MRI causes Failed Back Surgery
Ross Hauser, MD
In this article, Ross Hauser, MD explains why MRI readings may lead to INCREASED incidents of failed back surgery syndrome.
When radiologists say we are doing too many inappropriate MRIs, and that research underestimates the true extent of how many inappropriate MRIs are ordered for back pain,1 we know there is a problem in helping patients with unspecific back pain.
When “more than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms,” we know that that there is a problem.
The biggest problem is that this treatment course is the standard of care.
- MRI to diagnose the problem, surgery to correct the problem.
The problem is, as pointed out in the research mentioned above and below:
- the diagnosis is often wrong,
- the surgery is correcting something that is not a factor.
- The surgery itself is causing more pain post-operatively.
Where is the evidence for all this? It is all around us in the medical literature.
MRI has little value in helping patients cure their back pain
In a recent study published in the New England Journal of Medicine doctors questioned MRI’s usefulness as a frequently performed test during follow-ups in patients with known lumbar-disc herniation and persistent symptoms of sciatica. The association, they noted, between findings on MRI and clinical outcome is controversial, with several studies showing a high prevalence of disk herniation, ranging from 20 to 76%, in persons without any symptoms.
The doctors looked at patients who had MRI performed before treatment and after treatment in two groups. Group one had surgery and group two did not and received conservative care instead.
The two groups were divided, regardless of the treatment into two groups: 1) Favorable outcome after treatment. 2) Unfavorable outcome after treatment.
After one year they compared MRIs “before and after.”
- In 35% of patients who had a favorable treatment outcome (reduction of symptoms), MRI still showed a herniated disc.
- In 33% of patients who reported a non-favorable outcome, MRI still showed a herniated disc.
What did the doctors conclude?
- Patients with symptomatic lumbar-disk herniation at baseline who were treated with either surgery or conservative treatment and followed for 1 year, the presence of disk herniation on MRI at 1-year follow-up did not distinguish patients with a favorable clinical outcome from those with an unfavorable outcome.Even in the acute setting of sciatica, evidence for the diagnostic accuracy of MRI is not conclusive.2
Nearly 1 in 3 back pain patients should not even get an MRI according to one report because it may lead to unnecessary spinal surgery. “MRI alone may provide insufficient or inaccurate information upon which to base surgical/technical decisions in about of 30% of cases (of back pain).”3
Despite this evidence, patients are lead to believe that the MRI is the final truth.
In a recent study, doctors found that a surprisingly high percentage of patients have misconceptions regarding their MRI diagnosis and their treatment of lumbar spondylosis (degenerative – osteoarthritic changes in the spine).
The researchers asked patients questions designed to assess patient understanding of the role of MRI imaging in the diagnosis and treatment of low-back and leg pain, and patient perception of the indications for surgical compared with conservative management.
- More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms. 4
An amazing research paper appeared in May 2015. In this medical paper, doctors wanted to know what were the 100 most influential or frequently cited studies about lumbar spinal surgery.
Many would think the most frequently cited articles would be about spinal surgery techniques or spinal pain treatments. NO it is about positive readings on MRI in pain negative patients! Clearly the medical community recognizes that spinal surgery recommendations based on MRI finding are troubling.
Here is the findings:
- The top-ranked paper–cited more than 1,000 times–was a classic 1990 study showing that many people have common spinal abnormalities on magnetic resonance imaging (MRI) scans–despite having no back pain or other symptoms.5
- A 1994 study on a similar topic was the second most-cited paper, highlighting the need for a “clear correlation” of patients’ symptoms and imaging findings.6
The top two most cited papers were studies that questioned how to interpret an “abnormal” MRI in patients who had no pain and were written more than 22 years ago.7 Nothing has changed since.
With this evidence, we tell many patients we don’t need an MRI
When we see a new patient with back pain, they will often ask: “Do I need to get a ‘fresh’ MRI?”
We do not advocate the use of MRI’s for diagnosing the cause of pain because the main reason surgeons perform spinal surgery is the above mentioned findings of abnormalities on MRI scans. As stated, most MRI findings have nothing to do with why the person has pain and this is the reason for most back surgery failures.
In one study, researchers noted that more than 85% of patients seen have low back pain that cannot be attributed to a specific disease or an anatomic abnormality and it is well known that imaging of asymptomatic patients often reveals anatomic abnormalities, such as herniated discs.
- “One of the risks of routinely imaging uncomplicated acute low back pain is patient “labeling”; no evidence exists that labeling patients with low back pain with a specific anatomic diagnosis improves outcomes.”8
The same thing was noted by JC Andersen of the University of Tampa in his paper determining whether or not MRI should be ordered in treating athletes with back pain.
- “Available evidence indicates that immediate, routine lumbar spine imaging (MRI or CT) in patients with lower back pain and without features indicating a serious underlying condition did not improve outcomes compared with usual clinical care without immediate imaging.”9
Despite the fact that low back pain MRIs made the top five list of overused tests and treatments, according to the American Academy or Family Physicians and the American College of Physicians, and despite the fact that lumbar spine scans have a poor track record of connecting findings to clinical signs and symptoms, the number of scans has risen dramatically.10
Asking patients what hurts has significant diagnostic value
In a new study looking at ways to minimize failed back surgery, doctors suggest that “Factors such as a lack of knowledge or recognition of the common structure specific pain referral patterns, poor clinical reasoning, unappropriate referral and predilection for popular management approaches also contribute to misdiagnosis and mis-management.”11
Further that doctors should broaden their approach in managing low back pain by using patient questionnaires and health quality of life surveys.
The amazing summary of this paper? Let’s ask the patient!
In recent research, investigators found that talking to patients about their back pain could have significant diagnostic value. Doctors explored patient diagnosis in nerve root compression in men. Things that help doctors were answers to questions such as “pain worse in leg than in back,” and “a non-sudden onset.” 12 Things that could not be determined by an MRI.
Summary – MRI for back pain
Best evidence does not support the use of MRIs for patient surgical selection
One of the most difficult things to tell a patient with significant back pain is that the MRI may not be telling the true story. This, despite an abundance of research suggesting it is not possible to accurately predict who spinal fusion will or won’t work for, using standardizing radiological scans:
- “No subset of patients with chronic low back pain could be identified for whom spinal fusion is a predictable and effective treatment. Best evidence does not support the use of current tests for patient selection in clinical practice.”13
- “Although MRI is appealing, its utility in assessing fusion remains unproven.”14
Reliance on MRI for determining surgical treatment for spinal pain has been shown to be faulty, inaccurate, and leads to unnecessary surgery. This is why it is very important that the patient seek an opinion from a doctor who performs a physical examination to determine the exact cause of pain.
In one research study, doctors said that nearly one in four patients who had a lumbar discectomy had positive scans for recurrent disc herniation following the surgery, the majority of which displayed no pain symptoms.
MRI validated disc herniation which did not cause pain or other symptoms was not associated with clinical consequences in two years following surgery. Clinically silent (patient’s not reporting) recurrent disc herniation is common after lumbar discectomy.
In other words doctors are telling each other that when they order a MRI within the first 2 years of discectomy, they should expect that the MRI will show abnormalities that are of no consequence to the patient and that they should not rush to surgery.15
At Caring Medical, we perform a physical examination on each and every patient, even those who bring in MRI or X-ray results, to determine the exact cause of pain. We then chooses the best course of Prolotherapy treatment to heal the injury and rid the patient of pain. The average patient receives 3-6 treatments spaced four weeks apart. So if your doctor prescribes an MRI, take caution. Your MRI could be your Failed Back Surgery cause. A physical examination is essential in diagnosing pain.
Are you a candidate for our non-surgical treatments? Ask of specialists:
- Ross Hauser MD – Danielle Steilen, MMS, PA-C – Tim Speciale, DO
1. Avoundjian T, Gidwani R, Yao D, Lo J, Sinnott P, Thakur N, Barnett PG. Evaluating Two Measures of Lumbar Spine MRI Overuse: Administrative Data Versus Chart Review. J Am Coll Radiol. 2016 Jun 22. pii: S1546-1440(16)30218-6. [JACR]
2. el Barzouhi A, Vleggeert-Lankamp CL, Lycklama à Nijeholt GJ,et al. Magnetic resonance imaging in follow-up assessment of sciatica. Leiden-The Hague Spine Intervention Prognostic Study Group. N Engl J Med. 2013 Mar 14;368(11):999-1007. doi: 10.1056/NEJMoa1209250. [New England Journal of Medicine]
3. Weiner BK, Patel R. The accuracy of MRI in the detection of Lumbar Disc Containment. Journal of Orthopaedic Surgery and Research 2008, 3:46 [Pubmed]
4. Franz EW, Bentley JN, Yee PP, Chang KW, Kendall-Thomas J, Park P, Yang LJ. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. J Neurosurg Spine. 2015 May;22(5):496-502. doi: 10.3171/2014.10.SPINE14537. Epub 2015 Feb 27. [Pubmed]
5. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8. [Pubmed]
6. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73. Magnetic resonance imaging of the lumbar spine in people without back pain. [Pubmed]
7. Steinberger J1, Skovrlj B, Caridi JM, Cho SK. The top 100 classic papers in lumbar spine surgery. Spine (Phila Pa 1976). 2015 May 15;40(10):740-7. [Pubmed]
8. Srinivas SV, Deyo RA, Berger ZD Application of “Less Is More” to Low Back Pain. Arch Intern Med. 2012;172(11):1-5. doi:10.1001/archinternmed.2012.1838 [Pubmed]
9. Andersen JC. Is immediate imaging important in managing low back pain? J Athl Train. 2011 Jan-Feb;46(1):99-102. [Pubmed]
10. Emery DJ, et al “Overuse of magnetic resonance imaging” JAMA Intern Med 2013 [JAMA]
11. Monie AP, Fazey PJ, Singer KP. Low back pain misdiagnosis or missed diagnosis: Core principles. Man Ther. 2015 Oct 19. pii: S1356-689X(15)00193-9. doi: 10.1016/j.math.2015.10.003. [Pubmed]
12. Verwoerd AJ, Peul WC, Willemsen SP, Koes BW, Vleggeert-Lankamp CL, el Barzouhi A, Luijsterburg PA, Verhagen AP. Diagnostic accuracy of history taking to assess lumbosacral nerve root compression. Spine J. 2014 Sep 1;14(9):2028-37. doi: 10.1016/j.spinee.2013.11.049. Epub 2013 Dec 8. [Pubmed]
15. Willems P. Decision making in surgical treatment of chronic low back pain: the performance of prognostic tests to select patients for lumbar spinal fusion.Acta Orthop Suppl. 2013 Feb;84(349):1-35. doi: 10.3109/17453674.2012.753565. [Pubmed]
16. Selby MD, Clark SR, Hall DJ, Freeman BJ. Radiologic assessment of spinal fusion. J Am Acad Orthop Surg. 2012 Nov;20(11):694-703. doi: 10.5435/JAAOS-20-11-694. [Pubmed]
17. Lebow RL, Adogwa O, Parker SL, Sharma A, Cheng J, McGirt MJ.Asymptomatic same-site recurrent disc herniation after lumbar discectomy: results of a prospective longitudinal study with 2-year serial imaging.Spine (Phila Pa 1976). 2011 Dec 1;36(25):2147-51. [Pubmed]