MRI overuse?

[oreosandsake]

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http://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html

Sports Medicine Said to Overuse M.R.I.’s
By GINA KOLATA



Dr. James Andrews, a widely known sports medicine orthopedist in Gulf Breeze, Fla., wanted to test his suspicion that M.R.I.’s, the scans given to almost every injured athlete or casual exerciser, might be a bit misleading. So he scanned the shoulders of 31 perfectly healthy professional baseball pitchers.


Steve Ganobcik nearly had unneeded knee surgery.


The pitchers were not injured and had no pain. But the M.R.I.’s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews says...

 

[latinman]

These findings are not surprising at all. That is why I dont put as much weight to Xrays, and MRI's because it will lead u down the road of perdition many times. I look/listen at the what the patient says and what my physical exam suggests. I have seen in multiple instances how patients were ready to go for surgery because of a rotator cuff tear or meniscal tear showing up on MRI. I did a good hx and physical exam and came up with different pain source generator. I treated the pt accordingly and the patient's problem improved or went away.

 

[fozzy40]

Gandikota Girish et al., "Ultrasound of the Shoulder: Asymptomatic Findings in Men," American Journal of Roentgenology 197, no. 4 (October 1, 2011): W713 -W719.

Same thing with ultrasound...for the newbies, tests should confirm your clinical suspicions not the other way around.

 

[PMR 4 MSK]

Every spine MRI on someone over 30 is abnormal.

Every shoulder MRI is abnormal. Probably 90% of MRIs have something that can be read as abnormal.

Radiologists "over-read" the MRI's due to so many lawsuits for "missed Dx." I don't blame them for the problem.

MRI's are over-ordered for CYA. Non question about that.

MRIs are over-ordered for financial incentives. Again, no question about that.

MRI's, in general, should only be ordered when the Dx is in doubt, and the results may change the treatment plan.

If the case is an injury, IMHO, with the potential for a lawyer to be involved, MRI should be obtained ASAP after injury to sort out better what was caused by the injury, and what was pre-existing.

 

[Jitter Bug]

Here's a question-do you guys want to see an MRI before you would do an interventional procedure?

I am risk averse and don't like the idea that the tissue pushing on a nerve may be some vascular or cancerous zebra before sticking a needle in it. But I know this risk is extremely low and some of my partners would plan for a TFESI without prior MRI. Plus I think there is so much overlap in dermatomal patterns and spinal nerve root anatomy that it would be nice to correlate clinical picture with the MRI. (I know, not always possible to correlate with all the irrelevant "degenerative change" on MRI)

 

[facetguy]

http://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html

Sports Medicine Said to Overuse M.R.I.’s
By GINA KOLATA



Dr. James Andrews, a widely known sports medicine orthopedist in Gulf Breeze, Fla., wanted to test his suspicion that M.R.I.’s, the scans given to almost every injured athlete or casual exerciser, might be a bit misleading. So he scanned the shoulders of 31 perfectly healthy professional baseball pitchers.


Steve Ganobcik nearly had unneeded knee surgery.


The pitchers were not injured and had no pain. But the M.R.I.’s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews says...

It's clearly MRI overuse when you nearly do an unneeded knee surgery on poor ol' Steve Ganobcik based on a shoulder MRI. 🙂

 

[latinman]

[QUOTE=Jitter Bug;11759024]Here's a question-do you guys want to see an MRI before you would do an interventional procedure?

I am risk averse and don't like the idea that the tissue pushing on a nerve may be some vascular or cancerous zebra before sticking a needle in it. But I know this risk is extremely low and some of my partners would plan for a TFESI without prior MRI. Plus I think there is so much overlap in dermatomal patterns and spinal nerve root anatomy that it would be nice to correlate clinical picture with the MRI. (I know, not always possible to correlate with all the irrelevant "degenerative change" on MRI)[/QUOTE]

That's a good question, and you would probably get different answers depending on who u ask. Durings my fellowship most of the time we would get MRI before doing epidurals. However, there were moments in which epidurals to low back were done just with xray. With neck u probably want to be more cautious.

 

[PMR 4 MSK]

Here's a question-do you guys want to see an MRI before you would do an interventional procedure?

I am risk averse and don't like the idea that the tissue pushing on a nerve may be some vascular or cancerous zebra before sticking a needle in it. But I know this risk is extremely low and some of my partners would plan for a TFESI without prior MRI. Plus I think there is so much overlap in dermatomal patterns and spinal nerve root anatomy that it would be nice to correlate clinical picture with the MRI. (I know, not always possible to correlate with all the irrelevant "degenerative change" on MRI)

Facets, MBB, no.

ESI - in general, yes. There are times when that is not feasible, and a CT has to substitute.

I think the thought process for this not only has to include zebras, but also how many people have dis-concordant MRIs to their pain. E.g. pt presents with radicular symptoms on the left, but only finding on MRI is a right-sided HNP.

I personally think the spine is so variable in pain presentations, that clinical diagnosis and MRI don't agree much of the time. An acute HNP is fairly easy to diagnose without MRI,the rest is hit or miss.

 

[Paddington]

Not every doctor orders an MRI on every back pain patient that comes in. Some of the best doctors I've worked with order very few MRI studies, and try to get by with cheaper diagnostic tests if needed.

Sadly, these doctors aren't rewarded much today for taking on the extra risk or doing the extra cognitive work. So there isn't much incentive to be cost concious.

But I suspect that they might be in the near future. With records switching to EMR's, it will be a lot easier for insurers to track who orders how many MRI's for a given diagnosis. They have a strong incentive to cut down on the number of these $2,000 tests. In fact, way more so than fighting you over inadequate documentation for a level 5 visit or having done one too many sensory studies on a routine EMG looking primarily for radiculopathy. Or even trying to screw somebody out of their prescription Lyrica. So if you're ordering more MRI's than some benchmark, they will cut your compensation. I believe in IM/FM, there are already pilot programs in place where they track outpatient benchmarks closely.

 

[Gauss]

Here's a question-do you guys want to see an MRI before you would do an interventional procedure?

For atraumatic (excluding whiplash MVA from 20 years ago) and no prior interventions or past interventions were beneficial:
L spine; no
T spine; yes
C spine; variable

That is how I learned and trained, use your PE and Hx, fluoro during procedure as adjunct.
However, in practice do I still do this - Absolutely not. Too much liability, too many unrealistic expectations and demand from patients and referring providers, and too many secondary gain issues.