MRI radicular back pain - what's your trigger?

[dotcb]

Do you MRI for sensory asymmetry in the legs? Just for motor changes?

We all tend to MRI for cauda equina signs - bowel/bladder dysfunction, weakness, perineal anesthesia, progressive worsening, etc.

But how do you approach patients with sciatica-type picture with asymmetric sensation in the legs?

I had a patient yesterday that I didn't MRI. I've gone in both directions in the past. Just wanted to hear other people's thoughts...

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[deleted547339]

Do you MRI for sensory asymmetry in the legs? Just for motor changes?

We all tend to MRI for cauda equina signs - bowel/bladder dysfunction, weakness, perineal anesthesia, progressive worsening, etc.

But how do you approach patients with sciatica-type picture with asymmetric sensation in the legs?

I had a patient yesterday that I didn't MRI. I've gone in both directions in the past. Just wanted to hear other people's thoughts...

PGY3 here - so take this with a grain of salt.

Obviously you MR anything that could be cauda.

Regarding sciatica, I have some attendings who essentially say nerve distribution = MRI. The attendings who do this also tend to be the ones I think couldn't cut it outside of academia. A lot of the attendings whose practice patterns I really respect only do it for motor. This is what I've done when I moonlight and this is ultimately the practice pattern I plan to keep (until I miss something horrible).

 

[RustedFox]

In my charts: "Care was taken during H&P to elicit signs/symptoms to indicate the possibility of serious neurosurgical emergency to necessitate MRI (cauda equina, epidural abscess, etc); but patient denies any fever, IVDU, recent instrumentation/surgery, focal motor symptoms, bowel/bladder incontinence, or saddle anesthesia."

No MRI unless you've got one of those symptoms that I listed.

 

[deleted77919]

…

 

[RustedFox]

What's an OSH ?

 

[deleted77919]

…

 

[RustedFox]

Outside hospital.

Thanks. Sorry.

 

[deleted547339]

What's an OSH ?

Really?

 

[RustedFox]

Really?

Outside hospital ? Outside of what ? Your residency program ?

All hospitals are outside, silly. That designation stops existing once you leave the nest.

 

[deleted547339]

Outside hospital ? Outside of what ? Your residency program ?

All hospitals are outside, silly. That designation stops existing once you leave the nest.

I stand by my response.

 

[Hook_EM]

Motor symptoms as well.

As for OSH:

 

[gman33]

Just sensory, with no other red flags.
No MRI.

 

[gutonc]

Outside hospital ? Outside of what ? Your residency program ?

All hospitals are outside, silly. That designation stops existing once you leave the nest.

I had an ICU attending during my IM residency who, anytime someone would say during rounds "transferred from outside hospital" would respond with "a hospital with no walls or ceiling? Where is that place?". It's lazy.

If you're in a position to accept transfers from other facilities, you need to learn the capabilities of the places that will transfer to you, as it will help you (in the ED, in the ICU and on the floor) understand what was and wasn't done before transfer (and why) and what needs to be done first when they land in your lap.

 

[Birdstrike]

Do you MRI for sensory asymmetry in the legs? Just for motor changes?

We all tend to MRI for cauda equina signs - bowel/bladder dysfunction, weakness, perineal anesthesia, progressive worsening, etc.

But how do you approach patients with sciatica-type picture with asymmetric sensation in the legs?

I had a patient yesterday that I didn't MRI. I've gone in both directions in the past. Just wanted to hear other people's thoughts...

Rarely will an ED MRI change anything.

Cauda equina, acute cord signs (neuro signs not localized to one dermatome.) Sensory changes not a big deal if chronic or just a single dermatome. Fever and back pain? rule out abscess (if not renal) get MRI. Recent intervention (epidural) and neuro symptoms (injection, surgery) get MRI. Cancer or risk factors and sign of myelopathy/cord compression > acute MRI.

ED MRI for just acute uncomplicated sciatica? I can't think of a greater waste of MRI time, and I'm a tester. These walk into PCP, ortho, neuro, chiro offices all day long and don't get emergent MRI's. An ED MRI for acute sciatic accomplishes nothing.

"Okay sir. I thought you have sciatica. Guess what? You have sciatic. Here's this shiny CD that proves it. So there."

Think, cord, cord, cord, cord, cord, is this cord (or cauda equina just because messing with a big central disc and multiple roots to the bowel and bladder is badness and conus medullaris mimics this but is technically cord)?

But simple "My back hurts and it shoots down to my big toe and tingles doc."

Doesn't need an emergent MRI. Outpatient work up. In fact, an MRI for acute sciatica often will get denied even outpatient until it's been going on > 6 weeks and until it's failed conservative treatment.

 

[Xerxes1729]

If they only have radicular symptoms, nothing suggest of cord compression, cauda equina syndrome, or conus medularis syndrome, they either have to have a motor deficit or red flags for something bad - metastatic cancer, IV drug use, trauma, severe osteoporosis with lots of prior fractures, etc. And for fracture, I'd start with a films in a young person or CT in an old person.

 

[Greenbbs]

I never really thought about this until my L5-S1 blew while on shift (but was likely injured awkwardly picking up one of my parasites).....

.....until I couldn't a) get off the ground, and b) feel my balls. Nothing is more terrifying when you can't feel your balls after something like that.....

Really changed my perspective on back pain. If there is any signs of motor defect, I'll get the MRI. Sciatica is sciatica. I get that. Can't feel your junk? Win an MRI.

I had surgery 2 days later. Best decision of my life.