Is your MRI sending you to a back surgery you do not need?
Ross A. Hauser, MD. Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida
Is your MRI sending you to a back surgery you do not need?
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 a lot of research and our observations in 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 operation. Their failed surgery proceeded forward with the undersatnding that the surgery may not work but what else could these people do after conservative care options had failed and MRI reveled disc damage? Unfortunately, some of these people were not presented with other options.
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 was recently published by the University of Sydney. It appeared in the British Medical Open Journal. (1) 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:
- “Little is known about how to reduce unnecessary imaging for low back pain. Understanding clinician, patient, and general public beliefs about imaging is critical to developing strategies to reduce overuse.”
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:
- “Unnecessary diagnostic imaging is associated with substantial harm including the risk of overdiagnosis.”
- “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.”
- “Unnecessary diagnostic imaging for low back pain drives flow-on effects such as:
- overuse of advanced imaging,
- opioid prescriptions,
- (epidural and cortisone) spinal injections and
- spinal surgery”
- “Evidence from clinical guidelines suggests that most of these interventions have little to no benefit, and substantial risk for harms, in patients with non-specific low back pain.”
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.
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.
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.(2) The 2016 research appears in The American journal of managed care.
- They looked at over 110,000 lumbar spinal MRIs performed on veterans in 2012.
- Of the 110,661 lumbar spinal MRIs performed, 31% were classified as inappropriate.
- Most scans that were considered appropriate were characterized as such because they were preceded by conservative therapy (53%).
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 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 patient 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
The above research is from 2016, here is one from April 2020. In following up on the research we just reported, a Journal of General Internal Medicine (3) paper noted:
- Clinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded MRIs do not improve patient outcomes, lead to unnecessary surgeries and procedures. Why primary care providers order unneeded MRIs for acute, uncomplicated low-back pain is poorly understood. (No one knows why).
This is considered “the” appropriate MRI
- In this study, most MRIs that were considered appropriate for the patient to get were those following failure of conservative care options therapy (53%).
- What are typical conservative care options?
- Pain medications
- Yoga, Pilates, low impact exercises, physical therapy
- Chiropractic care, massage
- Back braces
- What are typical conservative care options?
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
- 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 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, pain will continue after the surgery.
- The surgery made the lower back MORE unstable. Foraminotomy, Laminectomy, Microdiscectomy, disc surgery, all have to remove parts of bone in the spine.
- 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.
- Too much sitting after surgery.
- 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.
- This is the medicine of chronic back pain: MRI to diagnose the problem, surgery to correct the problem.
- Problem: the diagnosis based on MRI is often wrong, as we will see in the research below.
- Problem: the surgery is correcting something that is not a pain-causing factor. If it is not broken, don’t fix it, is replaced by “It’s not broken, we will fix it anyway.”
- Problem: The surgery itself is causing more pain post-operatively. What was not broken was broken by the surgery.
- Ultimate Problem: Failed back surgery syndrome.
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, (4) doctors at the Hospital for Special Surgery, Spreemo Quality Research Institute, and Thomas Jefferson University Hospital wrote of their observations of what happened when the sent a 63 year old women 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.”
- In other words and more simply, you should be able to walk into any Imaging Center, get an MRI and the results should be the same everywhere.
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.”
- In other words, the authors of this study do not believe you can walk into any Imaging Center and get the same diagnostic results. This is a big problem:
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.
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. (5) In their findings the doctors noted:
- MRI is regularly used by clinicians in making a decision of whether to treat a patient conservatively using physiotherapy, rehabilitation and pain medication or consider surgical intervention for degenerative disc disease, or spinal stenosis.
- There is a documented trend of increasing excessive utilization and over-dependence on MRI in assessing lumbar spine disorders among clinicians.
- Based on the findings of this review, the lack of sufficient high-quality scientific evidence in support or against the use of MRI, the on-going debate among experts regarding the cost, diagnostic utility and accuracy of MRI in diagnosing nerve root compression and radiculopathy, clinicians should always correlate the findings of MRI with the patients’ medical history and clinical presentation in clinical decision making.
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 recent study published in the New England Journal of Medicine, (6) 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-disc herniation at baseline who were treated with either surgery or conservative treatment and followed for 1 year, the presence of disc 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.
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.
In a 2008 study, (7) 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 of 30% of cases (of back pain).”
A 2017 study (8) using the above 2008 study as a reference made these observations on the accuracy of sending patients to surgery based on their MRIs
- “Imaging results are frequently considered as hallmarks of disease by spine surgeons to plan their future treatment strategy. Numerous classification systems have been proposed to quantify or grade lumbar magnetic resonance imaging (MRI) scans and thus objectify imaging findings.”
- In other words, there is no standardization of how to read an MRI
- “The clinical impact of the measured parameters remains, however, unclear.”
- In other words, even if you had standardization of how to read an MRI, the findings could still be considered unclear.
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 patients pain.
- So 50 patients with chronic lumbar back pain who had an MRI received facet joint injections into their spine at points that the MRI said there was damage. What happened?
- 27 patients showed no improvement
- 16 reported good improvement
- and 7 reported excellent improvement
- MRI features assessed in this study did, however, not show any relevant correlation with reported pain after facet joint infiltration
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.
Despite this evidence, patients are lead 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).
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.(9)
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. (10) What did this research team have to say?
- “Patient’s conception of ‘positive’ imaging findings can also drive inappropriate treatment expectations. (The study by Wayne State University School of Medicine) reported that among patients referred to neurosurgery for symptoms of low back pain [spondylosis], 52% were willing to undergo surgery based on imaging abnormalities, even in the absence of symptoms.
- Knowledge of positive imaging findings seemed to push these patients toward surgery, even if it was not an appropriate treatment option.
- A significant proportion of patients believe that imaging findings are more important than physical examination findings and critical for their care.”
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 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.(11)
- 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.(12)
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.(13) 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.
“Less is More”
In a 2012 study researchers at the University of Connecticut Health Center (14) 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.”
- Published data also document harms associated with early imaging for low back pain, unneeded follow-up tests for incidental findings, irradiation exposure, unnecessary surgery, and significant cost. Routine imaging should not be pursued in acute low back pain. Not imaging patients with acute low back pain will reduce harms and costs, without affecting clinical outcomes.”
The same thing was noted by JC Andersen of the University of Tampa in his paper published in the Journal of athletic training, (15) 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.”
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.(16)
In 2017, an editorial published in the journal Patient Safety in Surgery (17) accounted for this research when the authors asked: “Why do surgeons continue to perform unnecessary surgery?”
- Unnecessary surgery is any surgical intervention that is either not needed, not indicated, or not in the patient’s best interest when weighed against other available options, including conservative measures.
- Multiple clinical trials have shown that spinal fusions for back pain do not lead to improved long-term patient outcomes when compared to non-operative treatment modalities, including physical therapy and core strengthening exercises.
- In spite of these insights from high-quality trials, spinal fusion rates continue to dramatically increase in the United States.
Building on these opinions, a 2018 paper published in the Surgical Neurology International,(18) 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.”(19)
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 leg than in back,” and “a non-sudden onset.” (20) 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.(21) 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:
- “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.”
- “Although MRI is appealing, its utility in assessing fusion remains unproven.” 
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.
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
1 Traeger AC, Reed BJ, O’Connor DA, Hoffmann TC, Machado GC, Bonner C, Maher CG, Buchbinder R. Clinician, patient and general public beliefs about diagnostic imaging for low back pain: protocol for a qualitative evidence synthesis. BMJ open. 2018 Feb 1;8(2):e019470. [Google Scholar]
2.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]
3 Nevedal AL, Lewis ET, Wu J, Jacobs J, Jarvik JG, Chou R, Barnett PG. Factors influencing primary care providers’ unneeded lumbar spine MRI orders for acute, uncomplicated low-back pain: a qualitative study. Journal of General Internal Medicine. 2019 Dec 12:1-8. [Google Scholar]
4. 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]
5 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]
6. 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]
7. 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]
8. Hofmann UK, Keller RL, Walter C, Mittag F. Predictability of the effects of facet joint infiltration in the degenerate lumbar spine when assessing MRI scans. J Orthop Surg Res. 2017;12(1):180. Published 2017 Nov 21. doi:10.1186/s13018-017-0685-x [Google Scholar]
9. 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]
10. Tousignant-Laflamme Y, Longtin C, Brismée JM. How radiological findings can help or hinder patients’ recovery in the rehabilitation management of patients with low back pain: what can clinicians do? [Google Scholar]
11. 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]
12. 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]
13. 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]
14. 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]
15. Andersen JC. Is immediate imaging important in managing low back pain? J Athl Train. 2011 Jan-Feb;46(1):99-102. [Google Scholar]
16. Emery DJ, et al “Overuse of magnetic resonance imaging” JAMA Intern Med 2013 [Google Scholar]
17. Stahel PF, VanderHeiden TF, Kim FJ. Why do surgeons continue to perform unnecessary surgery? Patient Saf Surg. 2017 Jan 13;11:1. doi: 10.1186/s13037-016-0117-6. PMID: 28096899; PMCID: PMC5234149. [Google Scholar]
18. Ghaly RF, Knezevic NN. What happened to “Patient first” and “Do no harm” medical principles? Surg Neurol Int. 2018 Aug 29;9:176. doi: 10.4103/sni.sni_447_17. PMID: 30221021; PMCID: PMC6130150. [Google Scholar]
19. 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]
20. 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]
21 Kim JH, van Rijn RM, van Tulder MW, et al. Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review. Chiropr Man Therap. 2018;26:37. Published 2018 Aug 21. doi:10.1186/s12998-018-0207-x [Google Scholar]
22 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]
23 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]
24 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]