CT scan for low back pain

[PinchandBurn]

I have recently seen a string of patients by a PCP who for all his patients that have Low Back Pain/Radiculopathy orders a CT scan of the L spine after trying some conservative stuff: NDSAID, PT,etc.

I asked him why he does this, as I always thought MRIs were 'better' in picking up disc pathology etc. His response made some sense:

1) CT scans of the L spine are easier to get approved by Insurance companies d/t I believe being cheaper
2) He quoted the Steve Cohen article, about how MRIs of the L spine have minimal value as they minimally chnage management. He does have a point. You can usually see small disc protrusions/bulges on a CT L spine definitely on sagital cuts, harder on Axial. Of course it is nowhere near the clarity of an MRI. Additioanlly, the point he was making was that with a CT scan you will still see all the red flags and things you dont want to miss "cancerous lesions,etc, fx". Additionally if you see something strange, you can always then go ahead an order a MRI.

3) the con to the CT is of course added radiation.


It got me thinking for interventional pain management is a MRI reallly that necessary or can we use hte infor on a CT of the L spine for our purposes (finding levels to do ESIs, facet MBBs). Of course as indicated above we can always get a MRI to rule in certain things (acute vs chronic compr fx).

Food for thought....

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[lobelsteve]

I have recently seen a string of patients by a PCP who for all his patients that have Low Back Pain/Radiculopathy orders a CT scan of the L spine after trying some conservative stuff: NDSAID, PT,etc.

I asked him why he does this, as I always thought MRIs were 'better' in picking up disc pathology etc. His response made some sense:

1) CT scans of the L spine are easier to get approved by Insurance companies d/t I believe being cheaper
2) He quoted the Steve Cohen article, about how MRIs of the L spine have minimal value as they minimally chnage management. He does have a point. You can usually see small disc protrusions/bulges on a CT L spine definitely on sagital cuts, harder on Axial. Of course it is nowhere near the clarity of an MRI. Additioanlly, the point he was making was that with a CT scan you will still see all the red flags and things you dont want to miss "cancerous lesions,etc, fx". Additionally if you see something strange, you can always then go ahead an order a MRI.

3) the con to the CT is of course added radiation.


It got me thinking for interventional pain management is a MRI reallly that necessary or can we use hte infor on a CT of the L spine for our purposes (finding levels to do ESIs, facet MBBs). Of course as indicated above we can always get a MRI to rule in certain things (acute vs chronic compr fx).

Food for thought....

Your
Job should be to help educate him. Sounds like he missed the lecture.
http://www.aafp.org/afp/2002/0601/p2299.html

I'd modify the algorithm to get MRI w stir instead of ct for suspected fx.
Ask him to get no imaging and send to you earlier.

 

[bedrock]

Ask him to get no imaging and send to you earlier.

1+ that

MRIs ordered by a specialists have a better chance of being approved..............(not guaranteed mind you)

The crackdown on MRIs started with PCPs because insurance companies felt, (often rightly) that PCPs and primary care NPs/PAs ordered many unnecessary MRIs on patients, when they had no idea what was going on with a patient, hoping the MRI would just give them the diagnosis.
(Which is more expensive than a specialist consult)

 

[SSdoc33]

would you want your wife's ovaries fried in a CT scan? i would literally only let them do one on me if it was ABSOLUTELY necessary (say i popped an intestine or something) or to r/o a bleed prior to giving me tPA. we go thru so much to try to limit radiation, but a CT scan is just a crapload of it at once.

i have said to patients that i wont do certain injections because MRI was not authorized and i personally wouldnt order a CT scan b/c of the radiation.

 

[epidural man]

I have recently seen a string of patients by a PCP who for all his patients that have Low Back Pain/Radiculopathy orders a CT scan of the L spine after trying some conservative stuff: NDSAID, PT,etc.

I asked him why he does this, as I always thought MRIs were 'better' in picking up disc pathology etc. His response made some sense:

1) CT scans of the L spine are easier to get approved by Insurance companies d/t I believe being cheaper
2) He quoted the Steve Cohen article, about how MRIs of the L spine have minimal value as they minimally chnage management. He does have a point. You can usually see small disc protrusions/bulges on a CT L spine definitely on sagital cuts, harder on Axial. Of course it is nowhere near the clarity of an MRI. Additioanlly, the point he was making was that with a CT scan you will still see all the red flags and things you dont want to miss "cancerous lesions,etc, fx". Additionally if you see something strange, you can always then go ahead an order a MRI.

3) the con to the CT is of course added radiation.


It got me thinking for interventional pain management is a MRI reallly that necessary or can we use hte infor on a CT of the L spine for our purposes (finding levels to do ESIs, facet MBBs). Of course as indicated above we can always get a MRI to rule in certain things (acute vs chronic compr fx).

Food for thought....

What Cohen article?

 

[bedrock]

I have recently seen a string of patients by a PCP who for all his patients that have Low Back Pain/Radiculopathy orders a CT scan of the L spine after trying some conservative stuff: NDSAID, PT,etc.

I asked him why he does this, as I always thought MRIs were 'better' in picking up disc pathology etc. His response made some sense:

1) CT scans of the L spine are easier to get approved by Insurance companies d/t I believe being cheaper
2) He quoted the Steve Cohen article, about how MRIs of the L spine have minimal value as they minimally chnage management. He does have a point. You can usually see small disc protrusions/bulges on a CT L spine definitely on sagital cuts, harder on Axial. Of course it is nowhere near the clarity of an MRI. Additioanlly, the point he was making was that with a CT scan you will still see all the red flags and things you dont want to miss "cancerous lesions,etc, fx". Additionally if you see something strange, you can always then go ahead an order a MRI.

3) the con to the CT is of course added radiation.


It got me thinking for interventional pain management is a MRI reallly that necessary or can we use hte infor on a CT of the L spine for our purposes (finding levels to do ESIs, facet MBBs). Of course as indicated above we can always get a MRI to rule in certain things (acute vs chronic compr fx).

Food for thought....

The PCP is wrong. As a specalist, it's your job to politely educate him of the error of his ways when ordering a test that is less helpful than an MRI, and adds a lot of unnecessary radiation.
Just because he read some article by someone we've never even heard of, and doesn't want to be bothered to do what is necessary to get the proper study approved, that doesn't make it right for him to skip the MRI and get a CT.

 

[Tenesma]

I like Lumbar CTs for specific reasons - but a Lumbar MRI is still far superior on many levels - and not just to figure out radics... you can see end-plate changes/fractures and get a sense of acuity w/ MRI which you can't always with a CT...

your PCP is lazy (if he is doing this because of insurance issues) - and would be better off just referring to you, and that you will help decide which imaging is indicated and deal w/ ins co. instead.

 

[geauxg8rs]

I think the PCPs should just let me do the imaging. I saw two
Patients yesterday who had unaffected areas MRI'd. They basically just MRI l spine when it was the t spine and MRI t spine when it was c spine. Cost to the system of 1000s of obamadollars and frustrates patients.

 

[PinchandBurn]

If a PCP ordered teh CT scan already of the L spine. and it's simply likely facet pain or a radic, would you bother ordering a MRI? I personally dont think there's a value to ordering a MRI if he/she has already ordered a CT scan. Wht do you think....

 

[painstop]

At that point, I probably wouldn't unless the clinical picture was hazy or the indication was obviously there (infection, etc). The data is suboptimal but still of good enough quality to proceed (remember the prior thread about some of us not ordering an MRI at all for certain indications if it weren't for defensive reasons...I am not taking it to that extreme but at this point enough dollars have been spent that I don't think any more time or money is worthwhile...let's face it if we were all in a third world country and all we had were CT scans we would probably not stray too far from our current way of practicing...just politely let him know that you can manage these patients (including imaging) after NSAIDS and PT have not worked.

 

[Aether2000]

The vast majority of both CT and MRI of the lumbar and cervical spines ordered by PCPs and virtually all MRIs of the thoracic spine are inappropriate, have no medical indication, and are a waste of health care resources.

 

[ghost dog]

The vast majority of both CT and MRI of the lumbar and cervical spines ordered by PCPs and virtually all MRIs of the thoracic spine are inappropriate, have no medical indication, and are a waste of health care resources.

On the flip side of this, how many times a week / month do you have to write to the referring doc and ask them to send the basic imaging that has been done already on their patient ?

The typical referral I get is " back pain / chronic back pain". I count myself luck if they list their meds.

 

[Aether2000]

We contact the patients directly before the first visit and give them explicit instructions on how to obtain DVDs or films directly from the imaging location, and inform the patient it is an expectation that these will be presented at the time of the initial visit. We also screen all patients medical records for the past 6 months before deciding on whether or not to accept them, and if imaging reports are missing, we capture that during the review.

 

[Ducttape]

The vast majority of both CT and MRI of the lumbar and cervical spines ordered by PCPs and virtually all MRIs of the thoracic spine are inappropriate, have no medical indication, and are a waste of health care resources.

but the consensus on these forums seems to suggest that almost everyone on this forum orders an MRI on patients that they see...

 

[SSdoc33]

but the consensus on these forums seems to suggest that almost everyone on this forum orders an MRI on patients that they see...

Bc I don wanna get sued. If it wasn't for the layers the mris I order would be cut in half

 

[lobelsteve]

I just tell it like it is.

If they need an MRI I order it. If I'd like an MRI I tell them the red flags that they don't have and why I'd like one anyway. If they don't an MRI but want one, I always oblige.

 

[Tenesma]

we over-image purely for legal reasons...

 

[Ducttape]

we over-image purely for legal reasons...

the primary care physicians do the same thing....

 

[SIIMS]

Imaging.......

I end up ordering MRI's on most of my patients who have greater than 4-6 weeks of function limiting spine pain who have tried but haven't found relief with NSAID's, chiropractic, PT

I believe it to be far superior to CT's , x-rays, bone scans in many instances b/c of the detailed anatomy and potential for identifying acuity (edema on STIR within endplates, vertebral bodies, facets etc.)

I don't do it b/c I'm afraid of getting sued, I do it b/c I want to help diagnose and treat, plan appropriate interventions and avoid potential complications from interventions

If your a spine/pain physician and this is your livelihood there is no other way to separate the myriad of spine somatic concerns many of your patient have.

Many patients, despite their (and your) best attempts can't provide an adequate history, many of spine physical exam maneuvers are crap (SI, facet, SLR, etc.)

If a 35 yr old female comes to me with diffuse cervical, thoracic and lumbar pain and MRI is relatively benign for structural cause, has negative screening serology (ESR, CRP, CK, thyroid studies) that patient get's education, possible pain psych, a trial of Lyrica, Cymbalta or Savella and relatively little if any attempted interventional procedures. Is the MRI expensive, yes, but burning and churning multiple epidurals and trigger point injections on this patient like many pain groups do is likely going to end up being more expensive

If a patient came to you with clear cut Cervical radic, would you just do a cervical epidural at C7-T1 without any imaging??? What if the MRI showed no epidural fat at this interspace on T1 imaging, what if T2 imaging showed a narrow spinal canal without any CSF reserve, that means the second you pass ligament what awaits you is the spinal cord without any room in between. Starting with a cervical TFESI in this patient with DSA and non-particulate might actually be safer and put your medicine closer to the affected nerve.

IMHO treating people with chronic spine conditions without an MRI is like pissing in the wind, do CT surgeons do a CABG on everyone with chest pain?? Do spine surgeons take a disc out at L5-S1 without any imaging just b/c the patients leg pain is in an S1 distribution?? No, so why would I attempt to do a pain procedure without the added benefit of the best available imaging?

"Previous poster, MRI of thoracic spine worthless" Just ordered a thoracic spine MRI on a female who has aching chronic thoracic pain who had a thoracic x-ray read as normal, it was normal in fact except that her thoracic spine MRI ended up showing hot corner lesions indicative of spondyloarthropathy, If I hadn't ordered that scan she would have ended up at the pain group around the corner who would have ordered a series of three thoracic epidurals and done thoracic RF at multiple levels. Is this the case with all thoracic MRI's, absolutely not but if it were your mom would you order the scan or balk b/c it is expensive and "worthless" Is it worthless an a 80 yr old with osteoporosis or an a younger patient after a trauma??

There is a pain group in town who does 10 page consults on every patient chalk full of meaningless crap only to bill a P5 and their is absolutely NO correlation or medical decision making in many of these notes from the patients pain complaint to a structural cause on imaging. One patient simply had groin pain so a L1 TFESI was performed, I take that back, the interventionalist initially had intrathecal spread on L1 so a L2 was pursued. This patient had an MRI done and the doc made no mention in his 10 page note about wether there actually was a posterior disc at T12/L1 or a lateral disc at L1-2 (there was not), he just simply blasted away b/c of groin pain. This patient actually had symptomatic hip joint disease with clear asymmetrical OA on x-rays and positive hip provocative maneuvers and I sent her to an orthopedic surgeon.

In my very short time practicing imaging has diagnosed, two cases of diffuse metastatic disease (one patient with mets was receiving 8 weeks of PT, and unguided SI joint injections and trigger point injections, 4 undiagnosed spondlyoarthropathies, one case of paget's disease, one disc space infection

Just my two cents

 

[ampaphb]

Does anyone do interventional procedures without first obtaining an MRI of the region in question?

 

[PinchandBurn]

Does anyone do interventional procedures without first obtaining an MRI of the region in question?

no

 

[doctorlarry]

The PCP is wrong. As a specalist, it's your job to politely educate him of the error of his ways when ordering a test that is less helpful than an MRI, and adds a lot of unnecessary radiation.
Just because he read some article by someone we've never even heard of, and doesn't want to be bothered to do what is necessary to get the proper study approved, that doesn't make it right for him to skip the MRI and get a CT.

Never even heard of? Look up Cohen SP on PubMed. I think anyone who is board-certified in pain medicine ought to know who he is and how much he has contributed to our specialty. I do not think many others can match it. And, I'm not sure I would follow any algorithm from the American Academy of Family Practice (AAFP). Just my 2 cents.

 

[facets]

Do I order an MRI on everyone before a procedure? no sometimes I think🙂
If an 85 year old patient with no red flags (no cancer, fever, neuro exam normal) has axial back pain, tenderness over the facets and pain on loading what is an MRI going to tell you? That she has facet arthropathy and DDD? Really we need to treat patients not MRIs. Patients can have significant changes on MRI with no symptoms or neuro signs. Ignore them. Knee jerk imaging is an unnecessary expense, and a hardship for severely debilitated patients. Use your medical judgment, that's what distinguishes us from NPS and PAs and treat the patient. Now id you have a 45 y/o with pain, thats different, image them. If the patient is a lawyer or married to one, image both partners everywhere and refer out.

 

[SSdoc33]

Does anyone do interventional procedures without first obtaining an MRI of the region in question?

Sij only. Lots of people do them without the MRI,though

 

[Ducttape]

Imaging.......

I don't do it b/c I'm afraid of getting sued, I do it b/c I want to help diagnose and treat, plan appropriate interventions and avoid potential complications from interventions

If your a spine/pain physician and this is your livelihood there is no other way to separate the myriad of spine somatic concerns many of your patient have.

You are a pain physician because you have undergone training to be able to diagnose what is the most likely pain generator, not how to fill out an MRI form and let the MRI determine the cause of the pain.

Use your doctor skills, i.e. your clinical judgement based on your history and physical exam skills. Use the MRI as an adjunct to confirm your hypothesis. if you dont trust your clinical skills, then go back to fellowship.

25% of patients with no pain have what one would consider clinically significant findings on MRI. if you rely on MRIs to determine what is causing your patients pain without correlating it to the H&P, then you are no better than those surgeons doing all these unnecessary spinal fusions.

 

[PinchandBurn]

You are a pain physician because you have undergone training to be able to diagnose what is the most likely pain generator, not how to fill out an MRI form and let the MRI determine the cause of the pain.

Use your doctor skills, i.e. your clinical judgement based on your history and physical exam skills. Use the MRI as an adjunct to confirm your hypothesis. if you dont trust your clinical skills, then go back to fellowship.

25% of patients with no pain have what one would consider clinically significant findings on MRI. if you rely on MRIs to determine what is causing your patients pain without correlating it to the H&P, then you are no better than those surgeons doing all these unnecessary spinal fusions.

I dont think Fellowship trained Pain Physicians just 'routintely or blindly' order L/S MRis. I'd say, for the most part a diagnosis is clinically already established. The MRI is to r/o insidious bad things like tumors, infections,etc ESPECIALLY in this legal climate.

Similar to a poster above in my short career already, I've come across two patients, both in their late 50s. Both afebrile, no exacerbation of pain at night, extension, lateral rotation, side bending are all painful. They were both TTP over the spinous processes/facets. Pain was getting worse over the last 3mo. No history of cancer. I got a MRI, one had a mets to the vertebral body, then other had a disciitis. The 'mets' to the vertebral bone, prompted a w/u. Patient's primary lesion was in the lung.

In fellowship, our attendings would say that atleast 3 times a year, malignancies and other 'incidental' findings would be brought to light by an MRI.

Moral of the story. Absolutely physical exam findings and history are mandatory. But, MRIs help to r/o those 1:100000 chances of something bad. I coudl have done diagnostic MBBs,etc as some on here would have suggested. I'm so glad I didnt.

 

[101N]

CYA. If you are not going to image then document the risks, benefits, and alternatives with the patient in the chart before doing a procedure. Also document that they MUST follow up with you
post-procedure so that you can assess the efficacy of what you did, and change course - to obtain imaging - if their clinical situation should warrant.

While zebra's are rare, the longer you work the more you will see. I have injected a patient with Pott's disease and another with discitis, both without prior imaging. The Pott's disease patient - radicular pain - was sent to me for injection by a spine clinic during fellowship. The spine clinic doc's rationale was: looks like a disc, smells like a disc, taste's like a disc, must be a disc. The patient didn't get well post injection and I MRI'd him. I learned the hard way that we have state reporting responsibilities when we find Pott's ds.

The discitis patient was a woman with radicular pain - and diabetes of course - who was admitted to a small rural hospital with no onsite MRI. She didn't get well and I ended up getting a CT - & sed rate - on her. A month or so later I was asked by a hopitalist at another small rural hospital to inject another diabetic who was admitted with back and sciatic pain. I'd learned my lesson and got the sed rate and MRI prior.

 

[lobelsteve]

CYA. If you are not going to image then document the risks, benefits, and alternatives with the patient in the chart before doing a procedure. Also document that they MUST follow up with you
post-procedure so that you can assess the efficacy of what you did, and change course - to obtain imaging - if their clinical situation should warrant.

While zebra's are rare, the longer you work the more you will see. I have injected a patient with Pott's disease and another with discitis, both without prior imaging. The Pott's disease patient - radicular pain - was sent to me for injection by a spine clinic during fellowship. The spine clinic doc's rationale was: looks like a disc, smells like a disc, taste's like a disc, must be a disc. The patient didn't get well post injection and I MRI'd him. I learned the hard way that we have state reporting responsibilities when we find Pott's ds.

The discitis patient was a woman with radicular pain - and diabetes of course - who was admitted to a small rural hospital with no onsite MRI. She didn't get well and I ended up getting a CT - & sed rate - on her. A month or so later I was asked by a hopitalist at another small rural hospital to inject another diabetic who was admitted with back and sciatic pain. I'd learned my lesson and got the sed rate and MRI prior.

Got you beat (for stupidity). In fellowship did a discogram based on failed facets, axial lbp, and MRI with ddd. MRI 3-4 yrs old. Gets "infected" with worsening pain as excruciating. Esr 100+, MRI with discitis/osteomyelitis. Call patient and tell her to go to ER. Call NS and he agrees to meet in ER and admit. Gets Bx at time of corpectomy and fusion.

When I had him on phone he said that if you don't het complications, you aren't doing enough procedures. He called POD1, bx revealed metastatic breast cancer. WTF moment.

 

[Louisville04]

CYA. If you are not going to image then document the risks, benefits, and alternatives with the patient in the chart before doing a procedure. Also document that they MUST follow up with you
post-procedure so that you can assess the efficacy of what you did, and change course - to obtain imaging - if their clinical situation should warrant.

While zebra's are rare, the longer you work the more you will see. I have injected a patient with Pott's disease and another with discitis, both without prior imaging. The Pott's disease patient - radicular pain - was sent to me for injection by a spine clinic during fellowship. The spine clinic doc's rationale was: looks like a disc, smells like a disc, taste's like a disc, must be a disc. The patient didn't get well post injection and I MRI'd him. I learned the hard way that we have state reporting responsibilities when we find Pott's ds.

The discitis patient was a woman with radicular pain - and diabetes of course - who was admitted to a small rural hospital with no onsite MRI. She didn't get well and I ended up getting a CT - & sed rate - on her. A month or so later I was asked by a hopitalist at another small rural hospital to inject another diabetic who was admitted with back and sciatic pain. I'd learned my lesson and got the sed rate and MRI prior.

What do you think of getting routine (CBC, BMP) and nonroutine labs (ESR, CRP, Rheum Panel)? This would be less expensive than a MRI.

At my old VA, they had two MRI machines running 12-16 hours/day 7 days/week. Since it was a fixed cost, the only ones who complained of too many MRIs were the radiologists 😉

 

[101N]

What do you think of getting routine (CBC, BMP) and nonroutine labs (ESR, CRP, Rheum Panel)? This would be less expensive than a MRI.

At my old VA, they had two MRI machines running 12-16 hours/day 7 days/week. Since it was a fixed cost, the only ones who complained of too many MRIs were the radiologists 😉

During my residency @ the VA we used to say: Any diabetic with a foot/ankle fracture has a Charcot foot until proven otherwise. So now I'm proposing: Any diabetic who gets admitted for back/sciatic pain has discitis until proven otherwise.

I think that any diabetic who gets ADMITTED for back and sciatic pain should have a sed rate at a minimum.

 

[Ducttape]

I dont think Fellowship trained Pain Physicians just 'routintely or blindly' order L/S MRis. I'd say, for the most part a diagnosis is clinically already established. The MRI is to r/o insidious bad things like tumors, infections,etc ESPECIALLY in this legal climate.

on the contrary, a trained (and it doesnt have to be fellowship, but someone with extensive experience who has grandfathered in) pain physician knows when to look and what to look for that are red flags.

on the contrary, inexperienced or physicians lacking in medical ability will order every test on every patient and then, after stirring things around, will look at the millieu of tests that they have ordered, then blindly reach down and state that, whatever they pick up will be the etiology of a patient's current crisis.

The examples that are all mentioned are unquestionably interesting, but they also speak to the fact that there should have been some hint of a concern in the back of someone's mind and that test correlated with the underlying pain generator, such as steve's example. otherwise, then we as physicians should CYA and MRI everyone from head to toe when they have any complaint, be it neck, head, toenail, etc.


now mind you, i do MRI patients who i do spine interventions. but not if they have GT bursitis or SI dysfunction, unless they fail the initial conservative therapy/simple injections.

 

[SIIMS]

on the contrary, a trained (and it doesnt have to be fellowship, but someone with extensive experience who has grandfathered in) pain physician knows when to look and what to look for that are red flags.

on the contrary, inexperienced or physicians lacking in medical ability will order every test on every patient and then, after stirring things around, will look at the millieu of tests that they have ordered, then blindly reach down and state that, whatever they pick up will be the etiology of a patient's current crisis.

The examples that are all mentioned are unquestionably interesting, but they also speak to the fact that there should have been some hint of a concern in the back of someone's mind and that test correlated with the underlying pain generator, such as steve's example. otherwise, then we as physicians should CYA and MRI everyone from head to toe when they have any complaint, be it neck, head, toenail, etc.


now mind you, i do MRI patients who i do spine interventions. but not if they have GT bursitis or SI dysfunction, unless they fail the initial conservative therapy/simple injections.

No, I think one fellowship was enough, and with a physiatry background I have "some experience" with PE maneuvers and quite frankly (as stated in previous thread) for the most part they have low sensitivity and specificity for spine conditions, especially when trying to apply to general pain population , so I guess I don't know what your hinting at...

It seems like your making a hasty generalization about a "pain physician's" medical ability and experience based on wether they order an MRI as part of their clinical work-up of someone with persistent pain that hasn't responded to conservative care.....

Assuming on my part b/c it is you have "experience" and some sixth sense that allows you to sniff out red flags entirely based on history.....

Your post's have you definitely riding high on the saddle

Yet you say you end up ordering MRI's on most of your procedure patients that aren't SI's or GT's (which in the hundreds of injections I do every month consist of about 3-5 % of my total injections b/c I believe both are over diagnosed as pain generators)

So why do you get imaging on those patients, why don't you just rely on you superior experience and medical acumen??

 

[Ducttape]

No, I think one fellowship was enough, and with a physiatry background I have "some experience" with PE maneuvers and quite frankly (as stated in previous thread) for the most part they have low sensitivity and specificity for spine conditions, especially when trying to apply to general pain population , so I guess I don't know what your hinting at...

It seems like your making a hasty generalization about a "pain physician's" medical ability and experience based on wether they order an MRI as part of their clinical work-up of someone with persistent pain that hasn't responded to conservative care.....

Assuming on my part b/c it is you have "experience" and some sixth sense that allows you to sniff out red flags entirely based on history.....

Your post's have you definitely riding high on the saddle

Yet you say you end up ordering MRI's on most of your procedure patients that aren't SI's or GT's (which in the hundreds of injections I do every month consist of about 3-5 % of my total injections b/c I believe both are over diagnosed as pain generators)

So why do you get imaging on those patients, why don't you just rely on you superior experience and medical acumen??

being a doctor is as much an art as a science. relying on imaging to decide what is causing a patient's symptoms is not being a doctor, its being a technician.


i order MRIs on my spine intervention patients. ESI, TF, caudal, etc. please read carefully. and adding caveats into your previous position, such as "persistent pain that hasnt responded to conservative care", does not strengthen your argument.

im actually making comments about ordering MRIs on every patient that crosses the doorstep, regardless of the underlying complaints or history or physical examination.


Irresponsible spine surgeons decide what to do based almost solely on imaging, pain physicians should be better than that. but how many times has a patient had ESI for axial dominant low back pain because their imaging shows stenosis?

 

[101N]

being a doctor is as much an art as a science. relying on imaging to decide what is causing a patient's symptoms is not being a doctor, its being a technician.


i order MRIs on my spine intervention patients. ESI, TF, caudal, etc. please read carefully. and adding caveats into your previous position, such as "persistent pain that hasnt responded to conservative care", does not strengthen your argument.

im actually making comments about ordering MRIs on every patient that crosses the doorstep, regardless of the underlying complaints or history or physical examination.


Irresponsible spine surgeons decide what to do based almost solely on imaging, pain physicians should be better than that. but how many times has a patient had ESI for axial dominant low back pain because their imaging shows stenosis?

You are riding high in the saddle.

 

[PMR 4 MSK]

If you rely on imaging to make your diagnosis much of the time, you are not a very good doctor, IMHO. The only real role for MRI in spine care is confirmatory and CYA. Much like any other test.

 

[SIIMS]

"Irresponsible spine surgeons decide what to do based almost solely on imaging, pain physicians should be better than that. but how many times has a patient had ESI for axial dominant low back pain because their imaging shows stenosis?"

I would counter and say there are plenty of irresponsible spine surgeons that do inconceivable things NOT EVEN based on imaging.......one ortho spine surgeon at the tertiary care academic center I did my fellowship routinely, and i mean routinely did multilevel fusions on young patients with axial back pain, i made it a point to look at pre-op scans, possibly an HIZ at L5-S1, but the other 17,000 fused discs were contained and hydrated, inexcusable IMO.....

However, we apparently have a fundamental difference of opinion if you really don't believe in the possibility of predominately axial claudicatory back pain which the HISTORY AND imaging could clue you in (not saying all axial back pain, but yes some is certainly claudicatory)

Anyway, I certainly respect your opinions and our little banter is becoming somewhat circular at this point

Happy Independence day peeps, be sure to wear some flame ******ant clothing lighting off those tanks and bottle rockets!!

 

[101N]

However, we apparently have a fundamental difference of opinion if you really don't believe in the possibility of predominately axial claudicatory back pain which the HISTORY AND imaging could clue you in (not saying all axial back pain, but yes some is certainly claudicatory)

This is controversial. Check out speaker #10 Low back pain and lumbar spinal stenosis.

http://main01.hostcast.com/custom/iconomed/kostuik2006/agenda.html

 

[Ducttape]

If you rely on imaging to make your diagnosis much of the time, you are not a very good doctor, IMHO. The only real role for MRI in spine care is confirmatory and CYA. Much like any other test.

I would say that PmR has been able to succinctly state my position in a much more elegant way than I have been able to...

 

[ampaphb]

I do not pretend to be right everytime I examine a patient, and therefore, prior to performing spinal interventions, I use imaging as an adjunct tool to give me greater information.

I never inject at the level of greatest stenosis on the first injection, and so use the information gleaned from imaging to perform my procedures in the safest possible manner.

I am not smart enough to identify facet cysts by physical exam alone, and so will only know to target such structures if imaging has been obtained.

Physical exam findings create a differential diagnosis. Imaging can confirm or confound, but almost always provides additional data.

 

[PinchandBurn]

To play devil's advocate.

Imagine MRIs were free and readily available. Given the fact there is no radiation and no real downside (assuming you do not have brain clips, pacemakers,etc) would you image everyone before any injection aroudn the spine?

 

[Ducttape]

in essence, if an MRI were like using a stethoscope, then yes.

not infrequently i will grab the US machine and use it as part of my physical exam, free of charge.

 

[SSdoc33]

in essence, if an MRI were like using a stethoscope, then yes.

not infrequently i will grab the US machine and use it as part of my physical exam, free of charge.

Spine is different. You know that.

 

[Ducttape]

my point all along has been that we as doctors have to, oh, to prevent from getting longwinded, see PMR 4 MSK post. H&P, hypothesize, MRI imaging if necessary to confirm a hypothesis or if necessary to screen for risk of complications from spine interventions, but guided by clinical judgement.

(crap started rambling anyways)

 

[SSdoc33]

my point all along has been that we as doctors have to, oh, to prevent from getting longwinded, see PMR 4 MSK post. H&P, hypothesize, MRI imaging if necessary to confirm a hypothesis or if necessary to screen for risk of complications from spine interventions, but guided by clinical judgement.

(crap started rambling anyways)

and your "succinct" point is wrong. MRI is primarily done to cover my butt. patient comes in with L5 symptoms, im gonna do a L5 TFESI. i know that. i dont need an MRI to tell me that. maybe the results change where i inject, but not usually. but i need the MRI so i dont get sued. simple as that

 

[Ducttape]

and your "succinct" point is wrong. MRI is primarily done to cover my butt. patient comes in with L5 symptoms, im gonna do a L5 TFESI. i know that. i dont need an MRI to tell me that. maybe the results change where i inject, but not usually. but i need the MRI so i dont get sued. simple as that

and i think you miss my point. when reading some of the comments posted here, the gist is that some of the posters practice by obtaining MRI scans on everyone that come in the door, irrespective of any clinical assessment, then use the MRI to figure out what was causing the pain afterwards. oh and to CYA.

too often doctors are practicing image based medicine, using images to determine what is causing the pain and treating the images rather than the clinical presentation.

based on your example, that is not how you are practicing medicine.

 

[PinchandBurn]

Let's say you look at MRI. Disc bulge paracentral at L3/4. However, patient's symptoms are all left sided esentially L5 and s1.

Assume no psych issues.

Where are you going to inject?

 

[SSdoc33]

and i think you miss my point. when reading some of the comments posted here, the gist is that some of the posters practice by obtaining MRI scans on everyone that come in the door, irrespective of any clinical assessment, then use the MRI to figure out what was causing the pain afterwards. oh and to CYA.

too often doctors are practicing image based medicine, using images to determine what is causing the pain and treating the images rather than the clinical presentation.

based on your example, that is not how you are practicing medicine.

didnt miss the point and i dont order MRIs on everyone.

if you are an interventional spine doc and make every decision based off of imaging, then obviously you are a bonehead. who would argue otherwise?

all im saying is that CYA is the main reason i order MRIs. and i really dont think im alone.

 

[101N]

didnt miss the point and i dont order MRIs on everyone.

if you are an interventional spine doc and make every decision based off of imaging, then obviously you are a bonehead. who would argue otherwise?

all im saying is that CYA is the main reason i order MRIs. and i really dont think im alone.

1+

I took ampaphb's original question - he's a recovering attorney - to be rhetorical.

 

[Tenesma]

pinchandburn: when i look at the MRI and the symptoms are not consistent with imaging, then I do more detective work, I don't inject just based on symptoms...

 

[PinchandBurn]

pinchandburn: when i look at the MRI and the symptoms are not consistent with imaging, then I do more detective work, I don't inject just based on symptoms...

obviously.

But for example. If you have a L4/5 paracentral disc protrusion typically the symptoms maybe along the L5 dermatome/nerve root. If the disc protrusion is more foraminal, then likely that level (L4) will be effected.

Also as we know the dermatomal distribution of the pain isnt usually just down one nerve root distribution and it isnt as clear cut as in those dermatomal maps in the textbooks. Sometimes it is a combo of a L4 and L5 dermatome. So where would you inject? Pick the worse one? or do a 2 level TFESI.