Image courtesy: lower-back-pain.toolkit.com

A randomized control trial, entitled “Rapid Magnetic Resonance Imaging vs Radiographs for Patients With Low Back Pain” by Jarvik et al 2003 in JAMA, looked at several clinical consequences of ordering plain film radiographs or a rapid MRI for individuals with low back pain.  This is worth sharing to your patients.

From a general perspective, we all know that MRI yields many false-positives for individuals with low back pain, and I usually state to my patients that up to 70% of persons without low back pain show a disc herniation on MRI.  This study’s introduction even went further to state that “subjects without low back pain, disk herniations are seen in approximately one third, disk bulges in half to two thirds, and disk degeneration in up to 90% of the scars”.

So what did this study find?

Roland back pain disability scale was used as primary outcome to determine how back pain affects common daily activities.  It was performed initially and 12 months later with hypothesis that MRI group would yield better results.  Denied.  X-ray resulted in score of 8.75 vs 9.34 in rapid MRI group, which is not a clinically significant difference. Deyo-Diehl patient satisfaction questionnaire was used to measure patient satisfaction and again showed no significant difference between the groups.  In short, no difference between function, pain, general health status or satisfaction one year later.  I do want to point out though that re-assurance in the test per patient was greater in the rapid MRI and surprisingly the cost between the tests were no different.

However, we would all guess that this would be true.  The biggest outcome from this study I want to point out is that it leads to more specialist consultations and more importantly, surgery.

Ten patients (6%) randomized under rapid MRI had lumbar spine surgery within 1 year compared to 4 patients (2%) in the x-ray group.  This is a 3-fold increase…quite a bit jump for no change.

If there was no difference at 12 months in general health, pain, function or disability; why have surgery?  Costs are higher and risk is greater, with no change in function.  All characteristics were similar at baseline and with those who had surgery, there was no additional benefit.  Bottom line, symptoms and function were no different between the groups at 1 year out.

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2 comments

  1. I think you missed the point here. One cannot extrapolate from this article whether or not surgery is warranted in cases of non-specific lumbar dysfunction. The point is simply to assess the feasibility and cost of radiography vs. MRI at one year after initial assessment of pain. Throwing surgery considerations into the discussion with such a tiny sample size and implying a drastic difference in post-op versus non-operative outcomes is completely faulty and not supported in this article at all.

    1. @ bill,
      Thanks for your reply and comments. You are right, there is much data that comes out of this study. It would be difficult to make an unconditional decision making based on one study in anything, but it does lend good results for not only PTs but patients. The cost was not much different (surprisingly honestly) but I would suggest even from clinical experience that imaging early on leads to unnecessary interventions.
      Hv

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