MRI Scans Dont Help Back Pain
BBC Health carries an article about a review of six trials covering 1800 patients which concluded that MRI scanning does not help in the management of normal low back pain and should be reserved for specific conditions such as nerve root lesions, infections and tumours. The outcome of low back pain is not improved by the use of scans and there were no differences between the two groups, one group with typical management and the other having an MRI scan at some stage. This was the same for the early outcomes and for up to a year after the onset of acute low back pai
MRI scans are commonly requested perhaps because of patient expectations or because the referrer thinks it is a concrete thing to do and might show up the cause of the patient's back pain. Studies have shown that it is very rare for an MRI scan to shows up something important about a person's back problems but it is easier to do this than take the time to communicate the strategy clearly and answer the patient's many problems.
The incidence of MRI scanning as a choice for back pain investigation is increasing, perhaps because it is an easy thing to request. However it often raises more questions than it answers and leads to particularly difficult questions and misconceptions in patients' minds. Many of us explain the findings to patients using the wrong terminology. Our job partly is to reduce patient expectations about what scanning can achieve.
The examination and medical history of the patient should indicate whether there is a serious underlying cause for the back pain or whether it is mechanical. MRI scanning is not very useful in mechanical low back pain and should be reserved for cases where there are findings which indicate the necessity to do so and not just because the next step is not clear.
The management of low back pain includes patient education as to the likely underlying reasons for their pain (although they are often not clear), the absence of a need for imaging, manual therapy trial, acupuncture and a structured exercise programme. For people with severe and chronically disabling back pain or other pains then a pain management programme approach can be useful.
Reassurance about what is going on in a patient's back is difficult to provide and it has been shown that imaging such as MRI scanning does not reassure people about what is going on in their backs. Typically many abnormalities are found on scanning someone's back but then we have to decide which changes are relevant and how to explain these and the irrelevant changes to the patient. It is easy to generate unhelpful beliefs and images in a patient's mind and unravelling these attitudes is important but takes time and communication skills.
MRI scanning rarely provides reassurance in the many patients for which it shows up very little in the way of explanatory findings for their pain problems. It also brings another problem. Since abnormal findings on MRI scanning are very common, the question arises about how to explain this to the patient. Which of the abnormal findings is relevant to the patient's pain? What words should be used to communicate the changes which have occurred in the spine without alarming the patients or generating unhelpful images in their minds?
The reasons, limits and outcome of the MRI scan should be carefully considered with the patient before the scan is ordered or there will be difficulties afterwards. There should be an overall plan formed by the history and examination, into which an MRI scan might fit if the signs justify it. A surgical opinion should be accessible to discuss the findings, answer the questions and make a decision as to the outcome. The scan findings need to be managed appropriately to avoid disappointing and frustrating the patient in their struggle to understand.
Careful explanation must be given if we agree to scan a patient otherwise the answers we give will bring their own problems. Once we agree to scan someone there must be a plan for what we are going to do next. There should be an opinion we can access without delay as an MRI scan on its own has little relevance, it needs to be interpreted, explained and acted upon. Much of the frustration comes from the patient's expectation about what can be shown on the scan and when, as is overwhelmingly the case, little of diagnostic value emerges, there is a feeling of what's next?