Controversy: Imaging, is it helping your patient or wallet?


Controversy: Imaging, is it helping your patient or wallet?

When diagnosing the culprit of lower back pain, many clinicians rely on diagnostic imaging (i.e.: x-ray, MRI, CT). Lumbar pain is reassuringly benign, 85-90% of the time. Lumbar pain involving nerve compression comprises 10% of lumbar pain patients. Sinister or serious disease make up the remaining 2% of lumbar pain patients. The great news is that these ‘sinister’ conditions are ruled out by a proper history and exam. However, many clinicians still seem to be ordering imaging during the initial exam. The question often raised is

“structural pathology is often evident in images, so why wouldn’t we (the clinician) want to identify such abnormalities?”

While structural pathologies do have there place in medicine, they usually have little to do with lower back pain. In fact, most lumbar pain patients do not have a structural pathology that can be precisely identified as being a cause of their symptoms. McGuirk et-al found that 1.4% of lumbar pain patients had serious causes as a result of their lumbar pain, but they were suspected from the initial exam and history.

What about disc herniation?

Because the false positive rates are so high, in identifying a herniated disc, it makes imaging inappropriate as a screening procedure. Moreover, it can lead to labelling thus allowing the patient to assume a sick role or cause the doctor to prescribe unnecessary treatment. In a study performed by Bonenstein et-al, 67 asymptomatic individuals received MRI’s. The results were staggering, in that, 31% of them showed abnormality of the disc or spinal canal. Moreover, additional studies showed that these abnormalities didn’t predict a greater chance of future problems. Multiple studies have also shown that common “positive” findings are present in 28% to 50% of people with no pain at all! Disc herniations have a tendency to resolve in a natural process without surgery. But, what about the herniations that require surgery? The Danish guidelines show the following as being surgical indicators for herniated discs. 1: No improvement after 4-6 weeks 2: Progressive weakness in the leg 3: Leg symptom remains severe despite treatment and medication 4: There is a positive correlation between clinical findings and imaging reports. What about spinal degeneration (decay)? Again this is a term that instils fear into a patient. Disc degeneration is demonstrated with equal properties between those with and without pain. The prevalence of disc degeneration in people without pain and in their middle ages ranges from 46% to 93%! Therefore there is little correlation between radiological signs of degeneration and clinical symptoms.

When is imaging appropriate?

Most acute lumbar pain patients resolve quickly and with little intervention. In fact, It has been shown time and time again that reassurance, simple pain relief and staying active, is the best strategy for managing active lumbar pain. If there are red flags (sinister conditions) present, they should be picked up during the initial history and exam. Red flags of the serious disease are as follows: Mri of the back 1: Age younger than 20, older than 50 2: Trauma 3: History of cancer 4: Night pain (unremitting) 5: Fevers 6: Weight loss (unexplained)\ 7: IV drug use 8: Cortico steroid use 9: Recent infection 10: Cavda Eqvina 11: Generalised Systemic Disease (diabetes) 12: Saddle Anesthesia 13: Motor weakness of lower limbs 14: Sphincter Disturbance 15: Failure of 4 weeks conservative care Given these guidelines we are able to form a simple strategy. If there are no red flags, consider: 1: Reassuring the patient no serious disease is present 2: Relieve and reduce pain (simple analgesics, manipulation) 3: Reactivation (stay active, no bed rest) If there are red flags present consider the following: 1: Imaging 2: Lab work 3: Referral Informing your patient that you are able to rule out sinister conditions, even though an exact cause of their pain may not be identified, will register as very reassuring news. Craig Leibenson gives a wonderful analogy for simple back pain:

“liken the pain to a common cold or the pain experienced from gardening for the first time after a long winter”.

Conclusion

In a study by Kendrick, patients who received x-rays were likely to report a longer duration and greater severity of pain. Why reinforce a patient’s belief that they are unwell and cause them to limit their activities and in essence promote a more negative outlook? Yes patient satisfaction may be higher but the patient must be educated on why radiography is unable to improve therapy, decision making, or outcomes. If after 4-6 weeks there is no sign of improved function or red flags are identified from the patients history and exam, then consider (imaging or appropriate refferal). But always remember, a picture of a car doesn’t mean its running.

References. Leibenson C, Rehabilitiation of the spine. 2nd edition: 2007 Bonenstein DG, et-al. The value of MRI of the lumbar spine to predict lumbar pain in asymptomatic subjects. J Bone and Joint Surg 2001:83-A:1306-1311. Boden SD, abnormal MRI of the lumbar spine in people without back pain. N engl J med 1994;2:69. Kendrick D, Radiography of the lumber spine in primary care patients with lower back pain: Randomised controlled trial.  BMJ 2001; 322: 400-405. Jaruik JG, the longitudinal assessment of imaging and disability of the back study.  Spine 2001; 26:1158-1166.

 

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About doctoranthony
As a spinal rehabilitation specialist with over 7 years clinical experience in the areas of - Spinal Manipulative Therapy, Active & Passive Spinal Rehabilitation, Functional Movement and Orthopedic Assessment, Strength and Conditioning Coaching, Fitness Programming, Business Development, Cognitive Behavioral Therapy, Motivational Interviewing and Consultancy - you can feel safe knowing that I understand the worry and concern surrounding spinal pain. This is why self-efficacy lies at the heart of my practice. For more info: nz.linkedin.com/in/anthonyclose

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