Is your MRI or CT Scan sending you to a back surgery you do not need?

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

Is your MRI sending you to a back surgery you do not need because of fear and panic?

In this article, we are seeking to offer one simple piece of information. Your MRI may be sending you to a spinal surgery you do not need. We are going to support this simple idea with research and scientific papers and our observations of the many patients we have seen after failed back surgery syndrome. We will further help you understand how MRIs can be wrong and inaccurate and why MRI readings may lead to INCREASED incidents of failed back surgery syndrome.

People do have very successful spinal surgeries. These spinal surgeries were recommended after an MRI reading showed some type of degenerative disc disease. People who have successful spinal surgeries are not the people we see in our office. We see the people for whom spinal surgery was not the right option. For many of these people, they were advised prior that this surgery they are embarking on may not help them. But for these people, many thought, “what else could they do?” Especially after conservative care options had failed and MRI revealed disc damage? Unfortunately, some of these people were not presented with other options beyond surgery, painkillers, and “live with it.”

Did your spinal MRI scare you into surgery you did not need?

In July 2021, two surgeons and a radiologist published a randomized control trial study in the European Spine Journal.(1) The basis of this study was, did the MRI interpretation scare the patient into a surgery they did not need? Further, did the patient have poor surgical outcomes because their MRI report sent them into “catastrophic thought?” This is what the researcher team reported:

“Inappropriate use of MRI leads to increasing interventions and surgeries for low back pain. We probed the potential effects of a routine MRI report on the patient’s perception of (his/her) spine and functional outcome of treatment. An alternate ‘clinical reporting’ was developed and tested for benefits on low back pain perception.”

Explanation: Patients are getting MRIs, some inappropriately as a routine diagnostic tool. Some of the MRIs may report routine degenerative disc disease, much of it is asymptomatic. Yet, the patient is told about these findings in sometimes ominous terms and these findings send some into a panic. So much so that they fail conservative care treatment and even surgery because they believe that they may be “too far gone.” The doctors of this study conjecture that there should be another way developed to let patients know about their MRI findings without causing them to go into catastrophic thought.

In this study, the doctors then the doctors separated out 44 patients.

Then the progress of the patient’s pain and symptoms were assessed.

Let’s stop here again. The patients in the group who had their MRI interpretations given to them in more reassuring terms went to surgery less.

Conclusion of this research: “Routine MRI reports produce a negative perception and poor functional outcomes in LBP. Focused clinical reporting had significant benefits, which calls for the need for ‘clinical reporting’ rather than ‘Image reporting’.” In other words, treat the patient, not the MRI. Stop frightening patients with MRI interpretations and send them to surgery that they may not need.

When your back doesn’t hurt but your MRI looks terrible:

Overdiagnosis occurs when diagnostic imaging detects incidental findings that are common in the asymptomatic population (eg, intervertebral disc degeneration) and provides the patient with a diagnostic label that brings them no benefit or causes harm.”

Research into the problems of MRI overuse and over-reliance is hardly new. Interestingly is the frequent use of the word catastrophic. The above study carried the title: “The catastrophization effects of an MRI report on the patient and surgeon and the benefits of clinical reporting.” Recently published by the University of Sydney was a paper in the British Medical Open Journal. (2)  This is the introductory sentence to their paper on the need for examining MRI overuse and the catastrophic problems it can create for some patients:

The researchers have identified a problem that everyone knows about but little is being done about it. Too many people are getting unnecessary MRIs and this is causing unnecessary and unneeded spinal surgeries.

“Unnecessary diagnostic imaging is associated with substantial harm including the risk of overdiagnosis.”

Let’s continue on with statements from the researchers:

How are these researchers tackling this problem? They hope that at the completion of their study they can make useful recommendations to help doctors understand when and when not to rely on MRIs and this, in turn, will prevent opioid abuse and unnecessary spinal surgery.

In the image below we see an MRI showing lumbar spondylosis. It shows endplate sclerosis, disc space narrowing, osteophytes, or bones spurs. According to the research studies we are looking at, the patient can be told in one of two ways what this MRI says.

  1. They can be told that they have endplate sclerosis and the developing of bone spurs or boney overgrowth osteophytes. This is causing disc space narrowing and compression and spinal problems. (This can cause people to catastrophize that they have significant spinal problems).
  2. They can be told that they have endplate sclerosis and the developing of bone spurs or boney overgrowth osteophytes. This is causing disc space narrowing and compression and spinal problems. BUT, this is part of the normal aging process, and that it can be treated without surgical intervention. (These are the patients who, according to research, do not require as many surgeries and the first group).

Lumbar Spondylosis MRI

“Overuse of diagnostic imaging for patients with low back pain remains common.” “Patients may underestimate the harms of unnecessary imaging tests.”

This study was cited by another study from The University of Sydney published in August 2020 (3) which offered these observations on the overreliance of spinal MRIs.

In this paper, the researchers examined 69 studies with 1747 participants.

Key findings included:

Conclusion: “Clinicians and patients can believe that diagnostic imaging is an important tool for locating the source of non-specific low back pain. Patients may underestimate the harms of unnecessary imaging tests. These beliefs could be important targets for intervention.”

“Participants appeared to gain a better understanding of the concept of over-diagnosis and the importance of not rushing to imaging.”

In April 2021, (4) this same research team conducted two focus groups of 19 people with or without low back pain to test their concepts of a public health campaign aimed at educating patients about the risks and harms of unnecessary imaging tests for non-specific low back pain. They published their results in the journal “Health expectations: an international journal of public participation in health care and health policy.”

What they found was people wanted the MRI. How did they make this assessment? They asked the people in the study group to look at components of a public health campaign that included digital posters and an information leaflet using strong imagery and messaging about the risk of over-diagnosis.

Results: “(The people of the focus groups) reacted with surprise, initial mistrust, and occasionally anger towards imagery and messaging that suggested diagnostic imaging tests could be unnecessary and harmful. With further reflection and discussion, and after reading longer format information about over-diagnosis, the participants found some of the messages informative and useful. Participants appeared to gain a better understanding of the concept of over-diagnosis and the importance of not rushing to imaging.”

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, we know there is a problem.

Nearly one-third (31% of MRIs) were deemed inappropriate or not helpful to the patient’s condition.

The theme of this article is over-reliance on MRI use for routine back pain problems and what these MRIs are doing to people emotionally and mentally. That is what radiologists at the Health Economics Resource Center, at the Veterans Affairs Palo Alto Health Care System in Menlo Park, California writing about the inappropriate use of magnetic resonance imaging (MRI) for patients with low back pain. (5) The 2016 research appears in The American Journal of Managed Care. As you can see in the last five years there is still a concern.

We see many patients who visit us and the first thing they want to do is get an MRI to bring to the first visit. Many of these people are shocked to hear that we very rarely order one and in almost every case it is not necessary. Some of these patients get very confused, “How can there be no MRI?” In treating degenerative disc disease and spinal ligament damage, our 25+ years of experience tells us that we can get the answers we need to help the patient with a consultation and physical examination, no need for an MRI. In fact, the MRI may just confuse things because all the patients can think about is bulging discs when bulging discs are not what is causing them pain. Please see our article Non-surgical treatment of a herniated or bulging disc, I hope you will find the information helpful in understanding what your spine is telling you and what an MRI is telling you. Listen to your spine.

Unneeded MRIs do not improve patient outcomes and lead to unnecessary surgeries

Let’s move forward again to an April 2020 paper in the Journal of General Internal Medicine. (6) Here researchers noted:

This is considered “the” appropriate MRI

“Patients with low back pain rarely have serious underlying pathology but frequently undergo inappropriate imaging.”

In March of 2020 researchers at King’s College London and the University of Sydney reinforced this message of inappropriate and appropriate MRIs for low back pain: Here is what they wrote in the European Spine Journal. (7)

“Patients with low back pain rarely have serious underlying pathology but frequently undergo inappropriate imaging. . . Greater clarity is needed on how we define and measure imaging appropriateness for low back pain, which also accounts for the problem of failing to image when indicated.”

In this video, Ross Hauser, MD describes the 5 main reasons that back surgery failed to help the patient’s condition. Number 1 is the wrong surgery.

Five reasons back surgery fails

  1. The surgery did not address the actual cause of the patient’s pain. The diagnosis is wrong.  The main cause of ‘”missed” low back pain is an injury to the Sacroiliac Joint. If your MRI showed disc degenerative disease and you had the discs operated on but the Sacroiliac Joint was not addressed, the pain will continue after the surgery.
  2. The surgery made the lower back MORE unstable. Foraminotomy, Laminectomy, Microdiscectomy, disc surgery, all have to remove parts of the bone in the spine.
  3.  The “missed secondary problem.” The surgery may have successfully addressed what was considered your primary problem, but, you really had two problems. This could be a multi-segmental problem that was not discovered until after the first surgery.
  4. Too much sitting after surgery.
  5. A more rare situation is when scar tissue forms and pinches on the nerves.

Research: “more than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms.”

This is the medicine of chronic back pain: MRI to diagnose the problem, surgery to correct the problem. But what if the MRI was wrong? Was the surgery wrong too?

As we will see below in cited research: 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 there is a problem.

The biggest problem is that spinal surgery is a standard of care that has been scrutinized for excessive failures.

Where is the evidence for all this? It is all around us in the medical literature.

A 63-year-old woman with lumbar radiculopathy walks into 10 different imaging centers. What happens next?

In the medical publication Spine Journal, (8) doctors at the Hospital for Special Surgery, Spreemo Quality Research Institute, and Thomas Jefferson University Hospital wrote of their observations of what happened when they sent a 63-year-old woman with back pain complaints to ten different imaging centers:

“In today’s health-care climate, magnetic resonance imaging (MRI) is often perceived as a commodity, a service where there are no meaningful differences in quality and thus an area in which patients can be advised to select a provider based on price and convenience alone.”

Back to the study: “If this prevailing view is correct, then a patient should expect to receive the same radiological diagnosis regardless of which imaging center he or she visits, or which radiologist reviews the examination. Based on their extensive clinical experience, the authors believe that this assumption is not correct and that it can negatively impact patient care, outcomes, and costs.”

A 63-year-old woman with lumbar radiculopathy walks into 10 different imaging centers – what does she get? An MRI with a broad range of interpretive errors. . . patients may get a surgery they do not need or a surgery that addresses the wrong concern.

The researchers tested their troubling hypothesis that radiologists’ reports from multiple imaging centers performing a lumbar MRI examination on the same patient over a short period of time will have (one) marked variability in interpretive findings and (two) a broad range of interpretive errors.

So they sent a 63-year-old woman with a history of low back pain and right L5 radicular symptoms to get 10 MRIs

Across all 10 study examinations, there were 49 distinct findings reported related to the presence of a distinct pathology at a specific motion segment.

Based on that one statement alone, it is easy to understand the author’s conclusion to the study:

“This study found marked variability in the reported interpretive findings and a high prevalence of interpretive errors in radiologists’ reports of an MRI examination of the lumbar spine performed on the same patient at 10 different MRI centers over a short time period.

As a result, the authors conclude that where a patient obtains his or her MRI examination and which radiologist interprets the examination may have a direct impact on radiological diagnosis, subsequent choice of treatment, and clinical outcome.”

In other words, the patients may get a surgery they do not need or a surgery that addresses the wrong concern.

Do women, in general, have a greater risk for MRI variants? Especially for swelling and fluid build up?

Above is a case of women that had MRIs at different locations and received a series of different recommendations for treatment based on what was interpreted from these images.

A December 2018 study in the journal European Radiology (9) examined and highlighted the potential MRI imaging features that might be misleading.

In this study, the researchers examined a group of patient MRIs looking for “potential misleading edematous (swelling or fluid buildup) or structural changes associated with Sacroiliac (SI) joint pain anatomical variations.” The final group studied consisted of 157 patients.

It’s the image, not the inflammation

The conclusion of this research: “Several anatomical variations of the Sacroiliac joint are relatively commonly seen on MR images, particularly in females. These variations may be associated with signal intensity changes, which may be mechanical and not necessarily inflammatory in nature.”

MRI has little value in helping patients to cure their back pain

In a recent study, university researchers published their findings in the online medical journal BioMed Central Musculoskeletal Disorders. (10) In their findings the doctors noted:

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.

In a study published in the New England Journal of Medicine, (11) 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 MRIs 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.”

What did the doctors conclude?

1 in 3 back pain patients should not even get an MRI

There are many people who suggest that technology is changing so fast that research on imaging studies is nearly outdated as soon as it is published. This is not so. Throughout this article, we have demonstrated that concerns about inappropriate MRIs, the impact on the patient’s mental well-being, and the subsequent poorer results that MRI interpretation can cause can make someone’s back pain worse.

In a 2008 study, (12) doctors at Weill Cornell Medical College and the Methodist Hospital Houston found that nearly 1 in 3 back pain patients should not even get an MRI because it may lead to unnecessary spinal surgery.  They wrote: “MRI alone may provide insufficient or inaccurate information upon which to base surgical/technical decisions in about 30% of cases (of back pain).” As we saw from the late 2021 study that we started this article with. This problem is still a problem.

A 2017 study (13) using the above 2008 study as a reference made these observations on the accuracy of sending patients to surgery based on their MRIs

To answer this problem, the researchers suggested that “image-guided local infiltrations (injections)” to target defined areas such as the facet joints could be a useful tool in correlating damage seen on MRI as the true cause of the patient’s pain.

Now the conclusion: “Despite the trend in evidence-based medicine to provide medical algorithms (a scoring system for MRIs to justify surgical intervention), our findings underline the continuing need for individualized spine care that, along with imaging techniques or targeted infiltrations, includes diagnostic dimensions such as good patient history and clinical examination to formulate a diagnosis.”

In other words, you cannot rely on the MRI alone.

This was also supported by a 2016 paper in the journal BioMed Central musculoskeletal disorders (14) which also cited the 2008 research and stated: “There is lack of sufficiently high-quality scientific evidence in support or against the use of MRI in diagnosing nerve root compression and radiculopathy. Therefore, clinicians should always correlate the findings of MRI with the patients’ medical history and clinical presentation in clinical decision making.”

Despite this evidence, patients are led to believe that the MRI is the final truth.

 “more than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms.”

And now we have arrived at a recent study from Wayne State University School of Medicine published in the Journal of Neurosurgery Spine. Here, 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). (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.

Researchers warn patients: STOP AGREEING TO SURGERY

Researchers at the University of Sherbrooke in Canada and Texas Tech University Health Sciences Center, cited this same research from Wayne State University School of Medicine in their medical paper “How radiological findings can help or hinder patients’ recovery in the rehabilitation management of patients with low back pain: what can clinicians do?,” published in The Journal of Manual & Manipulative Therapy. (16) What did this research team have to say?

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.

Positive readings on MRI in pain negative patients

Many would think the most frequently cited research articles on back pain 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 solely on MRI findings are troubling.

Here are the findings:

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 25 years ago. (19) 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 MRIs 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.

“Less is More”

In 2012 study researchers at the University of Connecticut Health Center (20) 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.

The same thing was noted by JC Andersen of the University of Tampa in his paper published in the Journal of Athletic Training, (21) determining whether or not MRI should be ordered in treating athletes with back pain.

Despite the fact that low back pain MRIs made the top five list of overused tests and treatments, according to the American Academy of 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. (22)

In 2017, an editorial published in the journal Patient Safety in Surgery (23) accounted for this research when the authors asked: “Why do surgeons continue to perform unnecessary surgery?”

Building on these opinions, a 2018 paper published in the Surgical Neurology International, (24) wrote: “The majority of updates, conventions, and meetings, particularly in neurosurgery, are no longer about how to improve the quality of care. Rather, they largely address new regulations, protocols, surveys, and how to maximize billing for surgical procedures, some of which are unnecessary, irrespective of outcomes.”

Asking patients “What hurts?” has significant diagnostic value above what an MRI suggests

In a 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, inappropriate referral and predilection for popular management approaches also contribute to misdiagnosis and mismanagement.” (25)

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 about their back pain.

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 the leg than in the back,” and “a non-sudden onset.” (26) Things that could not be determined by an MRI.

This research was expanded on in a 2018 study published in the medical journal Chiropractic and Manual Therapies. (27) Here researchers suggested: “The diagnostic accuracy of CT, myelography, and MRI of today is unknown, as we found no studies evaluating today’s more advanced imaging techniques. Concerning the older techniques, we found moderate diagnostic accuracy for all CT, myelography, and MRI, indicating a large proportion of false positives and negatives.”

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.

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:

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 an 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. [30]

CT scans in patients under the age of 40 may lead to improper diagnosis and improper treatment

A 2017 study from researchers at Tel Aviv University in Israel (31) suggested that CT scans in patients under the age of 40 may lead to improper diagnosis and improper treatment.

Here are the learning points of their research:

“Total diagnostic accuracy for these reports only and for the entire readings were 49% and 69%, respectively, and 13% and 1.3%, respectively, for the pathological findings.”

Physical examination

At Caring Medical, we perform a physical examination of each and every patient, even those who bring in MRI or X-ray results, to determine the exact cause of pain. We then choose 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.

If you have questions about back pain, get help and information from our Caring Medical Staff

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This article was update November 4, 2021

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