A sample conversation explaining the necessity of MRIs – inspired by social media.

By Nash Anderson B.Sc. M.Chiro @sportmednews

Many people come to see me because they are suffering from a new occurrence of back pain. Globally, pain in the lower back is one of the most common causes of disability. One comment I often hear in those visits is: “Should I have an MRI scan before I start my treatment?”  My short answer to these questions is “An MRI is generally not required for new onset back pain, however sometimes it is. We’ll see what is best for you and will cooperate with your doctor”.

There are many causes of a new low back pain. Simple mechanical back pain is the most common type. Although an MRI is the gold standard for diagnosing many causes of back pain, we are aware that it is not useful in most cases of new low back pain complaints as most cases have simple mechanical causes. How do we explain that something established as the gold standard of back pain diagnosis is not the best idea for their back pain? I’ve written a sample conversation based on studies and things I’ve learnt on social media which can help to explain to athletes, patients and the public why MRIs are no magic bullet in diagnosing new low back pain every time.

Q: “Surely, if you can see more then you have a better idea of what is going on?”

A: Yes, you can see a lot more. Being able to see inside the human body with incredible detail is miraculous. However, do we have a much better idea what is going on compared to a normal physical exam and a comprehensive history? Not necessarily. There is not always a correlation between what we see on an MRI and what you are suffering from.

An ‘incidentaloma’ is a harmless mass found that is seen on MRIs that is unlikely to be causing problems. The term incidentaloma can be extended to other features on an MRI which are incidental. These incidentalomae (the plural of incidentaloma, I may have just made up a word!) may lead to more testing, more costs, more stress and unnecessary invasive treatments. People who have MRIs are much more likely to go down a surgical route which may not necessarily have better outcomes.

To diagnose someone solely off their scan and not their symptoms or their history is called ‘BARF’ or Brainless Application of Radiologic Findings. ‘VOMIT’ or Victim of Medical (or modern) Imaging (or investigational) Technology) is an (other) acronym for our times. This term VOMIT first coined by Richard Hayward in 2003 in the BMJ, is a term for patients who suffer unnecessary interventions for abnormalities observed by imaging or other investigational technology, but not found during surgery – Richard Hayward. This can also be those who have incidental abnormalities on imaging which alter recommendations. Having an MRI early on means that someone is much more likely to be judged by their scan rather than by their symptoms or history.

Simple abnormalities can be very common. A large study scanned individuals of different ages with no back pain. Despite the fact that these people had no back pain, abnormalities were seen in a large percentage (~76%) of scans. One example is that bulges or protrusions in people with low back pain seen by MRI are often coincidental. 60% of asymptomatic middle aged people have disc bulges. Seeing these changes on an MRI is much more likely to guide someone towards surgery and this may not necessarily lead to better outcomes. Some of the degenerative changes that we see on scans on people with new low back pain are not necessarily things we need to worry about. Many of these changes are more likely to come with age. If these changes were described as ‘getting wrinkles or grey hair’, they would be less frightening.

Q: “When is an MRI useful for new back pain?”

A: For new low back pain (simple aches and pains in the lower back), an MRI is often not required however, these do have their use. Occasionally back pain is caused by something serious rather than a simple mechanical problem. In these cases imaging is useful and can be lifesaving. In these cases, there are usually other situations that go with the back pain that may warrant and MRI including:

• Weight loss that you cannot explain
• A high temperature and fever over 102° F/ 40 degrees Celsius.
• Loss of bowel or bladder control
• Loss of feeling or muscle weakness in the legs
• A history of cancer
• Serious trauma
• Tried conservative treatment (physio/chiro/osteo) treatment for over 6 weeks with no improvements.

It is also a good that our patients and athletes understand not to jump into scans unnecessarily as many are personally funded. MRIs are expensive. They can be a substantial cost to an individual or organisation at ~ £300 per scan ($500).

Summary

A – There is no need to perform MRIs for new low back pain unless there is good reason to suspect there might be another cause for the pain. An unjustified MRI early on can lead to further testing, costs, stress and unnecessary invasive treatments.

I hope this sample conversation helps practitioners communicate to their athletes and patients about MRIs and when they are useful for a new case of back pain. The resources below and conversations with excellent practitioners on social media have inspired me to better answer this common question.

Resource:

VOMIT (victims of modern imaging technology)—an acronym for our time BMJ 2003;326:1273 (7 June), doi:10.1136/bmj.326.7401.1273)[1] http://www.bmj.com/content/326/7401/1273.1

http://www.huffingtonpost.ca/marilyn-linton/ct-scans_b_4166552.html.

https://blairconrad.wordpress.com/2010/01/19/acronyms-of-the-day-vomit-and-barf/

http://www.spinesurgeons.ac.uk/patients/patient-information/the-spine-and-mri-scanning

http://www.choosingwisely.org/patient-resources/imaging-tests-for-back-pain/

1995 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Boos N1, Rieder R, Schade V, Spratt KF, Semmer N, Aebi M.

If you have any questions or comments feel free to contact me on social media @sportmednews or

Let’s get a conversation started on the BJSM Google+ Group –  Sports & Exercise Medicine clinicians – https://plus.google.com/communities/101520200531074507996.

Thank you for reading this article!

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Nash Anderson BSc. M.Chiro (@sportmednews) is an Australian graduate of Macquarie University in Sydney. He works in private practice as chiropractor in Farnham, Surrey at Farnham Chiropractic Wellness. Nash is the founder of www.sportmednews.com, a sport and health resource for clinicians and the public.