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The Lumbar MRI Dilemma
If you’ve got low back pain, you’re in good company. Low back pain is the most common musculoskeletal condition in the adult population, with prevalence up to 84%.[1] The use of advanced imaging (such as MRI) is dramatically on the rise, despite lack of evidence to support its benefit.[2]
The fact pattern may be familiar to many defense attorneys: the injured worker has a well-documented injury involving the low back, and the treater recommends a lumbar MRI shortly thereafter. In pushing for authorization for the MRI, the Petitioner’s attorney argues that the IME physician will be unable to visualize any pathology without the testing. At first, the argument appears to make sense, and seems innocent enough: Let’s just see what’s going on diagnostically, and we’ll go from there.
In many cases, a lumbar spine MRI recommendation is not warranted. Respondent attorneys should tread carefully in recommending to their client that they authorize the lumbar MRI, especially shortly after injury. The American College of Physicians and the American Pain Society published a joint recommendation that lumbar MRI is only warranted in cases “when severe progressive neurologic deficits are present or when serious underlying conditions are suspected”.[3] Most cases don’t meet those criteria.
Lumbar MRI’s performed too early may lead to unnecessary referrals and, potentially, to invasive procedures. More concerning is the potential impact of MRI findings on the injured worker’s self-perception of health. “Abnormal” findings on a clinical basis are widely prevalent on a lumbar MRI, even when a patient is asymptomatic. In one study, patients with back pain were randomized to either receive their MRI results or not. The patients who received the results were shown to have a diminished sense of well- being compared with the subjects who didn’t receive the results.[4] In short, being labeled as having a “degenerative condition” can itself lead to a poor outlook on health, fear avoidance patterns, diminished activity and even depression. In the world of worker’s compensation, those factors may translate into reluctance to go back to work, and perception that working is too strenuous.
Pay special attention to the following when a lumbar MRI is recommended by the treating physician:
Time lapse between injury and MRI recommendation: Most patients with acute low back pain, with or without radicular symptoms, have substantial improvements in pain and function in the first four weeks. Look carefully to see whether the treater has (1) done plain radiographs first and (2) exhausted conservative measures, such as physical therapy, before making the recommendation for MRI. If conservative treatment has not been exhausted, you may consider getting a Section 12 examiner sooner rather than later to address the condition of ill-being, analysis of medical treatment provided, and recommendations for further treatment. Alternatively, Utilization Review is a good way to address medical necessity of the MRI. The UR process adds a layer of insulation against penalties.
Mechanism of injury and symptoms: No fact pattern and work injury is the same. Look carefully at the medical notes post-accident to assess the severity of the symptoms and outline those symptoms (or lack thereof) in your IME cover letter.
Identity of the Physician recommending the MRI: Imaging will have the greatest value if a spine specialist is involved. If the MRI recommendation is made by the primary care physician, and the injured worker is in the pain clinic shortly thereafter, red flags should be raised, and caution should be taken in authorizing the MRI. Again, get an orthopedic expert involved, for the benefit of all parties.
MRI Facility/Location: If the MRI is going to be done, you may advise your client to try to get involved in the MRI facility choice. The cost of an MRI can vary dramatically, depending on whether the MRI is done at a hospital versus an imaging facility. Imaging facilities can usually provide substantial savings, due to the lack of operational and overhead costs, without compromising quality. Wherever the MRI is done, it is always a good idea to provide the films to your IME physician.
As a final note, look at the big picture, take the time to weigh the options, and discuss the choices with your client. The objective for both parties should be to achieve a good medical recovery and healthy return to work for the Petitioner. That objective, it seems, might be better achieved by skipping the MRI altogether.
[1] Balagué F, Mannion AF, Pellisé F, et al. : Non-specific low back pain. Lancet. 2012;379(9814):482–91. 10.1016/S0140-6736(11)60610-7
[2] Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther 2011;41:838-46.
[3] Maus T. Imaging the back pain patient. Phys Med Rehabil Clin N Am. 2010;21(4):725-66.
[4] Id. at 728