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Discussion in 'Clinical Rotations' started by Poppy123, Dec 14, 2008.
Anyone have a good reliable source with detailed information? Thanks!
Neurological signs of cord compression (sensory level, gait disturbance, incontinence, etc.) or tenderness directly over a spinous process would be reasons to obtain imaging. The latter you would start with just XRays, the former you might skip directly to T-spine/C-spine MRI if obtainable in reasonable time. And obviously trauma with significant backpain would most likely warrant an XRT. As far as there being any clear cut guidelines beyond this, I'm guessing not, you have to use your clinical judgment. If you have real reason to think it is not muscular or related to arthritis (you may do imaging at some point to evaluate arthritis but it is less acute), or in an elderly patient with osteoporosis who you're concerned may have a compression fx who is a poor historian due to dementia, then you do some imaging. Malignancy patients complaining of back pain you do X-ray and bone scan (and/or PET depending on the cancer type), etc.
One of the introductory chapters in harrison's, the one on back pain, summarizes the work-up, etc.
you might be interested in this - http://www.kevinmd.com/blog/2008/12/why-too-many-ct-and-mri-scans-can-be.html
So I was wondering this myself, and the above posters have given a good medical explanation, but I found out quickly in the "real world" of medicine (at least outpatient family practice), insurance companies require any imaging to start with plain films before proceeding to higher cost imaging (CT or MRI). Although, most of the time, you know there is not going to be any pertinent findings on the plain films, they still have to be ordered first (so much for cost saving!!! )
Insurance companies know what they are doing, they have all this stuff calculating. They're assuming if just 1 in 10 x-rays or whatever have a positive finding or a reassuring negative finding and as a result, result in your not ordering the more expensive test (>10x more expensive) that 1 in 10 times, then it is worth it. And when I say assuming, I mean they have probably looked at the data they collect very meticulously. And getting an X-ray almost never delays getting the other more advanced study, so it makes no difference to us.
The other thing, as far as outpatient medicine is concerned, a physician may decide instead of sending their patient for 3 different tests starting with an X-ray, if they have a relatively lower index of suspicion, they might just decide not to put their patient through any tests. In this case, the insurance company comes out a big winner. Meanwhile, if you miss the diagnosis, you as the physician get sued, because technically the insurance company did nothing to prevent you from getting the necessary tests, they just made the process more cumbersome. It is a dirty game.
I guess my point was for the 9/10 times an advanced study is indicated, the insurance company has to lose money on getting a plain film. Whereas if the physician knew that an MRI would be indicated from the get-go, skipping the plain film would be cost-saving. But I guess 1/10 is worth it to them to save a $500 plus study.
sounds about right. emg/nerve conduction study would prob also be the first step in radiculopathy/disc herniation.
Have you ever seen anyone undergo an EMG/nerve conduction study?
Trust me, your patients will thank you if you go looking for a disc herniation with an MRI rather than an EMG.
Scaredshizzles is pretty spot on, though I'd go a bit further with my cancer patients - back pain in anyone with history of a malignancy (of any type) represents an oncologic emergency and you get films without question (cancer history needs to be part of your history for all your patients with back pain, especially if they are not well known to you). You may even give them a dose of steroids before getting pictures if there's going to be some reason for a delay in getting pictures.
If they are presenting with evidence of cord compression or you can really pinpoint the tenderness, then absolutely. But if you're confident in the history you've obtained and they are ambulating as well they have been for the past few months (no acute changes) and no sensory deficits, I would not be that agressive (and I say that as a future oncologist), especially if you feel the patient has poor prognosis to begin with. The most likely reason for back pain in a cancer patient is that they are cachectic and lying in bed. Secondly, even if they have osteoblastic mets compressing on the spinal cord, it is unlikely that you are going to do anything. The compression has developed over a chronic course and they tend to be poor surgical candidates at the time. You'll call a neurosurgery consult, but they won't intervene unless you're at a center with a very aggressive N.S. team that needs the practice for its housestaff. The exception would be multiple myeloma or the few other cancers that occasionally cause lytic bone lesions (renal cell carcinoma I've seen cause lytics lesions sometimes)---in that case you can develop acute compression from bone fracture, in which case it needs to be treated aggressively because you can still improve outcome. Generally speaking, blastic lesions of the spine don't result in pathological fractures, although it does happen.
It is unfortunate, but you see the patient with metastatic prostate cancer all the time who has gradually developed lower extremity weakness/numbness (occasionally that is their presenting complaint), and there isn't a darn thing you can do to improve it that point. Which underscores the importance of if you can pick it up early. So you would want the X-rays or more advances studies with in a few days, but I wouldn't necessarily send them to the ER if I saw them as an OP to get steroids and emergent MRI.
If that's what the oncologist says, I'll go with it.
Certainly clinical picture matters, but new onset back pain in a patient with history of malignancy, I don't think it's wrong to get images. Don't know what the evidence says though. I certainly believe the urgency of action is very different between your cachectic patients with current or very recent cancer and your patients who were previously in well documented remission. While it's a chronic process, it's easy to argue that in your previously healthy patients, aggressive action is appropriate. Besides, no one ever died from a dose of steroids (inappropriate dose sizes not withstanding)...the risk/reward ratio is pretty favorable.
I've noticed over and over - image ONLY if the result changes your management. It's a good rule when trying to come up with a quick answer and explanation while being pimped.
This is kind of a paradigm shift thanks to managed care. The problem is there are a lot of gray areas. You'll often hear people say if a patient has a DVT documented and on anticoagulation, then if they develop pleuritic chest pain, you can forego a CTA because it wouldn't change your management. But that's not necessarily true. For one, if they have been anticoagulated for a while, it indicated failure on heparin/warfarin and is a possible indication for IVC filter. You see resistence or inefficiency of anticoagulation often in patients with high acute phase reactants (fibrinogen, platelets, WBC, ESR, and the huindreds of things we don't test for, etc.)..i.e. malignancy, infected, or post-op type patients. The other issue is if you see a large percentage of V/Q mismatch or filling defects on CTA and large estimated clot burden, then that too might be an indication for IVC because the next even small embolus to reach the lungs might very well kill the patient.
I was just studying this for my primary care rotation...
an MRI is like $2000
Hey, is the EMG/nerve conduction study...same as a discogram? If it is, and I think it is, I have seen this procedure and I won't forget it anytime soon.
I spent a full and long week doing a medical student observership in Pain Management and was able to see many great procedures even though I'm still pre-med. Anyway, the point of the discogram is to replicate the patients pain within the specified disk, and of course rule out the disks above and below the pained one. (read: three disks are getting this painful diagnostic injection). The procedure injects contrast into the disk and is done using fluoroscopy. I remember holding the patient's hand under the anesthesia curtain as she WEPT. What made this even worse was the fact that she spoke broken english and I had to translate the Doctor's questions and give him translated answers. The woman was in so much pain though she could hardly speak. Which made the situation all the more worse.
I also saw many epidurals, spinals, scalene blocks etc done by the MD who I spent the week with, someone who is considered a real regional master, so it was great. Anyway, because 95% of what he sees is back pain, and that I was in patient visits, procedure room, OR, (i.e. able to follow some patients from start to finish) I can also say that films of the back were requested after doing a neuro exam that didn't necessarily speak to cord compression, as the first post or two said. But say, neuroforaminal stenosis, or a retrolysthesis (sp?), etc. Many patients would come in with your typical L2-L3 leg pain presentation, or L5 leg pain, or S1. None of which were stenotic, per se. It is very interesting and was educational to learn the patterns of nerve pain in the legs. On the MRI, often these folks often did NOT have spinal stenosis. So, I'd say in my premed wisdom (or lack thereof) that neuro and physical exams with back pain that presents in a typical or atypical leg pattern gets an MRI. At least it does at this swank hospital. Not just spinal stenosis. I'd say only 50% or less of the patients in severe back pain had evident stenosis on MRI that was causing their pain. MD and I read films before seeing any patient, and I was quizzed after wards. There's nothing as obvious as a Sagittal view of severe stenosis. It's not often there. As a matter of fact, I asked an attending about an MRI and he asked me what I thought. I saw spinal stenosis and he said that wasn't this patients' pattern, look lower, and I found the real culprit. It's those key hole foramen that are narrowed that causes so many people pain. And don't forget about the facet joints.
Anyway, i saw this thread going down insurance lane and thought I'd add my .02 cents. Which might be .01 to some of you, but nevertheless.
You would be wrong on every board exam you take. This patient falls, they are SCREWED and so are you. Breast cancer w/ severe back pain and some neurological signs/symptoms -- admit, scans, and 30mg/kg solu-medrol bolus over 15 mins, 5.4mg/kg/h x 23 hrs. This is the standard of care unfortunately, though somehow I doubt this always gets done.
That's pretty much what I said though. If you have sharp localized pain or neurological signs, you image. What I present as gray areas is if you have a cancer patient and they present with an achy breaky back with no clear signs or localization, how aggressive are you and secondly, if the patient has already had the neurological signs for a while but haven't presented until now. In the former case, I don't know what the answer is but I imagine aggressive management provides little benefit. The latter case, I think you need to get imaging as a baseline for legal terms more than anything, but it is naive to think you can provide any benefit to the patient at that point.
As far as being right or wrong on board exams, that's why I don't think board exams are the end all be all. I think they can be used as a generally useful tool, but they are not very precise, because quite frankly a fair number of questions on board exams, knowledgeable people in the field can disagree upon. This isn't mathematics.
bump this thread please
Patient's with lower back pain who have a positive straight leg test or neurologic symptoms tend to get an MRI whereas negative straight leg tend not to.
That's the only correlation I really see. Anyone have some better guidelines.
However, what about patients who have chronic lower back pain without SLT. Most of them want imaging on request. I need some guidelines for all of this.
This'll help. LBP without red flags as noted in the link = NSAID +/- muscle relaxant & follow up.
If you have a question about the most appropriate first-line study to order, check out the ACR appropriateness criteria. Not perfect, but gives you a good place to start.
Here's the one for low back pain, for example:
Just an M3 here, but I found this table helpful. It doesn't talk about imaging modalities too much but it seems nice (you need access from your school so hopefully you have that):