The Unintended Consequences of a Spine MRI

hi my name is dr. John Shem and today I want to talk about when you should get a spine MRI as a spine surgeon that's a very common question presented to me during an offices people will come in with complaints of neck or back pain and a concern is you know doc I haven't gotten an MRI yet well the truth is you don't normally need an MRI unless you have some problems that tell us and MRIs can be helpful to your care we know that most people with neck and back pain will have pain for about four to six weeks after four to six weeks the vast majority of people get better well if you got an MRI too early now you spend a lot of money getting the MRI you have some information that may hurt you later on when you apply for some sort of disability policy and now you're feeling better so that MRI provided you information that does not help you with your medical care if you have neck and back pain and you do not have the issues that bring concern to doctors like fevers, weight loss, severe increases in pain or developing increase in weakness, numbness and inability to walk. We typically won't get the MRI until you pass that 4 to 6 week time period. If you have severe leg pain that doesn't get better, if you have progressive weakness where you're having more and more loss of strength and if you develop some sort of issues where you can't control bodily functions like going to the bathroom, those are kind of emergent situations not only do you need an MRI, you probably need to be evaluated probably in an emergency room. But if you just have neck and back pain and it's early on and I know it's painful you still may not need to get the MRI. That's up to your doctor to discuss with you your doctor should identify any red flags that tell him or her and you need to be seen right away and treated right away if that occurs you may actually go to the hospital you may be admitted and then the MRI is performed. But for the most part doctors will order MRI's if you're not getting better after that 4 to 6 week time period and you're still having some complained of numbness weakness for pain down the arms and legs, or sometimes just neck and back pain, then we'll order the MRI at that time. But don't be surprised that the MRI finds a lot of things. We know after the age of 40 about fifty percent of us will have findings on the MRI. As a doctor sometimes we don't know if those findings are really the source of your pain. So the MRI gives us a lot of information. It may actually confuse the picture. So to avoid the confusion especially when you're better, we normally wait until that 4 to 6 week time period. The MRI is a very useful tool. I do order a lot of them, but understand sometimes the MRI really is not an advantage to you unless you actually need step. Again I'm Dr. Shim. Thanks for listening to us have a good day. you

So,  you have spine pain.  In the USA,  there is a natural tendency to want to get a Spine MRI as soon as possible.  We are in an instant information society,  and it would make sense that we would want to instantly see if there is a problem in our back.

Naturally,  there is aways the concern that the source of spine pain is something very serious.  We have all heard of situations where a MRI identified an unknown broken bone,  an infection,  or worse,  a tumor.   The reality is,  these bad things would have been discovered without a MRI.  By obtaining a good history of the person,  clues such as a recent traumatic even,  severe progressive pain,  developing numbness and radiations,  etc. are the clear signs that something is wrong.  You do not need the MRI to find the problem.  The MRI does help you better define the extent of the problem,  but that is not the same as the MRI will discover the problem.   These serious conditions will be identified by your Physician,  as long as you have established a good relationship with the physician,  and (s)he knows your health history well.  One reason many look for the MRI is secondary to the  lack of trust of the Primary Physician.  That reason may be secondary to the changing nature of medical care.  Our Primary Care Physician is asked to manage a larger and larger number of patients.  Without the individual care,  it is not a surprise Trust is not what it should be.

Media has also changed the way we look at MRI’s.  Most of us follow a sports team,  or a favorite sports athlete.  The instant reaction of Team Physicians are to get MRI’s of players almost immediately after the injury.  We have to remember professional athletes do not look at pain the same way normal people do.  These Athletes will play through significant pain.  MRI’s are used to identify dangerous situations to the players since pain is not a factor to discontinue play for those athletes.  You must remember these players usually are playing with broken fingers,  bruised ribs,  pulled muscles all the time.  The MRI is used to make sure the injury is not limb or career threatening.   In other words,  MRI’s have a very different goal in professional athletes versus us normal people.  Yet,  we think we should have the same treatments as those athletes.  If you go by that standard,  there would be very few “Doctor’s notes” for missing work.  If the MRI does not show a limb or career ending finding,  you will be put back to work.  Be careful  wanting the same standards as the Athletes.  Besides,  there are others reasons not to get a MRI.

Unfortunately,  there are unintended consequences to obtaining a Spine MRI.

1. MRI’s are very costly.  While the costs may vary,  total costs,  including the Radiologist interpretation can average near $1000.  In the USA,  one source indicates there were 7.5 million spine MRI’s performed in the US in 2010.  There has been a concerted effort by both Government and Private insurance to minimize the use of this procedure.  More strict criterion for authorization is coming.  Unless there is a very compelling reason,  most must now show at least 4-6 weeks of conservative treatments such as medications,  supervised exercise/PT or chiropractic care,  and signs of nerve irritation before an MRI is authorized.   Naturally,  you can pay for one out of pocket,  but unless you meet the criterion,  usually, the insurance provider will balk at paying for it.

2. Multiple studies suggest early use of MRI in patients that do not meet the criterion for getting an MRI definitely had increased utilization of additional testing,  and treatments including surgery. Some will question why these patients will receive surgery that may not have been necessary.  The answer is secondary to the nature of surgical opinions.  The default position of Surgeons is to offer surgery.  While the intentions are always noble,  Surgeons do look at diagnostic studies from the perspective of surgical management.  At the time of clinical presentation,  surgery might not be warranted.  The MRI however,  may show what is considered a surgical problem.  The typical recommendation is to give non-surgical means a chance,  however,  if the patient desires,  surgery can be an option.  Once the possibility of surgery has been discussed,  rationalization behavior may lead to surgery,  even though the clinical situation may not be idea.  There are non clinical factors that contribute to the use of surgery.  That is why most will agree that early use of MRI’s in the workup of spine problems can lead to greater surgical frequency.

3.  MRI studies may identify findings that are not related to the pain.  Many findings on the MRI are pre-existing to the complaint,  and can result in treatments for findings that have no bearing on the current clinical situation.  An example is a Spine MRI that identifies a disk herniation on the opposite side of the pain.   Another example is a Spine MRI that identify multiple disk herniations,  but the symptoms are very consistent with impairment of a single nerve root.  In these situations,  the findings are not the source of the problem,  yet some practitioners will continue to offer treatments based on these findings.  This is a corollary  to the point #2.  These findings will be part of the differential diagnosis,  and will likely receive some form of treatment,  even though it is not the source of the complaint.  Currently,  the default position is to over treat the situation,  and cause the many unintended consequences.    A scenario that comes to mind is a patient with a brief episode of back pain,  that resolved,  but the MRI identifies a large disk herniation.  The person is cautioned about activities,  and as a result,  is fearful to participate in work activities,  recreational activities,  and family activities.  You can imagine the ramifications of this reluctance. This is in the face of an otherwise completely normal physical examination.

3.  MRI findings on asymptomatic individuals now document a potential problem.  In terms of the insurance industry,  now that person is considered a risk.  It may result in premium changes for disability application.  It may have a negative impact on a personal injury claim in a future accident.  I know personally on one Physician who had MRI’s of their neck and back under a pseudonym, as that Physician was concerned about the future ramifications of the MRI findings.

The bottom-line is a Spine MRI has consequences that may not be obvious to the average person.  Please consider the unintended consequences before you request your Physician do what he can to try to obtain your MRI,  even though you do not met the criterion.   While it is true various entities are trying to limit the use of these studies,  the effects of a Spine MRI is not just an expense to the insurance company.  It can also start a process that could cause unnecessary treatments,  and risks to you.

 

As I was finishing this blog,  I came across a recently published article:

In the August 1, 2014 edition of Spine,  there is an article titled “The Cascade of Medical Services and Associated Longitudinal Costs due to Nonadherent Magnetic Resonance Imaging for Low Back Pain” by Barbara S. Webster, BSPY, PA.   To define,  nonadherent MRI means an MRI that was obtained while the patient did not meet the criterion for the MRI.  This study was also done on the worker’s compensation population.  Still the study again showed increased utilization of expensive services,  including surgery despite the patients not meeting the indications.

 

 

 

 

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