MRI causes Failed Back Surgery | Positive Spinal MRI readings in pain negative patients

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 we know there is a problem.

That is what radiologists at the Health Economics Resource Center, at the Veterans Affairs Palo Alto Health Care System in Menlo Park, California 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 non-specific back pain.

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 an imagining center

In the medical publication the Spine Journal, doctors at the Hospital for Special Surgery, Spreemo Quality Research Institute, and Thomas Jefferson University Hospital wrote:

“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.

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.”

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 (1) marked variability in interpretive findings and (2) 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.”(2)

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

MRI has little value in helping patients cure their back pain

In a new study, university researchers in Kenya and South Africa published their findings in the online medical journal BioMed Central musculoskeletal disorders. In their findings the doctors noted:

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.”

What did the doctors conclude?

In a 2008 study, 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.

“MRI alone may provide insufficient or inaccurate information upon which to base surgical/technical decisions in about of 30% of cases (of back pain).”(5) This research published in the Journal of Orthopaedic Surgery and Research shows how very little has changed in nearly a decade.

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

In a recent study, from Wayne State University School of Medicine in the Journal of neurosurgery. Spine, 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.

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 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!

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 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 23 years ago.(9) 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.

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.

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.(12)

 

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.”(13)

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.” (14) Things that could not be determined by an MRI.

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 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]

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.

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

 

1.Gidwani R, Sinnott P, Avoundjian T, Lo J, Asch SM, Barnett PG. Inappropriate ordering of lumbar spine magnetic resonance imaging: are providers choosing wisely?. The American journal of managed care. 2016 Feb;22(2):e68-76. [Google Scholar]
2. Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal. 2017 Apr 30;17(4):554-61.  [Google Scholar]
3 Tawa N, Rhoda A, Diener I. Accuracy of magnetic resonance imaging in detecting lumbo-sacral nerve root compromise: a systematic literature review. BMC Musculoskeletal Disorders. 2016;17(1):386. [Google Scholar]
4. 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. [Google Scholar]
5. Weiner BK, Patel R. The accuracy of MRI in the detection of Lumbar Disc Containment. Journal of Orthopaedic Surgery and Research 2008, 3:46 [Google Scholar]
6. 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. [Google Scholar]
7. 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. [Google Scholar]
8. 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. [Google Scholar]
9. 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. [Google Scholar]
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 [Google Scholar]
11. Andersen JC. Is immediate imaging important in managing low back pain? J Athl Train. 2011 Jan-Feb;46(1):99-102. [Google Scholar]
12. Emery DJ, et al “Overuse of magnetic resonance imaging” JAMA Intern Med 2013 [Google Scholar]
13. 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. [Google Scholar]
14. 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. [Google Scholar]
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. [Google Scholar]
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. [Google Scholar]
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. [Google Scholar]

2700

Our Facebook Reviews
Our Facebook Reviews
Celebrating 25 years of Prolotherapy! Are you a good Prolotherapy candidate?
How Can We Help You?
First Name:
Last Name:
Phone:
Email:
Question:

Enter code:
captcha

SEARCH
for your symptoms

Prolotherapy, an alternative to surgery

Were you recommended SURGERY?
Get a 2nd opinion now!

WHY TO AVOID:
★ ★ ★ ★ ★We pride ourselves on 5-Star Patient Service!Come see why patients travel from all
over the world to visit our clinics.
Current Patients
Become a New Patient

Chicagoland Office
715 Lake St., Suite 600
Oak Park, IL 60301
(708) 393-8266 Phone
(855) 779-1950 Fax
Southwest Florida Office
9738 Commerce Center Ct.
Fort Myers, FL 33908
(239) 303-4069 Phone
(855) 779-1950 Fax Fort Myers, FL Office
We are an out-of-network provider.
© 2017 | All Rights Reserved | Disclaimer
National Prolotherapy Centers specializing in Comprehensive Prolotherapy,
Stem Cell Therapy, and Platelet Rich Plasma.

Meet our Prolotherapy Doctors and check out our Prolotherapy research.