Do you require an MRI before injecting?

[dc2md]

I'm currently working on a new post for my website which will present a collection of research studies that show how common it is for asymptomatic individuals to have lumbar spine pathology on MRI.

This got me wondering, how many pain physicians require an MRI of an area before injecting? How recent?

Finally, if the MRI findings differ from the patient's history and physical exam, which one wins in the decision where to inject. The obvious answer to me is, treat the patient, not the film; but I've seen the opposite done too many times. Of course if the difference is just one level (MRI shows far lateral disc herniation contacting the exiting nerve root of L4, while the dermatomal pattern and weakness of the patient is L5), a two-level TFESI will be done. But I've seen where the patient has what appears to be textbook facet-mediated pain, but then the MRI is looked at and shows spinal stenosis and displacement of exiting nerve root (yada yada yada), but no facet arthropathy.....so the patient gets the ESI.

Just curious what you all think. Thanks.

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[lobelsteve]

I don't do ESI without MRI.
I'll do facet or SIJ based on sx and exam + plain films.

 

[SleepIsGood]

probably should get an MRI.

I've heard nightmare stories of docs that kept repeating LESIs,etc when it was later discovered the patient had a spinal pathology (tumor) of sorts. Of course physical exam is important. But I think there are limitations with physical exam. On the flip side, MRIs on asymptomatic people may show some derangements. Thus, it's important to utilize the MRI in conjunction with an MRI.

I think you should have a baseline MRI. Unless symptoms change dramatically (new onset of a different type of pain, foot drop, etc) the MRI should be good for a while.

 

[ostap747]

I do not get MRIs on the subset of patients who have no insurance and cannot afford MRI and when I get a pretty good idea as to the nature and level of their spinal pathology, everyone else gets MRIs.

 

[olafa]

I think generally speaking people get an MRI is their pain has changed significantly from what was originally reported. And to CYA- to rule out any other potential spinal pathology such as tumors etc... IF the pain complaints do not coordinate with imaging you should probably re-think your diagnosis.

Degenerative changes on MRI been reported in 25% asymptomatic people less than 40 yrs and 60% in those over 40 years. There are reports for disc pathology - HNP in asymptomatic people as well 10% greater than 40 yrs and 5% for those less than 40 and asymptomatic. (I don't remember the exact authors for the study.)
I think its more reflective of CYA nature of medicine - MRI's are probably over-utilized. Good physical exam should be the best indicator and if it collaborates with the MRI even better.

 

[clubdeac]

My general rule of thumb is MRI within last 2 years unless symptoms have changed recently. I do agree that MRIs are way over utilized however. But that's the lawyers fault, no ours. I don't put much stock in facet pathology on MR but do so for disc extrusions when the pt has radic symptoms. And i too have wondered which to go by when PE and MR don't correlate. For example I have a guy with a disc extrusion at L3/4 but pain in an S1 dermatomal distribution. I tried various ESIs w/o relief and am now considering a perc diskectomy. Just feel a little weird about it since the disk is at L3/4 and the pain radiates down his posterolateral leg. Any thoughts?

Oh and I hate it when I ask a patient what brings them in today and they respond with, "Well I've got degenerative disc dx and disc bulges at my L3-5 discs....." I always say, yadayadayada we all have that....

 

[olafa]

is the pain all the way down the leg? or at about knee level. Any suggestion of piriformis muscle tightness - or SI related? Agreed- I don't think the L3/4 levels make sense with his pain pattern. Any reflex changes?

For example I have a guy with a disc extrusion at L3/4 but pain in an S1 dermatomal distribution. I tried various ESIs w/o relief and am now considering a perc diskectomy. Just feel a little weird about it since the disk is at L3/4 and the pain radiates down his posterolateral leg. Any thoughts?

 

[Mister Mxyzptlk]

If I plan to enter the canal for any reason (ESI, pump, etc) I want a picture. For joints I don't bother.

Otherwise it's to confirm or rule out what the clinical exam suggests, e.g. is this spinal stenosis and if so, what level.

 

[bedrock]

I would probably get half as many MRIs if it wasn't for CYA purposes.

If Obama wants to save money in healthcare, first stop would be tort reform. Billions of dollars in unnecessary tests could be saved each year if physicians were allowed to be physicians and only order or prescribe what's medically indicated to diagnose and treat, instead of what's required to CYA.

Still, judged by the previous responses on this thread, many pain docs do a good job of limiting MRI ordering to when those studies truly add to the clinical picture. I'm biased, but I think docs on SDN tend be more conscientious than your average pain physician.

This is another financial arena where mid-level providers really add to the costs in the system because they order MRIs/advanced testing on everyone, because of their bare bones understanding of whatever specialty they're working in at the moment.

 

[dc2md]

Oh and I hate it when I ask a patient what brings them in today and they respond with, "Well I've got degenerative disc dx and disc bulges at my L3-5 discs....." I always say, yadayadayada we all have that....

That is one of my biggest clinical pet-peeves. PCPs will order an MRI and be impressed by the disc bulges/protrusions, and say, "no wonder you have pain...". So then patient obsesses over his disc bulges. And the crazy thing is, the patient is so convinced that the disc bulges are causing his axial low back pain, that even after explaining everything to the patient (high incidence of bulges in asymptomatic patients; axial vs radicular pain; etc), they'll still say something like, "well I don't about all that...but these "discs" are killing me". I've learned to not press the issue too much (like suggesting they quit smoking vs harping on them constantly).

 

[dc2md]

Degenerative changes on MRI been reported in 25% asymptomatic people less than 40 yrs and 60% in those over 40 years. There are reports for disc pathology - HNP in asymptomatic people as well 10% greater than 40 yrs and 5% for those less than 40 and asymptomatic. (I don't remember the exact authors for the study.)

Finally finished that post for my site which shows 4 studies that looked at the prevalence of lumbar spine pathology in asymptomatic individuals. It doesn't contain any mind-blowing studies the majority of us aren't aware of; I just wanted to collect a few of them for future easy reference. Seems like information to provide in presentations to PCPs (and other physicians) when marketing yourself/practice.
http://thepainsource.com/archives/314

I think its more reflective of CYA nature of medicine - MRI's are probably over-utilized.

Completely agree. axm posted a link to an article recently that was circulating the general news sites, regarding the amount of CYA done in emergency departments. Incredible!

 

[Aether2000]

Interesting topic...
False positives are upwards of 25% with MRI leading to unnecessary injections and surgery...
When correlated with a physical exam and history, the combination false positive rate is much lower.
The false negative rate is also present but is more difficult to ascertain. Lumbar pathology may or may not be the cause of referred pain to the lower extremity, and pathology in the spine itself may not be the cause of back pain...
In an ideal world without lawyers, MRI would only be used when there are clinical symptoms of non-vascular claudication, significant spinal instability on flexion/extension plain films, or radicular pain/radiculopathy. The overall number of MRIs would drop by 90% and the overall health of patients would not be diminished.

 

[PMR 4 MSK]

I want an MRI within 12 months if I am entering the spinal canal, unless I did the previous injection and symptoms have not changed, other than returned, for a condition like stenosis.

I've had a number of cases of what looks like acute HNP with radiculopathy, only to find on MRI there is an HNP on the contralateral side and nothing to explain the pain.

For facets, I prefer having an MRI, but don't demand it. For joints I just want an x-ray.

 

[Tenesma]

i don't stick a needle into the spine without imaging..... period... either a CT scan or an MRI... x-ray not enough.

why take on the risk? we are not good clinicians because so many of our physical exam findings are useless for non-specific low back pain and also quite useless for radicular pain without weakness/sensory deficits...

i have had WAY too many referrals for injections but instead pt had
1) metastatic prostate CA to spine
2) lymphoma in the nerve root
3) sacral insufficiency fractures
4) completely NORMAL spine
5) spinal AVM
6) even had a latin american gentleman with an intraspinal parasite....

if you are doing injections and you delay their diagnosis you will be left out to hang....

 

[SleepIsGood]

i don't stick a needle into the spine without imaging..... period... either a CT scan or an MRI... x-ray not enough.

why take on the risk? we are not good clinicians because so many of our physical exam findings are useless for non-specific low back pain and also quite useless for radicular pain without weakness/sensory deficits...

i have had WAY too many referrals for injections but instead pt had
1) metastatic prostate CA to spine
2) lymphoma in the nerve root
3) sacral insufficiency fractures
4) completely NORMAL spine
5) spinal AVM
6) even had a latin american gentleman with an intraspinal parasite....

if you are doing injections and you delay their diagnosis you will be left out to hang....

Great post. I do believe a good physical exam is important. However, just like you said, there are TOO many things that a good history and physical exam can not pick up.

 

[dc2md]

Great post. I do believe a good physical exam is important. However, just like you said, there are TOO many things that a good history and physical exam can not pick up.

This is what I love so much about this forum. Being able to get the input/advice from seasoned vets like Tenesma is well worth the time I spend here.

 

[clubdeac]

"I've had a number of cases of what looks like acute HNP with radiculopathy, only to find on MRI there is an HNP on the contralateral side and nothing to explain the pain."

I've had several patients with large paracentral disc protrusions contralateral to the side of their leg pain who responded well to TFESIs. The axial cuts on MRI showed the cord pushed way over to the opposite side. It think the whole canal was compromised and it just happened that for some reason the nerve roots on the other side were most affected. I dunno

 

[Aether2000]

Although I also require MRIs, let me present a contrarian view: evidence based medicine requires that we have statistically and clinically valid reasons to perform procedures or utilize a diagnostic test. Do we really have these reasons other than CYA in ordering MRIs? Or is it just a knee jerk reaction to order tests that typically cost $2700-3900 in my area? With patients increasingly uninsured can they really afford to mortgage their house to pay for a MRI so they can undergo an injection for pain relief? Are you willing to tell the patient up front the real cost of the injection will be $4000 since the MRI is required? Is overutilization of MRIs one of the cost drivers of health care when the results may not change the clinical course of action?

 

[olafa]

In my minimal experience these are my impressions.... I don't think MRI's are over-utilized by pain physicians but ARE more likely from the primary referring source. It seems its a knee jerk response- the patient complains of LBP, pain not getting better fast enough, patient demands MRI. MRI ordered and referral placed.
I do think that they are important for ruling out other pathologies prior to injecting, unless you have XR vision. In your mind you have a working diagnosis and the MRI confirms/solidifies that suspicion or it may surprise you and cause you to re-think what going on. Either way I believe it probably a useful part of diagnosis if you are planing on injecting. Over-utilized if the patient has mechanical back pain, last year's MRI with no surprises and pain has stayed the same, exam the same except patient has gained a few pounds and now requests a repeat MRI "to find out what's going on." Probably not helpful.

Although I also require MRIs, let me present a contrarian view: evidence based medicine requires that we have statistically and clinically valid reasons to perform procedures or utilize a diagnostic test. Do we really have these reasons other than CYA in ordering MRIs? Or is it just a knee jerk reaction to order tests that typically cost $2700-3900 in my area? With patients increasingly uninsured can they really afford to mortgage their house to pay for a MRI so they can undergo an injection for pain relief? Are you willing to tell the patient up front the real cost of the injection will be $4000 since the MRI is required? Is overutilization of MRIs one of the cost drivers of health care when the results may not change the clinical course of action?

 

[SleepIsGood]

In my minimal experience these are my impressions.... I don't think MRI's are over-utilized by pain physicians but ARE more likely from the primary referring source. It seems its a knee jerk response- the patient complains of LBP, pain not getting better fast enough, patient demands MRI. MRI ordered and referral placed.
I do think that they are important for ruling out other pathologies prior to injecting, unless you have XR vision. In your mind you have a working diagnosis and the MRI confirms/solidifies that suspicion or it may surprise you and cause you to re-think what going on. Either way I believe it probably a useful part of diagnosis if you are planing on injecting. Over-utilized if the patient has mechanical back pain, last year's MRI with no surprises and pain has stayed the same, exam the same except patient has gained a few pounds and now requests a repeat MRI "to find out what's going on." Probably not helpful.

Greatpost again.

I understand concept of saving healthcare dollars. However, I think when someone is sticking a needle close to someone's spinal cord (sounds very blnt I know), it's worth getting the MRI. I think we can all agree the cord is a very important area...

 

[SSdoc33]

Greatpost again.

I understand concept of saving healthcare dollars. However, I think when someone is sticking a needle close to someone's spinal cord (sounds very blnt I know), it's worth getting the MRI. I think we can all agree the cord is a very important area...

unless you are injecting at L1, there is no cord in the L-spine, sleep.

 

[SleepIsGood]

unless you are injecting at L1, there is no cord in the L-spine, sleep.

Who is talking about just the lumbar region SS?

Last I checked, we do injections in the Cervical, Thoracic, and Lumbar regions. What are you trying to say? If you were going to do a ILESI at L4/5 or L5/s1 you wouldnt get a MRI? Why because there's no cord?

Ever heard of cauda equinae?

You can still have spinal pathology at levels lower than L1/2 (tumors, cysts,frctures, mets, abscesses, etc).

 

[lovebailey2001]

My general rule of thumb is MRI within last 2 years unless symptoms have changed recently. I do agree that MRIs are way over utilized however. But that's the lawyers fault, no ours. I don't put much stock in facet pathology on MR but do so for disc extrusions when the pt has radic symptoms. And i too have wondered which to go by when PE and MR don't correlate. For example I have a guy with a disc extrusion at L3/4 but pain in an S1 dermatomal distribution. I tried various ESIs w/o relief and am now considering a perc diskectomy. Just feel a little weird about it since the disk is at L3/4 and the pain radiates down his posterolateral leg. Any thoughts?

Oh and I hate it when I ask a patient what brings them in today and they respond with, "Well I've got degenerative disc dx and disc bulges at my L3-5 discs....." I always say, yadayadayada we all have that....

Have you considered the possibility of Piriformis Syndrome, coz that can mimic S1 radic! recently I saw a patient who underwent microdiscectomy at L5 disc but no relief, then was examined ny a pain doc who gave her Piriformis injection and her pain was gone.

 

[Aether2000]

Playing the devils advocate...what would be the incidence of picking up something "surprising" on MRI if there are no significant neurological findings? The spine is important but Canada gets by just fine thank you, with only a small fraction of the number of MRIs per capita that we use? Do MRIs, from a perspective of overall healthcare costs, significantly improve the quality of life? They sound great if you pick up a metastatic tumor in one in 10,000 patients or a primary in 1:200,000, but does that really make financial sense? Just poking sticks here...

 

[hyperalgesia]

It will be cool some day when MRIs are super cheap, maybe even used as a screening tool. The results might be less misleading. There would be no -"Oh my God I have a bulging disk!", getting it permanently etched in their brain that their back is "bad" or "all messed up". Radiologists might start reading those images as "normal degenerative changes". We would catch an incredible number of real pathologies.

 

[dc2md]

Algos is right...it's definitely NOT evidence-based. But it does seem to be the standard of care.

It seems to me (yes, still just a resident) that you could safely obtain sufficient information from plain films to perform facet, TFESI, SI, lumbar MBB/neurotomy, and maybe even L2/3-L5/S1 ILESI (malunions of the posterior elements could be seen). Not perfect imaging, but sufficient. And if the patient doesn't improve with the diagnosis you obtained from a thorough history, physical exam, xray, and fluoroscopic views during the procedure, THEN MRI could be ordered. The scary zebras Tenesma mentioned are probably just that...zebras.

Especially in today's climate, cost-benefit analysis must be done. It would be great if MRIs only cost $100-200 and everyone could get full-body scans; zebras would be caught and lives saved...but at some point rationing of sorts has to start.

With all that said, until the litigation climate changes for us, I'm sure I'll be practicing CYA medicine as well, and requiring an MRI.

Update: GREAT. Algos and Hyperalgesia have to steal my thunder before me. Guess I didn't refresh before posting my comment.

 

[Tenesma]

algos:

i agree that MRIs are over-ordered.... and if "delay of diagnosis" wasn't hanging over my head, i would probably would consider ESI for radicular pain without imaging with the caveat that if there is no improvement of pain that an MRI would be appropriate...

HOWEVER, let's assume you do an ESI for radicular pain and patient gets pain relief for 3 months after just one shot... they come back with similar pain, and you inject again with again 3 months of relief... they come back with similar pain but much worse, and there is evidence of significant lymphoma... you have now delayed their diagnosis by up to 6-9 months...

clearly this is very rare... but why should we function different from surgeons... an orthopedic surgeon isn't going to scope a knee without diagnostic imaging for knee pain, a general surgeon isn't going to do an ex-lap without diagnostic imaging for abdominal pain, and a spine surgeon isnt going to do a discectomy for radicular pain without an MRI

are we so desparate for procedures that we are going to skip on imaging???

and in my neck of the woods an MRI costs $700 --- there are quite a few MRI centers, so that has driven down cash price....

i still insist on imaging.... those who don't, oy vey...

 

[lonelobo]

Playing the devils advocate...what would be the incidence of picking up something "surprising" on MRI if there are no significant neurological findings? The spine is important but Canada gets by just fine thank you, with only a small fraction of the number of MRIs per capita that we use? Do MRIs, from a perspective of overall healthcare costs, significantly improve the quality of life? They sound great if you pick up a metastatic tumor in one in 10,000 patients or a primary in 1:200,000, but does that really make financial sense? Just poking sticks here...

I don't have the statistics, but I suppose you could apply the same logic
to Interventional pain procedures in Canada and U.S.

My guess is we do about 10x per capita, with minimal if any better results
than the canucks(maybe they are just tougher-all that hockey)

 

[Tenesma]

furthermore algos:

statistically metastatic or even primary neoplastic dz of the spine is rare ... in the general population.... in the pain population with poor work-ups it is not rare...

i diagnose metastatic dz of the spine at least once a month....

i diagnose primary to the spine at least once every 3-4 months...

 

[Aether2000]

Excellent points...perhaps our metric should be different than the PCPs. At least for PCPs, here is a RCT that shows no difference between xrays and MRIs in diagnostic validity for patients with low back pain: http://jama.ama-assn.org/cgi/content/full/289/21/2810 Interestingly the PCPs have moved into the MRI ownership self referral market. Large groups of PCPs now own their own MRIs and perhaps that explains why there are so many MRIs being ordered that appear to have no clinical application. When you own a machine that is non-invasive and brings in $2K-4K per patient for self pay and around $500 per Medicare patient, there is an incentive to refer as many patients as possible. For a PCP that refers 3 patients a day (out of the 80 they see in the office) for a lumbar MRI, and if only one is high deductible or self pay, then with a 50% overhead for MRI operation and acquisition cost, the PCP derives an additional $1500 a day income. Multiply this x 220 days a year and one finds the PCP's overall income increases from an average of $1000/workday to $2500/workday. Perhaps this explains the 37% increase in imaging volume from 2003-2008 (Medpac data).

 

[SleepIsGood]

algos:

i agree that MRIs are over-ordered.... and if "delay of diagnosis" wasn't hanging over my head, i would probably would consider ESI for radicular pain without imaging with the caveat that if there is no improvement of pain that an MRI would be appropriate...

HOWEVER, let's assume you do an ESI for radicular pain and patient gets pain relief for 3 months after just one shot... they come back with similar pain, and you inject again with again 3 months of relief... they come back with similar pain but much worse, and there is evidence of significant lymphoma... you have now delayed their diagnosis by up to 6-9 months...
clearly this is very rare... but why should we function different from surgeons... an orthopedic surgeon isn't going to scope a knee without diagnostic imaging for knee pain, a general surgeon isn't going to do an ex-lap without diagnostic imaging for abdominal pain, and a spine surgeon isnt going to do a discectomy for radicular pain without an MRI

are we so desparate for procedures that we are going to skip on imaging???

and in my neck of the woods an MRI costs $700 --- there are quite a few MRI centers, so that has driven down cash price....

i still insist on imaging.... those who don't, oy vey...

This is precisely why it's important to get an MRI.

Even if it's 1:10000, if you are tht 1...then it's 100%

MRIs of one's spine is not where you want to skimp out and be cheap.

 

[Aether2000]

Statisticians, insurers, and the federal government must make financial choices on how to best allocate resources. What physicians might call "skimping" by not ordering a test might be seen quite differently by those that must pay the bills. If 9999 MRIs that are functionally negative, at an average total cost of around $10,000,000 of required expenditure to pick up one treatable tumor, then it is likely insurers and the government might determine the cost to be too high, and therefore begin denying coverage on statistical basis. Fortunately they have not become quite this sophisticated in their NNT analysis nor have the capital to fight the politically sensitive decisions that may require some to die for the good of society and to prevent Medicare bankruptcy. But it is probably coming, and if that is the case, anecdotal cases will not win the argument. We really need more data in order to become credible in our case to permit continued widespread and virtually unlimited expensive MRI usage.

 

[Tenesma]

i agree completely with you... however, if the decision is that diagnostic testing is going to be limited/rationed based on cost-benefit analysis, then we (physicians) have to be immune from prosecution for delay in diagnosis

 

[PMR 4 MSK]

i agree completely with you... however, if the decision is that diagnostic testing is going to be limited/rationed based on cost-benefit analysis, then we (physicians) have to be immune from prosecution for delay in diagnosis

This is already happening with managed care. MRI initially denied. A letter is sent to the pt and doc, advising that a peer-to-peer can be done. P2P says PT has to be done first - takes 8 weeks with scheduling, etc. 2 weeks passes after this to get the MRI authorized again, then the pt gets the MRI a week after that and follows-up with the doc a week after that.

With Work comp, it is often worse - several months go by while they get an IME and make a decision.

The insurance will always stand back in court and pontificate "We do not decide care. We merely advise what we will and won't pay for, given the available information." They will infer the patient can still have the MRI, the insurance company just won't pay for it.

And all the while, we are held liable.

 

[Aether2000]

It is interesting how they escape culpability for their actions, isn't it! Perhaps we will have to eventually use the legal system (that causes excess medical testing) against the insurers who want no testing, or permit it too late and only after unbelievable hassles....

 

[SSdoc33]

furthermore algos:


i diagnose metastatic dz of the spine at least once a month....

QUOTE]


i think we may be overstating a bit here. 60x in 5 years? really?

 

[Tenesma]

REALLY - it is absolutely unbelievable... it freaked me out so much, i spoke w/ the Oncologists and it turns out that we live in an area of high CA... primarily thyroid, but also TONS of breast CAs... also my patient population typically doesn't get much thorough care, so when they present w/ pain usually the staging is metastatic...

trust me --- in my training and in my previous practice in a different state, i diagnosed maybe TWO metastatic cases....

 

[SleepIsGood]

REALLY - it is absolutely unbelievable... it freaked me out so much, i spoke w/ the Oncologists and it turns out that we live in an area of high CA... primarily thyroid, but also TONS of breast CAs... also my patient population typically doesn't get much thorough care, so when they present w/ pain usually the staging is metastatic...

trust me --- in my training and in my previous practice in a different state, i diagnosed maybe TWO metastatic cases....

When I started fellowship, I our PD stated he also diagnoses tumors of the spine (primary or mets) atleast twice a year. We are a tertiary center, so patients typically have gone to many places (PMDs, ortho,etc) before coming here.

What saddens me, is that these types of cancers arent diagnosed earlier. Unfortunately, people are so concerned about healthcare dollars that they skimp out on imaging (MRIs,etc). It's unfortunate that the govt is so concerned about saving $$ that they wont allow for pretty much a completely unharmful and quick image (MRI) without putting up such a fight. I agree 1 in 10,000 isnt a big number and I do understand the need to allocate resources. But seriously...something like mets or a primary of the spine should be picked up WAY earlier by a PMD or someone, not by the interventional pain physician when it's already too late.

 

[Aether2000]

So true...many of the symptoms, especially nocturnal bone pain and weight loss, are present for months before the PCP begins to ask the right questions. Once red flag symptoms occur, then ordering a MRI is a no brainer. But for patients that have none of these, I must wonder if a MRI, that may cause patients to mortgage their house in order to pay for it, is financially justified given that one MRI would cost 15% of their annual income? There indeed are not good answers to be had, but it is a useful debate to bring in all the issues...

 

[Ligament]

My father died of non hodgkins lymphoma with primary in the L1 and L2 vertebral bodies. He was going to a chiropractor for over 6 months with increasingly worse back pain and by the time he finally got an MRI it was too late. He died 3 months after diagnosis.

The VERY FIRST patient I had has an attending pain physician turned out to have previously undiagnosed spine pain due to prostate mets in the spine.

I pick up about one case like this per year now...but I learned my lesson to watch for it.

 

[SleepIsGood]

So true...many of the symptoms, especially nocturnal bone pain and weight loss, are present for months before the PCP begins to ask the right questions. Once red flag symptoms occur, then ordering a MRI is a no brainer. But for patients that have none of these, I must wonder if a MRI, that may cause patients to mortgage their house in order to pay for it, is financially justified given that one MRI would cost 15% of their annual income? There indeed are not good answers to be had, but it is a useful debate to bring in all the issues...

Very true.

But let's say there is institution of a 'screening' MRI...which from the sounds of it on this board can range b/w $700-2000. Let's say 800 for argument sake. Then surgeon is consulted, the primary tumo is resected.

On the other hand, let's assume a patient has late staged tumor that was discovered by "you". By now it's very late. Mets to spine, lung, liver. Patient now is in the ICU for 20 days, then hospice for another 10. What's the avg ICU bed cost these days, $10K a night?

 

[Aether2000]

It all comes down to population statistics if one wishes to make a financial argument. If 1:10,000 has a metastatic tumor detectable on screening lumbar MRI and once metastatic, the treatment options are limited, then the MRI is really being used as a life expectancy predictor and guides the use of palliative measures. On the other hand, if a primary tumor is discovered incidentally on lumbar MRI, but these are much more rare, say 1:200,000, then the MRI may help with long term treatment options, some of which may be curative. Most lumbar MRIs do not permit diagnosis of primary tumors in other areas of the body, including the prostate, but effectively will reveal metastasis, which means lumbar MRI only reveals late disease that is too late for cure. In order to be effective as a screening tool, complete body MRIs would be required every 3-6 months given the propensity of invasive tumors to grow. Unfortunately, the cost of MRIs has not decreased over time, and competition in MRI ownership may drive some centers out of business, but on a global fee capture basis, has not lowered the costs of MRIs. Therefore, screening MRIs for the entire body remain outside the reach of the population. Screening lumbar or cervical MRIs have sensitivity to detect only to metastatic disease due to the small window selected around the spine. The detection of metastatic disease does not appreciably alter its outcome. It would be nice to have a kinder, gentler total body screening exam. Interestingly the cheap, total body screening CTs that were being marketed by radiologists a few years ago have fallen into disrepute given the massive radiation exposure that is now known to have increased the incidence of cancer by up to 2% for each of these screening tests....
Perhaps we will all be armed with diagnostic ultrasound machines in our office soon for a total body ultrasound.....

 

[dc2md]

In post #11 of this thread I posted a link to a collection of studies looking at the prevalence of lumbar spine pathology on MRI in asymptomatic individuals.

Now, here's an article examining pathology on CAT scans in people with no history of low back pain:
http://thepainsource.com/archives/419

In short, it showed herniated discs in 20% of those under 40 yo, and 50% pathology (herniated discs, facet arthropathy, stenosis) in those over 40.

Slightly lower than with MRI, but this would be expected since the detail in MRI is so much better.

 

[PMR 4 MSK]

Perhaps we will all be armed with diagnostic ultrasound machines in our office soon for a total body ultrasound.....

Can you imagine how long that would take?

I get patients periodically asking for a "whole body" MRI. I tell them I believe that would take probably 24 - 36 hours in the tube at a cost of about $75,000 - $100,000, and would not likely to be covered by insurance.

Many people are under the impression that an MRI automatically scan the whole body.

 

[Tenesma]

for some reason, most of my fibromyalgia patients come to me with "whole body MRIs" (cervical, thoracic, lumbar, brain, pelvis and occasionally knees).... talk about a HUGE waste of resources...

 

[Aether2000]

lol...so true...they come equipped with $10-15K worth of total body MRIs and yes, most people are disappointed the entire body wasn't scanned from a lumbar MRI....sigh...

 

[powermd]

for some reason, most of my fibromyalgia patients come to me with "whole body MRIs" (cervical, thoracic, lumbar, brain, pelvis and occasionally knees).... talk about a HUGE waste of resources...

I had one of these show up with individual x-rays of each and every major, and some minor joints- bilaterally. Tells you something about the desperation of the referring doctor... and what your experience will be.

 

[emd123]

Let's face it, 99% of health care dollars we spend are to pick up the 1% of things the patient doesn't have, but we can't afford to miss. You can thank lawyers and greedy people who see you and I as a lottery ticket. Most of us have been burned once or twice. If you feel you need a study, get it. If not, don't. How many multiple-million dollar lawsuits can you afford? I don't want to spent all my free time giving depositions to prove my innocence in a system in which we absolutely do not get a fair trail by our "peers". The government wants you to be the sacrificial lamb who saves the health care cost problem by himself. Does the government give out awards to the docs who order the least tests? The only awards I see given out are multiple-million dollar awards to plaintiffs regardless of whether the doc was wrong or not. I let someone talk me out of an MRI once, and the person ended up having a huge spontaneous epidural abscess, no fever, no risk factors, no neuro signs. How many health care dollars do I have to save to erase that one? My point: you and I didn't make the system this way. We just have to survive in it.

 

[SleepIsGood]

Let's face it, 99% of health care dollars we spend are to pick up the 1% of things the patient doesn't have, but we can't afford to miss. You can thank lawyers and greedy people who see you and I as a lottery ticket. Most of us have been burned once or twice. If you feel you need a study, get it. If not, don't. How many multiple-million dollar lawsuits can you afford? I don't want to spent all my free time giving depositions to prove my innocence in a system in which we absolutely do not get a fair trail by our "peers". The government wants you to be the sacrificial lamb who saves the health care cost problem by himself. Does the government give out awards to the docs who order the least tests? The only awards I see given out are multiple-million dollar awards to plaintiffs regardless of whether the doc was wrong or not. I let someone talk me out of an MRI once, and the person ended up having a huge spontaneous epidural abscess, no fever, no risk factors, no neuro signs. How many health care dollars do I have to save to erase that one? My point: you and I didn't make the system this way. We just have to survive in it.

practical guy

 

[Aether2000]

I don't think it is practical at all to order unnecessary tests. It may be necessary due to our tort system, but it is also destroying the health care system via overutilization of tests that have little chance of being positive and almost are guaranteed to be negative. It is substitution of knee jerk reactions for clinical evaluation and expertise. It also becomes self-fulfilling as a system that encourages this type of malfeasance when patients now come to expect from all their doctors the same type of over reliance on tests as did their one doctor who orders batteries of tests. Additionally, the "standard of care" that is so loosely bandied about by the plaintiff's expert witness becomes escalated to the point that a reasonable prudent physician does not stand a chance if he does not order excessive and unnecessary testing.
But we are the shepherds of the financial pursestrings for healthcare in this nation. We cannot bury our heads in the sand and pretend the 13% consumption of GDP by healthcare is someone else's problem. We also cannot be spineless physicians refusing to take any risk at all by doing what is right rather than what we know is useless and costly. People that are risk adverse definitely do not belong in medicine....there are much "safer" harbors for those people such as being a lab technician or a ledger entry clerk.
So how can we rectify the dichotomy of the reality of imminent bankruptcy of the system and the CYA mentality perceived by physicians that want to cover all legal contingencies should they find themselves in court? The issue has to come to the forefront of the healthcare debate by demonstrating how these lawsuits are ultimately restricting care and increasing healthcare bills. Call your congressman one on one...you do not need to recite talking points fed to you by a pain society. Talk to your patients and mobilize them ....give them printed material and tell them to call their congressman's number listed on the paper you hand to them. Your insurers may be very interested in discovering they could reduce testing by up to 90% if tort reform were in play. The medical societies could develop standards of care that include sanctions at the medical board level for those doctors that testify against other physicians and make up their own standards that are unsupported by the literature rather than saying "there is insufficient support in the literature to suggest a particular test should be ordered".
However, after all is said and done, it is unclear that tort reform would alter the patterns of test ordering by physicians. Some doctors just don't give a flip about the solvency of health care system that has enriched them and instead prefer intransigence to expediency. They have enshrouded themselves in the veils of litigious preventative behavior so long that they have forgotten how to diagnose using the tools that were acquired in medical school and residency. They have become risk adverse technicians that find it much simplier to check off a box to order a $3900 MRI rather than do a physician exam and thorough history that show it is not needed. They gave up being doctors long ago, preferring to become entrepeneur and could not find their way back even if they so desired to do so.
So perhaps you are right...it is practical to over order medical tests so that we can sleep at night, knowing we have covered all the bases. The patients that have just lost their homes due to our over ordering of tests may have a different perspective.