Everyone wants an MRI for back pain. Society teaches us that more information is better, but which type of back pain doctor actually uses MRIs most effectively?
In interests of full disclosure…I’m a chiropractor. But, in my defense, what I’m about to say is not hearsay. The evidence of chiropractic care’s effectiveness and “correctness” continues to mount. Although at times we seem to remain at the bottom of the insurance company totem pole, I do believe that the future remains very bright for those of us that can survive the current storm of shrinking reimbursements despite high value care.
The term “high value care” is probably the best description of what we have to offer. Orthopedics is the highest cost driver for almost every insurance company. Within this, non-surgical spinal care is the biggest chunk. Costs in this category include providers (chiropractors, primary care, internists, physical therapists, neurosurgeons, orthopedic surgeons and a few others), medications, injection-type therapies (think epidurals) and imaging.
Ah yes. Imaging. MRIs. CT scans. X-rays.
Evidence be damned–we still hand out prescriptions for these like candy on Halloween.
Strong evidence links CT scans with thousands of cancer cases from radiation and yet their use in the emergency room setting has not changed.
Despite evidence against their use, 20% of primary care doctors hand out opioids for uncomplicated low back pain.
The standard recommendation for a course of 3 epidurals is not backed by evidence (but costs thousands of dollars for the series). Worse, evidence suggests it may cause more harm than saline injections.
Even early use of pain medication or anti-inflammatories can create a chronic problem out of an acute one.
Back to the imaging topic.
Ever since medicine has relied more and more on advanced imaging like CTs and MRIs, our physical exam and history taking has been getting worse and worse. In all honesty, in many cases, the evidence of involvement of a disc bulge or spinal stenosis can be determined without imaging. I know that in our office we are very conservative with ordering additional imaging.
However, patients seem to want the results from an MRI for whatever reason. Maybe it’s because they think that an MRI will give a definitive answer to what is wrong with them. (Not true–the only thing that will give an absolute answer to what is going on with your back is an autopsy, something we try to leave as the last resort)
After all, an MRI is harmless, right?
Very, very wrong.
The evidence that MRIs can create harm when ordered inappropriately is plentiful:
- MRI is always ordered before a course of epidurals, but has no actual influence on outcomes.
- MRI may actually increase the chance of you getting surgery.
Clearly an MRI needs to be ordered only when appropriate. The alternative is not only a waste of money and time, but come with an increased risk of something being done that doesn’t need to be done.
This particular study looks at what happens with MRI ordering within the context of a workplace injury. Researchers looked at what factors increased the risk of an injured patient getting an MRI within the first 6 weeks (termed an early MRI). The results are pretty much exactly what I would expect:
- 20% of the injured patients received an early MRI
- Initial visit type with a surgeon was associated with 78% greater likelihood of an early MRI than that with a primary care physician
- Having a chiropractor as the initial provider saw a 47% lower chance of an early MRI compared to a primary care physician
I DID clearly state in the beginning that I had a bias towards the chiropractic treatment of the injured worker, but it’s hard not to see my side of the story. Overall, getting an early MRI in the absence of certain red flags increases the risk of procedures like epidurals and surgery that may not be needed.
The bottom line is, according to this study, sending an injured worker to the chiropractor first, before a PCP or surgeon, results in a much lower rate of an inappropriate MRI being ordered which may lead to undesirable and unnecessary invasive procedures.
If you have been injured at work in the past, what type of provider did you see initially and how did that overall experience go?