Nathan M. Wnuk et al examines the “appropriateness” and “actionable” ability of lumbar MRI.
The authors argue just because an image is deemed appropriate based on case context, doesn’t mean the information obtained will be actionable.
The authors performed a retrospective study including MRI examinations in 2007 based on expert consensus for appropriateness of lumbar MRI and then again in 2008 based on the American College of Radiology (ACR) and American Pain Society (APS) published guidelines.
Actionable was defined as:
"Contributes to planning of an anatomically specific treatment”
"Contributes to a new diagnosis of fracture, cancer or infection”
"Is performed to follow known lumbar spine pathology (other than degenerative conditions)”
A total of 5,365 examinations were included for analysis, 2548 examinations (48%) occurred prior to the ACR/APS guideline changes.
Authors findings:
“In summary, our work highlights three points. Firstly, the percentage of lumbar spine MRI that has a detectable impact on patient management is surprisingly low and unrelated to the ‘appropriateness’ of the examination. Second, detection of significant disease other than spinal degeneration (cancer, infection, fracture) is rare, even in the presence of ‘red flags,’ and true positive findings are outnumbered by false positive findings with potential to result in patient harm. If lumbar spine MRI is to be effectively used to identify such pathology in high risk patients, additional research is required to further refine appropriateness criteria and identify more specific ‘red flags.’ Finally, it may be prudent to be conservative in offering recommendations for additional follow-up when the level of suspicion is low.”
Thats some pretty interesting statistics. Considering that most patients start their journey to rehab getting X-rays then into an MRI machine to finally have a clear diagnosis. Whilst i understand and could definitely see the reasoning behind getting an MRI for some cases of low back, I believe that most patients simply dont need to imaging and or be exposed to radiation for a diagnosis that will ultimately harm the patient.
I had a patient the other day with LBP. He said his wife wanted him to get an MRI. He had no red flags at all and I explained to him why it wasn’t needed and under what conditions it might be warranted. He understood but I still wonder if she will push him to it. It’s difficult to break down that barrier that pain = damage and I need a picture to show me this structural damage.
The findings here are really not surprising to me at all, we live in a society by which the medical community fosters a sense of catastrophic thinking. You can never be too sure mentality, clearly we need to reevaluate our criteria for red flag findings because the study said something like 81 percent of the suspected cancer, infection, fracture cases turned out to be false positive? And most likely they’ll find some anatomical deficit just because they’re so damn common, I mean the literature could not be more clear on that. Then no matter what happens this person will always deal with the narrative of “what if that pain I am feeling is my disc weakening, or my vertebrae slipping.” I mean maybe part of your pain experience is derived from that nociceptive input but pain is just so damn complicated we cannot be sure what is the main driver your experience. But we do know tissues heal, they’re adaptable, and they’re resilient as shit. So let’s trust your physiology to make the positive adaptions to your tissues to tolerate your activity and let’s dose your activity appropriately and understand you might just have some level of pain during exercise and that’s totally okay. But having a patient adopt that narrative when they’ve got the MRI narrative firmly seeded in their mind is a tricky situation. The medical community really does need to chill with the MRI’s in many cases it’s just totally unwarranted.