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I’m a neuroradiologist—that’s the doctor who reads the MRI of your brain or spine. Lately I’ve been having crushing back pain, the kind of pain that drops you to your knees. The kind where you wonder whether you’re going to be okay. But I’m not getting an MRI of my spine. And if you’re in the same situation, maybe you shouldn’t either, at least not urgently.
Pain can be scary. Most people worry that their pain is caused by cancer or some other debilitating problem that could leave them paralyzed. Although there are some conditions that should not be ignored (think: fever, numbness in the groin or rectal region, incontinence, worsening pain over weeks), in the vast majority of the cases, pain is not a sign of a life-threatening condition.
ChoosingWisely, a consortium looking to reduce cost and improve quality of care, summarized the views of 5 medical organizations. From primary care through specialty organizations (including spine specialists), all those polled suggested holding off on imaging early in the course of back pain if there is no clinical red flag that accompanies that pain.
If that’s the general opinion, why do so many people undergo an MRI or CT so early after back pain presents?
In short: Incentives aren’t aligned. The doctor ordering the study knows it’s faster and lower-risk to obtain imaging than trying to talk a patient out of the study. After all, no one ever got sued for over-ordering! And in our “We can fix anything!” American healthcare economy, patients have come to expect that providers are going to do something. If a doctor doesn’t order an imaging study, their patient satisfaction scores may suffer—many patients would perceive this as negligence or laziness on the part of their doctor.
If you do have imaging done, don’t do it in the emergency room! Imaging in an emergency room setting costs 5 to 10 times more than it does in an outpatient imaging center. Most emergency rooms use CT rather than MRI, because CT is generally available but a far worse diagnostic test for patients with back pain. And even though you’re in an “emergency” department, unless you have one of the red flag symptoms mentioned above, no one is going to do anything with the result for days, weeks, or even months.
So what’s the downside too imaging? As a radiologist, I can almost guarantee you that I’ll find something on your scan. But don’t be alarmed! That’s only because our backs develop degenerative changes over time. Some hospital systems have taken to putting a disclaimer on imaging reports to state that many patients without back pain have similar changes. Once an abnormality is identified, you begin your journey down the assembly line of chronic pain. Some data suggest that, for certain types of back pain, many patients who undergo surgery have similar postoperative scans at their 2-year followup to patients who didn’t undergo surgery. There is a wide range of surgical opinions, so if you ask for surgery, you’ll get surgery. From 1998 to 2008, hip and knee replacements were up 50% and 126%, respectively. Crazy, right? But these numbers are dwarfed by the 600% increase in spine fusion surgeries.1
So what’s the answer? Almost certainly you are not going to die or end up paralyzed. Fixing back pain is hard. Opiates are a disaster. Pain injections can help treat acute pain, but do not offer long-term relief. Losing weight and physical therapy require commitment, but in the long run are a much better path forward. Instead of surgery, I went to physical therapy for my back pain. And for now, that pain is under control. But I know I need to keep stretching and working on strengthening my core. Simply put, our backs were not engineered to last for a lifetime that exceeds 50 years! For thousands of years, humans only lived about 30 years. Until evolution catches up (not in this lifetime), we need to come to terms with the fact that aging well takes work.
- Rajaee SS, Bae HW, Kanim LE, Delamarter RB. Spinal fusion in the United States: Analysis of trends from 1998 to 2008. Spine (Phila Pa 1976). 2012 Jan 1;37(1):67-76.
Geoffrey Kaufmann says
You are right on Alan. I suffer from some chronic back pain from time to time as well. Stupid things in my youth and too much football and rugby over the years. Core strength is essential to getting through these infrequent back pain episodes and it keeps me upright and relatively strong. I swear by doing my back exercises daily, Yoga has been a godsend as well. Get better fast. I have never had an MRI for any of my back episodes because I know that those spells will past and have thus far. Fingers crossed.
Eileen Rubenstein says
Very interesting perspective, Alan…I am beginning to agree with you that you can be worse after surgery than before. That is certainly my situation. How did you deal with the crushing back pain while it was happening?
Michael Millenson says
Well done, Alan. Concise, scientific, personal and persuasive. My only nit: doctors were over-ordering scans, particularly for back pain, way before patient satisfaction scores were being used. Oh, those poor victimized doctors, especially the fragile egos known as orthopedic surgeons! Let’s not mention financial incentives: patients like scans and I can get rid of them and see more patients; I own MRI center shares; my health system employer likes referrals. Finally, not just patients, but doctors, genuinely believe in the “do something.” Surgeons believe sincerely in surgery.
Neuroradiologists? Not so much. 🙂
Good luck and best wishes.