MRI prior to MBB/RF?

[Timeoutofmind]

I think its pretty agreed upon that it is good practice to always obtain MRI before ESI.

What about before MBB/RF?

If non-radicular, normal exam...do I really need an MRI to show me the OA that is already on plain films?

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[SSdoc33]

I think its pretty agreed upon that it is good practice to always obtain MRI before ESI.

What about before MBB/RF?

If non-radicular, normal exam...do I really need an MRI to show me the OA that is already on plain films?

yes

 

[lobelsteve]

I think its pretty agreed upon that it is good practice to always obtain MRI before ESI.

What about before MBB/RF?

If non-radicular, normal exam...do I really need an MRI to show me the OA that is already on plain films?

Not a chance.

 

[lonelobo]

no

 

[Ligament]

I think its pretty agreed upon that it is good practice to always obtain MRI before ESI.

What about before MBB/RF?

If non-radicular, normal exam...do I really need an MRI to show me the OA that is already on plain films?

No, because one can often have facetogenic pain (proven by MBB x 2) in the presence of a totally normal MRI.

The MRI for ESIs or any spinal canal procedure is to ensure the procedure can be done safely (sufficient epidural space)

 

[drusso]

No. But, first administer PHQ-9, depression screener, fibromyalgia questionnaire, central sensitization questionnaire, SOAPP-R, ORT, early adverse childhood events questionnaire, stages of change questionnaire, and PCS. If they pass all those then proceed with MBB X2 because it is prima facie evidence of facet pain. After all, we treat patients not MRI's nor paper and pencil test scores...

 

[DODOCSS]

yes.....cya

 

[ampaphb]

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[lonelobo]

yes.....cya

CYA from what, if there are no red flags?

 

[ampaphb]

http://www.medscape.com/viewarticle/779987

 

[drusso]

http://www.medscape.com/viewarticle/779987

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But, lumbar MRI is a known risk factor for subsequent health care expenditure...

http://calchirogov.org/clients/19438/documents/Factors_Associated_With_Early_Magnetic_Resonance.pdf

"To our knowledge, this is the first study to evaluate individual-level
factors, including self-reported pain and functioning,
associated with early MRI for acute LBP. Results show that
early MRI for LBP is a common practice, which may contribute
to increased resource utilization and costs. 14 ,44 It is prudent
for providers to be aware of clinical practice guidelines and
follow recommendations to limit advanced imaging in the
first 4 to 6 weeks of LBP symptoms. Given the results of this
study, providers could provide more customized care, based
on the characteristics of patients with uncomplicated occupational
LBP, and policy makers may seek to direct patients
to certain types of providers early in the course of their LBP."

 

[ampaphb]

But, lumbar MRI is a known risk factor for subsequent health care expenditure...

http://calchirogov.org/clients/19438/documents/Factors_Associated_With_Early_Magnetic_Resonance.pdf

"To our knowledge, this is the first study to evaluate individual-level
factors, including self-reported pain and functioning,
associated with early MRI for acute LBP. Results show that
early MRI for LBP is a common practice, which may contribute
to increased resource utilization and costs. 14 ,44 It is prudent
for providers to be aware of clinical practice guidelines and
follow recommendations to limit advanced imaging in the
first 4 to 6 weeks of LBP symptoms. Given the results of this
study, providers could provide more customized care, based
on the characteristics of patients with uncomplicated occupational
LBP, and policy makers may seek to direct patients
to certain types of providers early in the course of their LBP."

Given that "Studies have shown that neurosurgeon, neurologist, and orthopedic surgeon providers are associated with increased likelihood of receiving advanced imaging", does that make pain management providers amongst the "certain types of providers" alluded to?

 

[Taus]

These are generally older patients with chronic pain. They get MRI or CT if pacer to cya and rule out badness IMO.


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[bedrock]

Without red flag symptoms, I wouldn't order an MRI before MBB.....if we had meaningful Tort reform in this country.

We don't, so everyone gets an MRI. Blame the lawyers.

 

[neutro]

no.

 

[willabeast]

CYA from what, if there are no red flags?

*reasons to order MRI*
1. it can tell you which facet joint is the problem. also - patient's love to see the images. usually they light up on T2.
why inject the wrong joint or MB or additional injections you may not need. MRI increases the specificity of your diagnosis.
2. what if patient comes down with something bad in the next 6 months? for example an infection or rare tumor... "Doctor your delay in Dx is the reason my client is suing you for loss of consortium with spouse and loss of job . we understand it is rare but if you thought the patient was having enough pain to do an invasive procedure should you not have considered a tumor ?. Dr. Green from across town says he would have gotten an MRI and it would have showed the osteoblastoma early enough to help my client "
*reasons to not order MRI*
1. it is not indicated unless there are red flags. (this depends on your definition of red flags - back pain for 6 months that is better supine ? red flag or not? how about 3 months?
2. MRI are one of the things bankrupting the USA. instead of paying engineers to build better cars or OLED TVs we pay radiologists to read normal MRIs on more and more people. so people lose their jobs because USA companies need to move abroad to survive the high cost of medical care in the USA.
3. if you work in an HMO, your supervisor will start hating you because it makes your superior look bad for the department to order too many MRIs. after all, they are paid to "manage" you. however - should you get sued - and the org lose money - that also makes the supervisor look bad for hiring you. sometimes explaining this helps, but if you lose the litigation good luck finding another job.

 

[Aether2000]

I would not initially order a MRI, but if the lumbar pain did not respond to RF or only short term relief was obtained, I would order a MRI to cya.

 

[ampaphb]

I would not initially order a MRI, but if the lumbar pain did not respond to RF or only short term relief was obtained, I would order a MRI to cya.

I still do double blocks prior to moving forward with RF. Given that you will need to get all three procedures authorized by insurance, isn't that an awfully long time to wait before you cya?

 

[lobelsteve]

I still do double blocks prior to moving forward with RF.

I still do double blocks prior to moving forward with RF. Given that you will need to get all three procedures authorized by insurance prior to moving forward, is there an awfully long time to wait before you cya?

No.

 

[ampaphb]

No.

Always good to get unsolicited insight from the peanut gallery

 

[lonelobo]

If you do MBB and they work and follow up with RF and pain goes away.....please explain to me how that is going to mask a tumor or something bad?

Does someone have an anecdotal experience of person who presents with low back and benign exam and symptoms who underwent this kind of treatment and then later sued because an MRI was not performed?

 

[BobBarker]

I always get an MRI.

 

[NOSfan]

.......What about before MBB/RF?

If non-radicular, normal exam...do I really need an MRI to show me the OA that is already on plain films?

No.

If negative response to MBB, then proceed with advanced imaging studies.

 

[plasma.]

Any Canadian pain physicians on this board? Would love to get a Canadian perspective on this. Starting my fellowship in July so I'll figure out what the local practice is but I can't imagine having an MRI for every patient prior to MBB / RFA. It takes 9 - 12 months to get an outpatient MRI in Canada.

 

[lobelsteve]

No reason to do it, not even for you wildlings North of the Wall..

 

[Ferrismonk]

Any Canadian pain physicians on this board? Would love to get a Canadian perspective on this. Starting my fellowship in July so I'll figure out what the local practice is but I can't imagine having an MRI for every patient prior to MBB / RFA. It takes 9 - 12 months to get an outpatient MRI in Canada.

Oof.

I'm American, but I also I agree with Steve. Plain film only.

 

[Multimodal]

Xray only for MBB/RFA even cervical. If there are no signs of radic/stenosis, then why go through the trouble/expense of getting an MRI to evaluate the epidural space if Im not going to put a needle near it. Xray shows me everything I need to know for an MBB (alignment, facet joint condition, and target site for needle placement). MRI is overkill unless you cannot rule out stenosis in the differential.

 

[SSdoc33]

No reason to do it, not even for you wildlings North of the Wall..

huh.

my renal cell and endometrial cancer patients might disagree with you.

 

[lobelsteve]

huh.

my renal cell and endometrial cancer patients might disagree with you.

And they get better with MBBs? Sounds confusing for you.

 

[SSdoc33]

personally, i think having an MRI can ALSO change management (levels to inject, possibly deciding NOT to inject, etc)

 

[SSdoc33]

And they get better with MBBs? Sounds confusing for you.

no, they just get their cancer treated before it kills them.

also, i do believe it changed management. do you still do an MBB if there is severe stenosis at L4-5? do you still do an MBB if there are gross modic/endplate changes on MRI? what about an angry looking schmorl's node? i could go on

 

[Baron Samedi]

huh.

my renal cell and endometrial cancer patients might disagree with you.

What's the Number Needed to Diagnose renal or endometrial cancers using lumbar MRI for axial low back pain without red flag symptoms?

 

[Baron Samedi]

no, they just get their cancer treated before it kills them.

also, i do believe it changed management. do you still do an MBB if there is severe stenosis at L4-5? do you still do an MBB if there are gross modic/endplate changes on MRI? what about an angry looking schmorl's node? i could go on

If negative MBB then MRI and look for that stuff.

 

[callmeanesthesia]

no, they just get their cancer treated before it kills them.

also, i do believe it changed management. do you still do an MBB if there is severe stenosis at L4-5? do you still do an MBB if there are gross modic/endplate changes on MRI? what about an angry looking schmorl's node? i could go on

Yes, I still do an MBB in those circumstances. MRI does not show pain, and there’s a good chance if they have bad discs they also have bad facets, and if they have stenosis odds are at least some of it is because of facet hypertrophy. I figure RFA is worth a go before sending them to the surgeon. regarding finding of cancer, are you saying in the absence of red flags all patients with axial pain should have an MRI? That’s a little heavy on the defensive medicine. You should probably get a complete abdominal ultrasound while you’re at it though.

 

[bedrock]

Without red flag symptoms, I wouldn't order an MRI before MBB.....if we had meaningful Tort reform in this country.

We don't, so everyone gets an MRI. Blame the lawyers.

This still applies 4 years later.

 

[chudat]

This still applies 4 years later.

Insurance will cover?

 

[bedrock]

Insurance will cover?

Medicare does without an issue , and those are the patients which are more likely to have a hidden tumor anyway.

most of the commercial carriers won’t pay for MBB/SIJ without conservative care anyway, and once the patient has done conservative care, then the same insurances will cover MRI, so that’s how I do it. MRI, then procedure.

 

[SSdoc33]

Yes, I still do an MBB in those circumstances. MRI does not show pain, and there’s a good chance if they have bad discs they also have bad facets, and if they have stenosis odds are at least some of it is because of facet hypertrophy. I figure RFA is worth a go before sending them to the surgeon. regarding finding of cancer, are you saying in the absence of red flags all patients with axial pain should have an MRI? That’s a little heavy on the defensive medicine. You should probably get a complete abdominal ultrasound while you’re at it though.

what if the MRI shows a huge facet diastasis at L4-5? what if the L3-4 facet on the left shows active inflammation? then, when you do an L3,4, and 5, but not L2 and they fail, you have egg on your face. what if there is a discitis? what if there is active SIJ infammation not seen on MRI?

ive just given what 7-8 what ifs that might change your decision making process, and that is off the top of my head.

anybody who fails a conservative course of treatment is getting an MRI anyway, so if you are gonna do an MBB, it is a logical and reasonable step before interventions.

my responsibility is to treat the patient in the best manner possible, not to worry about bloated medical spending. part of this is decision making, part is defensive medicine where there is no tort reform.

 

[Baron Samedi]

what if the MRI shows a huge facet diastasis at L4-5? what if the L3-4 facet on the left shows active inflammation? then, when you do an L3,4, and 5, but not L2 and they fail, you have egg on your face. what if there is a discitis? what if there is active SIJ infammation not seen on MRI?

ive just given what 7-8 what ifs that might change your decision making process, and that is off the top of my head.

anybody who fails a conservative course of treatment is getting an MRI anyway, so if you are gonna do an MBB, it is a logical and reasonable step before interventions.

my responsibility is to treat the patient in the best manner possible, not to worry about bloated medical spending. part of this is decision making, part is defensive medicine where there is no tort reform.

Do you not take a history and perform a physical exam when you see these patients?

 

[nvrsumr]

60% of time it works every time.

 

[SSdoc33]

Do you not take a history and perform a physical exam when you see these patients?

My physical exam cannot tell the difference between disc and facet. Can yours? Literature says it can't.

Realistically, i pretty much know who is going to benefit from mbbs even without the pictures. But the mri helps.

 

[pmrmd]

It’s really patient-dependent but mostly radiograph only for facet procedure.

 

[callmeanesthesia]

what if the MRI shows a huge facet diastasis at L4-5? what if the L3-4 facet on the left shows active inflammation? then, when you do an L3,4, and 5, but not L2 and they fail, you have egg on your face. what if there is a discitis? what if there is active SIJ infammation not seen on MRI?

ive just given what 7-8 what ifs that might change your decision making process, and that is off the top of my head.

anybody who fails a conservative course of treatment is getting an MRI anyway, so if you are gonna do an MBB, it is a logical and reasonable step before interventions.

my responsibility is to treat the patient in the best manner possible, not to worry about bloated medical spending. part of this is decision making, part is defensive medicine where there is no tort reform.

X ray is going to show me if the facets look terrible at L3-4. If the patient has new severe acute onset back pain and a fever, or a destroyed looking disc on X-ray, I’ll get that MRI based on that, not chronic axial back pain. Every case of discitis I can recall catching, the patient already had an MRI within the past 12 months anyway.

 

[Orin]

Get a bone scan if you're conflicted. It's cheaper, and married to a CT or quality plain films will give you enough to know if the facets are hot, or if there is a cancerous lesion, discitis, etc. The SPECT-CT is a bit more loot, but a simple bone scan has a lot of useful info for austere conditions.

 

[SSdoc33]

Get a bone scan if you're conflicted. It's cheaper, and married to a CT or quality plain films will give you enough to know if the facets are hot, or if there is a cancerous lesion, discitis, etc. The SPECT-CT is a bit more loot, but a simple bone scan has a lot of useful info for austere conditions.

Im trying to find cancer, not cause it.

 

[SSdoc33]

X ray is going to show me if the facets look terrible at L3-4. If the patient has new severe acute onset back pain and a fever, or a destroyed looking disc on X-ray, I’ll get that MRI based on that, not chronic axial back pain. Every case of discitis I can recall catching, the patient already had an MRI within the past 12 months anyway.

You have an answer for everything, and i get that. To not have an answer means you would have to move from your rooted position. But those answers are not good ones

 

[callmeanesthesia]

You have an answer for everything, and i get that. To not have an answer means you would have to move from your rooted position.

So because I have counterpoints to your points I’m wrong?
Hey, I’m in private practice and we have an on-site MRI. I make money on every MRI I order. So maybe you have some good points…

 

[callmeanesthesia]

You have an answer for everything, and i get that. To not have an answer means you would have to move from your rooted position. But those answers are not good ones

Also, don’t count on the MRI to eliminate medicolegal risk. It exposes you to the risk of missed findings. If you and the radiologist miss something outside the spine that later turns out significant, like a kidney cancer, psoas abscess, ovarian mass, brachial plexus mass, or brain tumor (have seen all of those missed by radiology in my 3 years in practice) that’s going to look really bad if you went ahead and did the MBBs and RF for them, not noticing the extraspinal finding. Not saying you wouldn’t catch it, but you might easily miss it in a busy clinic schedule.

 

[SSdoc33]

So because I have counterpoints to your points I’m wrong?
Hey, I’m in private practice and we have an on-site MRI. I make money on every MRI I order. So maybe you have some good points…

I dont think there is a right or a wrong. And i dont think every patient needs an MRI. Try to examine how and if your practice patterns would change on those mbb failures that you end up getting an MRI on

 

[Ferrismonk]

What's the Number Needed to Diagnose renal or endometrial cancers using lumbar MRI for axial low back pain without red flag symptoms?

huh.

my renal cell and endometrial cancer patients might disagree with you.

Cancer history is a "red flag" and an indication for MRI...

no, they just get their cancer treated before it kills them.

also, i do believe it changed management. do you still do an MBB if there is severe stenosis at L4-5? do you still do an MBB if there are gross modic/endplate changes on MRI? what about an angry looking schmorl's node? i could go on

I base my decision for MBB on history and physical exam. Bad discs don't always hurt and "normal" facets on imaging sometimes do. Treat patients, not pictures. Xray is to rule out any scary things like lytic lesions and for medicolegal.

Even an MRI isn't that helpful. Radic following the L4 nerve distribution almost always shows a L4 nerve being pinched...