First off, what exactly is an MRI (in plain-english)?
MRI’s function by forming a very strong magnetic field around the body part being studied. This powerful field has an effect on the water molecules in your body causing vibration and the machine creates an image of the body. These images are often viewed in “slices” (think of a loaf of bread) and they are often done in 3 different planes (up and down, side to side, front to back).
The MRI is one of the coolest things ever invented. To be able to see a detailed, 3 dimensional series of pictures of the inside of your body is an incredible tool for diagnosis and evaluation. However, the MRI is exactly that, a tool, nothing more and nothing less. And like all tools it has a time, place and function for best results. Unfortunately just like many tools it can be overused or completely misused.
Over the past few years MRI’s (magnetic resonance imaging) have become a mainstay in the evaluation and treatment of many musculoskeletal problems. In particular many patients with spine problems have had an MRI to help determine what might be the source of their spine problem. Recent Medicare data shows a 307% increase in MRI usage over a 10 year period.
Sorry, but MRI’s reveal lots of things that just don’t matter.
In the past few years the role of MRI’s for the evaluation, diagnosis and subsequent treatment of back pain has been called into question (Modic, Obuchowski et al. 2005). For the past 20 years many medical practitioners have utilized the MRI as the primary diagnostic tool to determine the source of back pain.
The logic was very simple, order the MRI, look for apparent abnormalities and obviously that must be the source of the patient’s pain.
However, the scientific research has shown that is absolutely not true. Numerous scientific studies have shown that perfectly healthy people with absolutely no back or neck pain have all kinds of abnormalities in their spine if they get an MRI. A recent study in Spine (which is the absolute gold standard for doctors) showed that 1,211 perfectly healthy patients received an MRI and over 70% of the people had a bulging disc but absolutely no pain! (Nakashima, Yukawa et al. 2015) This is just one of dozens of studies showing the same evidence. The MRI is a very sensitive test, and often finds “false positives”, things that may look like a problem but absolutely are not.
Actual Costs of MRIs (ouch)!
The costs of MRI’s has come down over the past few years. A typical MRI can range in price from $600 to $2,000 depending on a handful of factors. However the real costs of an MRI are often a bit underappreciated. What tends to happen is the MRI often tends to reveal “potential” problems and “false positives”. This starts a whole cascade of further investigation and additional testing which significantly increases the overall costs to the patient but unfortunately does nothing to actually help the patient recover from their original problem of back pain. (Webster B., et al. 2011)
A recent study showed that when patients with back pain were sent for an MRI before seeing a physical therapist their overall healthcare costs increased by $4,793 on average compared to patients who went to physical therapy first. (Fritz et al. 2015) Keep in mind, when this study was done the patients who were sent for an MRI were not worse in terms of back pain symptoms. It was simply the practice pattern of their doctor or patients that demanded an MRI (which happens often).
First time back pain is not associated with findings from an MRI.
A fascinating study was done in 2006 and patients were followed for 5 years. 200 patients with absolutely no history of back pain participated in the study and an MRI was performed to establish a “baseline” of what their discs, joints and other back structures looked like. Over the next 5 years 51 of these patients developed back problems and another MRI was done immediately. The results showed that only 2 of these patients had a dramatic change compared to their baseline MRI! Both of these patients had severe sciatic pain radiating all the way down their leg. The reality is for the 49 other patients the MRI was a waste of time, money and resources. (Carragee et al. 2006)
A second study done on the same topic pooled together numerous MRI studies and looked at the common findings. In the world of medicine and research this is called a Systematic Review and is the gold standard of doing scientific research. Here are a couple of direct quotes from this research: (Anderson et al. 2011)
“available evidence indicates that immediate routine lumbar MRI’s in patients with low back pain did not improve outcomes compared with usual clinical care…”
“clinical care without immediate MRI did not result in any increased odds of failure to identify any serious underlying conditions or risk factors…”
When evaluating all of this evidence it is very reasonable to conclude that if someone hurts their back, the last thing they should do is get an MRI. It has little to no value in guiding treatment and simply adds significant cost and financial burden to everyone.
MRI vs. Physical Therapy
The evidence is overwhelming, the usage of MRI’s has risen to an all-time high but the benefits to patients are very few and far between. Literally dozens of scientific studies have shown that unless you have severe sciatic nerve pain radiating down your leg, the use of MRI absolutely does not help guide treatment. MRI’s also significantly increase overall costs to patients with no improvement in their actual pain condition.
Another recent study with 122,723 patients showed that when patients had back pain and were sent to a physical therapist within 2 weeks of their symptoms starting had 60% less overall health care costs compared to those that didn’t see a physical therapist or waited to see a physical therapist. (Childs et al. 2015)
This is just a small sample of the scientific research available on the topic of MRI’s for spine related problems. However, the inescapable conclusion is that MRI’s are not helpful or useful for the vast majority of patients who have spine issues. Unless there is significant nerve related symptoms that are radiating down the arm or leg, the MRI is virtually a complete waste of time and money for the average patient. However, it has been elevated to a “gold standard” for diagnosis and nothing could be further from the truth.
ReferencesModic, M. T., N. A. Obuchowski, J. S. Ross, M. N. Brant-Zawadzki, P. N. Grooff, D. J. Mazanec and E. C. Benzel (2005). “Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome.” Radiology 237(2): 597-604. Nakashima, H., Y. Yukawa, K. Suda, M. Yamagata, T. Ueta and F. Kato (2015). “Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects.” Spine (Phila Pa 1976) 40(6): 392-398. Webster B et al., Medical utilization cascade following early magnetic resonance imageing (MRI) for work related low back pain 2011. Back Letter Volume 26, Number 9, 2011. Fritz J, et al. Physical Therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health Services Research 2015 Carragee E, et al. Are first time episodes of serious LBP associated with new MRI findings? The Spine Journal 2006, 624-635. Andersen J.C. Is immediate imaging important in managing low back pain? Journal of Athletic Training 2011, 99-102. Childs, J et al. Implications of early and guideline adherent physical therapy for low back pain on utlization and costs. BMC Health Services Research 2015, 15:150
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