Failed Back Surgery Risk Factors | Too many inappropriate MRIs
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. Patients will go to surgery with no pain symptoms because the MRI said so. How many of these MRIs fell into the category of inappropriate?
This is the treatment course that patients have been told will help their back pain. 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 literature.
If the patient does not complain of back pain – but the MRI shows herniated disc – leave the patient ALONE!
Here is what researchers in Germany found when they tested whether steroid injections could help patients following continued pain after surgery:
- “Of 479 patients who underwent microsurgical lumbar disc surgery, 69 had persistent radicular pain. . . injection of steroid achieved pain reduction of at least 50% in 26.8% of these patients.
- ” injection of steroid appears to be effective in only a minority of patients with radicular pain persisting after disc surgery…” PLEASE NOTE 479 PATIENTS – 69 HAD persistent radicular pain – ABOUT 15% 2
Doctors reveal in a new study that a surprisingly high percentage of patients have misconceptions regarding the diagnosis and treatment of lumbar spondylosis (degenerative – osteoarthritic changes in the spine), and that these misconceptions persist in patients even after they had spine surgery.
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.
- A total of 121 surveys were included in the analysis.
- More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms;
- more than 40% of patients indicated the same for plain radiographs.
- Similarly, a large proportion of patients (33%) believed that back surgery was more effective than physical therapy in the treatment of back pain without leg pain.
- Nearly one-fifth of the survey group (17%) also believed that back injections were riskier than back surgery.
These results show that a surprisingly high percentage of patients have misconceptions regarding the diagnosis and treatment of lumbar spondylosis.3
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.4
- 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.5
The top two most cited papers were studies that questioned how to interpret an “abnormal” MRI in patients who had no pain!6
Doctors question MRI’s usefulness as a frequently performed test
Here is another recent study that questions whether or not MRI has any value in follow up examination in patients being treated for sciatica and lumbar disc herniation.
In this paper doctors questioned MRI’s usefulness as a frequently performed test during follow-up 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. In other words, not accurate.
The doctors looked at patients who had MRI done before treatment and after treatment in two groups. Those who had surgery and those who did not and received conservative care instead. 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? “MRI performed at 1-year follow-up in patients who had been treated for sciatica and lumbar-disc herniation did not distinguish between those with a favorable outcome and those with an unfavorable outcome.”
- In other words, the MRI could not tell who was in pain, who was not, who needed treatment of any kind, and who did not.7
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.”8 Further that doctors should broaden their approach in managing low back pain by using patient questionnaires and health quality of life surveys.
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.” 9 Things that could not be determined by an MRI.
MRI – Failed Back Surgery cause? Here’s more
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.”10
The same thing was noted by researchers looking at athletes to determine whether or not MRI should be ordered. “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.”11
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).”12
“It is risky to comment on degenerate disc disease on a plain radiograph alone”
Doctors and Surgeons at one British hospital could not even agree if the MRI suggested surgery or not! “We found in our study that there is wide variation in diagnosing lumbar disc disease between the Orthopaedic Surgeons and the Radiologists at our institution…Due to this amount of inaccuracy, it is risky to comment on degenerate disc disease on a plain radiograph alone.” 13
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.
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.14
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.”15
- “Although MRI is appealing, its utility in assessing fusion remains unproven.”16
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.17
References for this article – please use the form below to ask us your questions
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. doi: 10.1016/j.jacr.2016.04.013.
2. Klessinger S. Radicular Pain in Post Lumbar Surgery Syndrome: The Significance of Transforaminal Injection of Steroids Pain Med. 2012 Aug 8.
3. 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.
4. 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.
5. 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.
6. 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. doi: 10.1097/BRS.0000000000000847.
7. 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.
8. 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.
9. 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. [Epub ahead of print]
10. 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
11. Is immediate imaging important in managing low back pain? J Athl Train. 2011 Jan-Feb;46(1):99-102.
12. Weiner BK, Patel R. The accuracy of MRI in the detection of Lumbar Disc Containment. Journal of Orthopaedic Surgery and Research 2008, 3:46
13. Madan SS, Rai A,Harley JM. Interobserver Error in Interpretation of the Radiographs for Degeneration of the Lumbar Spine. Iowa Orthop J. 2003; 23: 51-56.
14. Emery DJ, et al “Overuse of magnetic resonance imaging” JAMA Intern Med 2013; DOI: 10.1001/jamainternmed.2013.3804.
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.
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.
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.