“Do I need an MRI for low back pain?” Dr. Brady, from the Brady Back Institute, goes into detail on when you need an MRI, what it tells your doctor and why it’s so important to have a great ordering doctor and a great radiologist. With error rates as high as 48% the deck can be stacked against you. Learn how to take steps to prevent becoming a victim of the healthcare system.

Discussion highlights:

0:47- Low back pain describes a symptom, NOT a diagnosis.

12:07- Get the category right, put it in context, now you’re dealing with the truth. Anything shy of that is sloppy.

12:43- The average missed rate for disc herniation is 48%

12:54- There is a 44% average miss rate overall.

22:07- Case Presentation: #2

26:59- Case Presentation: #3

 

[First ten minutes transcribed]

 

[Sitting at the table are: Dr. Cody Scharf, Dr. Matthew Lytle, Dr. Carl Nottoli and Dr. William Brady.]

Dr. William Brady: 10% of low-back patients ever find out what’s causing their pain.

[Music]

Dr. William Brady:  Our topic today is back pain in the role of MRI and the devil is in the details. There is a lot of debate and discussion over [the] utilization of MRI and its value we will get those questions answered.

Joining us today we’ve got three other doctors: 

Dr. Matt Lytle: Dr. Matt Lytle from Precision Health Group in St. Louis, Missouri 

Dr. Cody Scharf : Dr. Cody Scharf of Thrive Care in Cedar Rapids, Iowa 

Dr. Carl Nottoli:  Dr. Carl Nottoli of Functional Pain Relief in Libertyville, Illinois outside Chicago.

Dr. William Brady: We’ll start with some basic definitions: Low back pain describes a symptom, not a diagnosis, located anywhere in the back from your ribs down to basically the bottom of your butt called the gluteal folds. Pain anywhere in there is low back pain it’s just a description of where the patient hurts and that’s it.

Number two: an MRI is the technology that takes pictures of the inside of your body and it has the added advantage of [doing so] without radiation so it’s not an x-ray or a CT scan which has a lot of radiation so it’s perfectly safe to do. This generates around 100 pictures and these are done through different angles and different orientations with different contrasts. It’s a black and white shaded gray image and you can basically turn the contrast up or down and alter it so you can see different things that the doctor needs to see. 

“When low back pain persists for longer than six weeks and you’ve had conservative care that is failing and there’s remains some diagnostic uncertainty, then an MRI is recommended,” and this is the American College of Radiology. So they’re saying don’t get this if your back pain started within the last six weeks or if you haven’t received some sort of conservative first-line care whether that be rest, physical therapy, exercise, following various advice, all of that constitutes conservative care.

When you get the MRI especially trained radiologists, which is usually an MD, reads the MRI and then makes a written report. So they get these 100 images, they look at them all and they dictate or write a report which has the findings. The doctor that ordered the film then reads the report and uses this information to make decisions about your diagnosis, your treatment and your prognosis, which is how good they expect you to do. And that’s a critical point. You get these pictures so you have more information about what’s wrong and the ordering doctor combines that with other information from the history examination and other tests to hopefully arrive at an accurate complete diagnosis that will improve with treatment and let the patient know what they’re in for. 

However, we run into our first problem, right? So far the story sounds great. Everyone’s doing their job. The error rate on these written reports is nearly 50%. Jaw-droppingly common errors. Over here [screen gesture 3:33]  we can see that only 1 in 10 patients 10% of low-back patients ever find out what’s causing their pain. Most of the time the doctors are like ‘yeah backs hurt what can you do?’ or ‘some people have disc injuries and never get a symptom. you’ve got some disc injuries and you have symptoms. we don’t know if they’re related.’ This is the standard story with back pain. It’s terrible. There’s very few other medical conditions where there’s a failure to diagnose in any meaningful detail 90% of the time. 

So there’s trouble here. So what does this mean, specifically the role of MRI with low back pain, and what can we do (ultimately when we go through this entire presentation) what are the solutions, if this is such a big problem, what can be done? And we’ll show you what we’re doing to fix this.

First question is: ‘why get an MRI if you have back pain?’ And the simple answer is to determine your structure. Structure is your anatomy. Is the shape of these tissues correct? Is the alignment correct? So an MRI can’t tell you range of motion, it can’t tell you strength, it can’t tell you the chemical status of the tissues. It just tells you structure: what is the shape size and location of what’s happening. So particularly in your back, the most common thing is it can tell you what your discs look like, what your bones look like what your alignment is. Those are super important things that are very hard to tell otherwise. So if it determines structure that’s, that’s its job. So you can say, ‘what is a healthy structure?’ 

Maybe four out of five of your disks look great. Great! we can take those four off your list of problems because they’re absolutely beautiful looking. And then what isn’t healthy? Say that fifth disk is degenerated or shortened or it’s squeezing out the back. There’s a lot of different ways this can be your problem. Or unexpected findings: maybe you’ve got a vertebra where the bone is sliding forward or backwards, or there’s a certain amount of degeneration. So what’s healthy and what’s unhealthy structurally, the MRI is very good it’s showing you. And then if it is unhealthy, how bad is it?

For most of the findings, there’s a grading scale. You can say ‘this is zero through five’,’ zero through six’, is zero being healthy six being terrible, where does this particular finding fall? So the technical way to put this–this allows us to grade the extent, meaning how many tissues are involved, and the severity, meaning how bad is each one of those things, for structural abnormalities. It does not by itself tell you what’s causing your pain, which is a point of much contention. All imaging findings have to be clinically correlated, meaning I need the history and examination to add to these pictures of structure. And there–that’s what we’re trained to do. But still, people don’t do it. Or at least it’s what we’re told we should do if we’re not trained to do it well.

And to put this in context, this is part of why there’s debate: structural changes are one of four categories that contribute to low back pain. So this category structure, the MRI tells you whether you have this or you don’t. Again, what’s the extent and severity of your structural status? Functional is what we get on the exam. This is your range of motion your strength of certain positions or motions hurt. ‘When did it start?’, comes from the history, but function, again as a testable measurable category, is mostly range of motion and strength. Metabolic is another category. This tells us, do you have an inflammatory disorder, what is the–you know you have diabetes, what is the chemical environment in your body and in your low back tissues? And then there’s a psychological component. If you have pain that can be stressful and that can have stress impacts on your life. What we’re talking about what psychology here, is more ‘this is causing your back pain’. So structural and functional deficits have psychological results, but also the psychological problem can come first and it manifests as back pain. 

So these are the four categories. An MRI doesn’t tell me anything about your ability to function, it doesn’t tell me anything about your chemical status, it doesn’t tell me anything about your thoughts and feelings and mental processing. So MRI is a structural component that needs to be integrated into these other three components because without the MRI, you don’t know this category [screen gesture at 8:58]  is one big question mark. You can assume because someone’s young that they’re less likely to have degeneration, which is great on a population statistic basis. But any given patient– we’ve all seen ugly MRIs on 16-year-olds, 12-year-olds, right? So you can have a working assumption for a short period of time which again, is why the MRI–after six weeks of not knowing what’s wrong and failed conservative care, that’s when you go okay let’s get a look at this structural problem. 

Dr. Carl Nottoli:  I really like the added statistics, so it’s a lot more powerful to have a graph. And one in ten, you know, people or ninety percent of people don’t get a diagnosis and don’t know why they have back pain. That’s something we take for granted, but something way too many patients have to live through on a daily basis.

Dr. Matt Lytle: I do appreciate the components you’re bringing up the MRI, on the fact that all it does is show you pictures of what structure looks like and that it is a big question mark if you don’t know the structure. But so many people link everything. [They think] that ‘if my MRI is fine then I should be fine’ and vice versa that ‘if my MRI is bad and there’s no hope for me’. So there’s a huge emotional component tied into what is on that picture and it’s only a portion of the story…

[End of 10-minute transcript. See the full video for more information]

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