisting are NOT bad for your back! I know… your mind is BLOWN. I guarantee the majority of people reading this article have heard this at one time or another. If you tell someone not to bend because they could “hurt a disc” or “pinch a nerve,” what do they do? That’s right, they stiffen up, breathe like crap and end up being in more pain because of increased tissue tension. {click here for more information}

 

Great strides have been made in the world of research to show us what has and hasn’t worked over the last couple of decades. We (medical providers) all have access to it, but for some reason we let our own bias or agendas dictate our decisions. According to Chou et al., “Diagnostic Imaging for Low Back Pain,” research from as early as 2002 has shown that acute back pain, with or without radiculopathy, often resolves in 4 weeks. Sadly, we still see imaging ordered when it is not warranted, resulting in no improvement in outcomes and increased costs to patients.

 

The National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey looked at trends between 1999 and 2010. Based on that data, here is what we know:

 

Facts About MRI:

  • An eight-fold increase in back surgery rates can been seen with early MRI use. (10)

 

  • Regions that perform more MRIs have higher surgery rates. The procedure used is also dependent on the MRI findings. (11)

 

  • In one study, 32% of subjects without pain had “abnormal” lumbar spines on imaging (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression). (11)

 

  • More than 90% of imaging in people over 60 years old showed degenerative changes of the spine, often times without any symptoms. (13)

 

  • 106% increase in primary care physician referrals to other physicians from 1999 to 2010. These referrals likely contribute to increased use of imaging, and in turn resulted in the rise in costly ineffective surgeries. (4-7)

 

Conclusion

The point of this article is to reassure people that degenerative findings on imaging are common for people without back pain. Seeking “answers” from MRI and x-ray has not helped medical providers lower the frequency of back pain. It has only caused health care related expenses to increase. Being educated allows you to be an active participant in discussions related to your care or a family members care. This helps you and your health care provider make decisions that lead to more effective results.

 

Overview

  • High-tech imaging should not be a first line of defense unless you meet the guidelines above

 

  • Degenerative findings on imaging is a commonality in people with and without pain

 

  • Most back pain resolves itself within three months (understanding pain, resuming activity and good self-care practices can drastically speed this up)

 

Michael Infantino, DPT

 

 

  1. Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189.
  2. Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3(3):230-238.
  3. Martell BA, O’Connor PG, Kerns RD, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146(2): 116-127.
  4. Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ trends and regional variations in lumbar spine surgery: 1992-2003. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
  5. Schafer J, O’Connor D, Feinglass S, Salive M. Medicare Evidence Development and Coverage Advisory Committee Meeting on lumbar fusion surgery for treatment of chronic back pain from degenerative disc disease. Spine (Phila Pa 1976). 2007;32(22):2403-2404.
  6. Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine (Phila Pa 1976). 2007;32(7):816-823.
  7. Gray DT, Deyo RA, Kreuter W, et al. Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine (Phila Pa 1976). 2006;31(17):1957–1963.
  8. Gibson JNA, Waddell G. Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine (Phila Pa 1976). 2005;30(20):2312-2320.
  9. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):1259-1265.
  10. Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52(9): 900-907.
  11. Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine (Phila Pa 1976). 2003;28(6):616-620.
  12. Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6:106-114.
  13. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations Brinjikji, P.H. Luetmer, B. Comstock, B.W. Bresnahan, L.E. Chen, R.A. Deyo, S. Halabi, J.A. Turner, A.L. Avins, K. James, J.T. Wald, D.F. Kallmes, and J.G. Jarvik
  14. Anthony Delitto, Steven Z. George, Linda Van Dillen, Julie M. Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R. Denninger, Joseph J. Godges (2012). Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy 42:4, A1-A57.
  15. Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine, 173(17), 1573-1581. doi:10.1001/jamainternmed.2013.8992
  16. Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. J., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals Of Internal Medicine, 147(7), 478-491.
  17. “Imaging for Low Back Pain.” Clinical Recommendation. AAFP, n.d. Web. 18 Feb. 2017.
  18. Chou R, Qaseem A, Owens DK, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med. 2011;154:181-189. doi: 10.7326/0003-4819-154-3-201102010-00008

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