MRI LS Spine... what's your threshold?

[pinipig523]

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Hey guys,

What's your threshold for getting an MRI of the LS spine?

Epidural abscess? Check

Recent procedure like an epidural or LP now w/ back pain? Check

Cord compression signs and symptoms? Check

But what about a guy with a history of laminectomy and has a recent mechanical mechanism where he lifted something and caused symptoms similar to his past radiculopathy for which he was already "cured" from for 5 years? Do you MRI the guy and send them for nsurg f/up?

I know it is not emergent, but this sounds like a case where conservative management may not alleviate the guy's complaints.

 

[Arcan57]

Hey guys,

What's your threshold for getting an MRI of the LS spine?

Epidural abscess? Check

Recent procedure like an epidural or LP now w/ back pain? Check

Cord compression signs and symptoms? Check

But what about a guy with a history of laminectomy and has a recent mechanical mechanism where he lifted something and caused symptoms similar to his past radiculopathy for which he was already "cured" from for 5 years? Do you MRI the guy and send them for nsurg f/up?

I know it is not emergent, but this sounds like a case where conservative management may not alleviate the guy's complaints.

If they have acute onset objective motor weakness then MRI. If they just have sensory symptoms (excepting perineal anesthesia), then I give steroids and have pt f/u with neurosurgery. MRI'ing the above pt is just setting them and you up for unrealistic expectations regarding duration of symptoms and possibility of a quick cure.

 

[deleted109597]

What's your threshold for getting an MRI of the LS spine?

Epidural abscess? Check

With neuro symptoms, sure

Recent procedure like an epidural or LP now w/ back pain? Check

With neuro symptoms, sure

Cord compression signs and symptoms? Check

As above

But what about a guy with a history of laminectomy and has a recent mechanical mechanism where he lifted something and caused symptoms similar to his past radiculopathy for which he was already "cured" from for 5 years? Do you MRI the guy and send them for nsurg f/up?

You order a lot of MRIs it seems. And the answer for radiculopathy is "no".

I know it is not emergent, but this sounds like a case where conservative management may not alleviate the guy's complaints.

The MRI won't alleviate it either.

 

[WilcoWorld]

I do not use prior neurosurgical intervention as a reason to MRI unless it's a recent intervention or there are signs of infection. Since the patient you described was 5 years post-op and his symptoms sound run of the mill, I wouldn't MRI in the ED unless there was a red flag present.

 

[Lumberg]

Agree. No MR given hx. Prompt referral to neurosgy. Return if any new motor deficits, usual cauda equina stuff.

 

[Rendar5]

Motor symptoms, infectious sx's+back pain, incontinence/retention + back pain.
Recent instrumentation + midline tenderness.

Did have a lady come in the other day 2 wk s/p LP c/o severe back pain with movement. Had lumbar spasm of L1-L3 (all above the needle insertion site), no midline tenderness, no neuro deficit, no midline sx's. Had to decide between sending her out for an MRI (no machine here) or having her f/u with her doctor in 2 days. Would anyone here have transferred her out for an MRI?

 

[deleted109597]

Would anyone here have transferred her out for an MRI?

No. And I wouldn't have been accepting doc on the other end either. Sure, you can use my MRI, but they're coming back to you when it's done.

 

[neusu]

Hey guys,

What's your threshold for getting an MRI of the LS spine?

Epidural abscess? Check

Recent procedure like an epidural or LP now w/ back pain? Check

Cord compression signs and symptoms? Check

But what about a guy with a history of laminectomy and has a recent mechanical mechanism where he lifted something and caused symptoms similar to his past radiculopathy for which he was already "cured" from for 5 years? Do you MRI the guy and send them for nsurg f/up?

I know it is not emergent, but this sounds like a case where conservative management may not alleviate the guy's complaints.

Unless he has a new focal deficit get him a follow up with his pcp. They or his neurosurgeon will get an mri. No one ever died or were permanently injured from a little back pain.

 

[pinipig523]

Thanks guys! Exactly what I thought. I didn't MRI the guy's back. I sent him off to nsurg.

Did have a lady come in the other day 2 wk s/p LP c/o severe back pain with movement. Had lumbar spasm of L1-L3 (all above the needle insertion site), no midline tenderness, no neuro deficit, no midline sx's. Had to decide between sending her out for an MRI (no machine here) or having her f/u with her doctor in 2 days. Would anyone here have transferred her out for an MRI?

2 weeks out? Was the lady anticoagulated? Is there any reason to think this was a hematoma?

 

[KiloAxe]

In the absence of acute motor neuro deficits and/or fever without source and complaints of 'back pain', or recent post-op, there really shouldn't be an indication for MRI. Could the lady post LP have hematoma? sure, but highly unlikely without neuro deficits, and no one would fault you for missing that (if not on coumadin). Clearly stating in discharge instructions to return with neuro symptoms is completely appropriate.
I certainly would not have MRI'ed her, but there are very few things I feel need emergent MRI.

 

[WilcoWorld]

No. And I wouldn't have been accepting doc on the other end either. Sure, you can use my MRI, but they're coming back to you when it's done.

Have you ever done that? Transfered a patient back after a negative study? Please do tell me more!

 

[Arcan57]

Have you ever done that? Transfered a patient back after a negative study? Please do tell me more!

My old shop had a close affiliate (different locations but same Medicare number) that used to send patients with one of their nurses to get cross-sectional imaging or fluoro on the weekends or when their scanner was down. If they crashed (which never happened) we'd need to resuscuitate and every once in a while a positive scan would lead to someone who was already in our ED being transferred to us with all of the usual EMTALA paperwork getting faxed over. Otherwise they were driven back to their ED and dispoed by the EP there.

 

[EM2BE]

If we send anyone out for imaging (days the CT is down), we always take the patient back after the imaging study. Only once did I request they wait for results, and it was just in case they needed neurosurg intervention, which we don't have, but they do.

If we do emergent MRIs, we have to clear it with the radiologist first. I have ordered 1 in the past 2 years at my place. It was person with recent LP, fever, back pain, motor and sensory deficit in the lower extremities, one worse than the other. And even then, talking with the radiologist I had to explain why this was emergent.