The ACR's new list of probably unnecessary procedures set this emeritus rheumatologist wondering about another procedure that might be unwarranted: MRI for low back pain or sciatica in an older patient with no red flags. What does it accomplish beyond satisfying curiosity?
The American College of Rheumatology's "Choosing Wisely" list, the society's top choices for procedures that merit reconsideration as unjustified, set me thinking about something that doesn't appear on the list: the use and misuse of MRI in patients with back pain, no red flags, and no reasonable suspicion of ankylosing spondylitis.
Patients with back pain and sciatica seem to get these tests even though they are not ready for a surgical referral.1,2 The patients indeed do have pain that may not respond well to the initial medical management. The long-term data in these patients show that only a fraction will actually need surgery. For the rest, the long-term outcomes show that medical management is effective in the long run. Patients need to know about this evidence before pushing for a surgical referral.
I'm no content expert in this area, just an interested party. But I suspect that these MRIs are usually unwarranted, and (more troubling) may prompt a surgical referral when one is not needed. Spine surgeons do surgery for a living, after all, and the referral itself may prompt some surgeons to embark on a surgical intervention.
My approach is to ask at the time of the decision about doing the MRI whether I really would consider sending the patient with no red flags for surgery. I honestly believe that for most cases doctors would answer no, but I have no data to support that position.
I fear that all too often the rationale is that the doctor "wants to see what's going on." But in folks over the age of 60 the MRI is abnormal in many cases (about a third have a herniated disc and more than 90% have a degenerated or bulging disc),3 and there may not be a cause-effect relationship between the imaging findings and the pain..
Some time ago, I read that there were more MRI machines in the Pittsburgh area than in Canada.4 I'm not sure that is still true, but there appears to be nothing stemming the tide of MRIs for low back pain in Baby Boomers. Like so many elements of US medicine, it inflates the cost without improving quality.
Even scarier is that the increase in cost may be accompanied by a decline in quality, brought on by unnecessary surgery.
1. Chou R, Qaseem A, Owens DK
and 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.
Annals of Internal Medicine
2. Webster BS, Courtney TK, Huang Y-H,
Physicians' Initial Management of Acute Low Back Pain Versus Evidence-Based Guidelines: Influence of Sciatica
J Gen Intern Med
3. Boden SD, Davis DO, Dina TS
Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects: A Prospective Investigation.
Journal of Bone and Joint Surgery
4. David Whelan.
Cranking Up the Volume.
Forbes Magazine, February 25, 2008.