By Chris Bellmar, DPT Regional Director, Colorado Outpatient and Physical Therapy
Register for the upcoming Pinnacol Healthcare conference to attend a panel discussion on the multidisciplinary approach to treating back pain.
Most guidelines on management of low back indicate a lack of need for imaging except in the case of significant trauma or neurological deficit or red flags indicative of back-related tumor, cauda equina syndrome, back-related infection, compression fracture or abdominal aneurysm.1 The American College of Occupational and Environmental Medicine (ACOEM) does not recommend MRI for patients with radiculopathy unless, at four to six weeks, symptoms are “severe and not trending towards 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 towards 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 acute or subacute radiculopathy, MRI at three to four weeks (before the epidural steroid injection) 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.2
The rationale behind the use of caution when considering imaging in occupational-related low-back is related to the prevalence of significant findings in the absence of pain, which may complicate the clinical picture in those with current symptoms. Studies investigating MRI results of individuals without back pain have found significant anatomic changes, including 91 percent having disk degeneration, 56 percent having loss of disk height, 64 percent having disk bulges, 32 percent having disk protrusions and 38 percent having annular tears.3 When MRIs are performed, it is important that results are communicated to patients using language that is easy to interpret and will not induce fear. Many existing medical terms included in MRI reports have been shown to have different meanings to patients than intended.4 One study demonstrated value in the inclusion of the following statement on MRI results: “The following findings are so common in people without low-back pain that while we report their presence they must be interpreted with caution and in context of the clinical situation.” This simple statement included by radiologist on the MRI report was associated with decreased prescriptions of narcotic medications from primary care physicians.3 Performance of MRIs in the management of low-back pain has been linked to worse health outcomes, increased likelihood of disability and longer disability duration.5 Workers who present with low-back pain that have an early MRI, in the absence of key indicators for significant pathology, have a higher risk of disability and surgery, irrespective of the severity of the MRI findings.6,7
Using MRI and other imaging in the absence of significant clinical findings in search of the problem is associated with poorer outcomes and higher costs. MRI and all imaging should be used judiciously and for specific indications and to confirm a clinical picture and execute a predetermined plan.
1. Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. (2012) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 42(4): A1-A57.
2. Low back disorders. In: Hegmann KT, editor(s). Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2011: 333-796.
3. McCullough, BJ, Johnson GR, Martin BI, Jarvik JG. (2012) Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology. 2012;262(3): 941-946.
4. Sloan TJ, Walsh DA. (2010) Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. Spine (Phila Pa 1976). 2010 Oct 1;35(21): E1120-E1125.
5. Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers. Spine (Phila Pa 1976). 2012;37(18): 1617-1627.
6. Webster BS, Cifuentes M. (2010) Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010 Sep;52(9): 900-907.
7. Webster BS, Cifuentes M. (2010) Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010 Sep;52(9): 900-907.