Last week, I had an experience that demonstrates one of the problems with management of low back pain (LBP). This occurred while standing in line at my usual coffee spot where I have a good relationship with my barista. She additionally works as a massage therapist and we occasionally have some discussion related to our professions. As I was picking up my coffee, her co-worker who overheard us talking asked me, "What do you do when you are 22-years-old and have two disc bulges on MRI?" I asked her the questions that should be asked of everyone prior to considering an MRI.

 

Early MRI in the absence of indications of significant pathology have been linked to worse health outcomes, increased risk of disability, longer disability and higher surgical rates.1,2 An MRI is rarely indicated in the first six weeks of onset of low back pain. Exceptions are listed in guidelines published by the American College of Occupational and Environmental Medicine (ACOEM) and include the demonstration of progressive neurologic deficit, cauda equina syndrome, significant trauma with no improvement in atypical symptoms, a history of neoplasia (cancer) or atypical presentation (e.g., clinical picture suggests multiple nerve root involvement). ACOEM does not recommend MRI for patients with radiculopathy in the first four to six weeks unless symptoms are "severe and not trending toward improvement and both the patient and the surgeon are willing to consider prompt surgical treatment, assuming the MRI confirms ongoing nerve root compression." Following four to six weeks from onset, ACOEM recommends MRI for subacute or chronic radicular pain syndromes when the symptoms are not trending toward improvement if both the patient and surgeon are considering prompt surgical treatment, assuming the MRI confirms ongoing nerve root compression. In cases where an epidural glucocorticosteroid injection is being considered for temporary relief of radiculopathy, MRI at three to four weeks may be reasonable. In cases where conservative treatment (including NSAIDs, aerobic exercise, other exercise and considerations for manipulation and acupuncture) over the course of three months have failed, MRI is recommended as an option for the evaluation of select chronic LBP patients in order to rule out concurrent pathology unrelated to the injury.3

 

When MRIs are indicated, it is important that results be reviewed with the patients using language that they will understand and will not induce fear or hopelessness. Terms often included in radiology reports have different meanings to patients than intended.4  For example, patients may interpret "wear and tear" as a "loss of structural integrity," "deterioration" as their spine is "crumbling" and "collapsing," "non-specific" as "nonexistent," "instability" as "liable to pop out."5 Use of these terms by patients is associated with a poorly perceived prognosis, which at times can be self-fulfilling. Explanation of MRI findings to a patient using language that is reassuring, such as "the spine is strong" or "these findings are normal and are not correlated with pain," among other true but calming language, is a great opportunity to change a patient's prognosis and improve outcomes. This approach minimizes psychological stress in the form of fear of movement or a perception of hopelessness of recovery based on anatomic findings, which have been demonstrated to not be warranted. It has been shown that strategies to decrease these thoughts and beliefs can increase return-to-work and healthcare outcomes.6 

 

In summary, the judicious use of MRI in the management of LBP is likely to reduce costs and improve outcomes. MRI should be reserved for cases where there are signs of severe pathology, to confirm a diagnosis made on a thorough physical examination and proceeded by a discuss as to what findings are expected and how they will be incorporated into the treatment plan. The use of MRI to "search for the cause" of the patient's complaint can be misleading given the frequency of "abnormal findings" in the absence of pain.

 

When communicating results that do not correspond with the clinical examination, clinicians should be careful not to induce or reinforce beliefs that the spine is fragile, unstable or lacks the ability to heal or recover. Recent case reports indicate that even large disc extrusions present on MRI and corresponding to patient complaints can resolve in a relatively short time period.7,8  For examples see:

 

 

Author: David A. Hoyle, P.T., DPT, MA, OCS, MTC, CEAS, National Director of Clinical Quality, WorkStrategies Program