Treatment for back pain

MRI Is Sending People to Surgery Who Don’t Need It

All too frequently, a medical study comes across my desk that says patients are too often choosing to have elective orthopedic surgery. In a recent paper, doctors found that more than 50% of the patients would have a spinal surgery if their doctor told them they had an abnormal spinal MRI, even if they had no pain or restricted movement. The authors surmised that patients overemphasize the value of MRIs and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management. (1)

Doctors analyzed the most frequently cited papers in lumbar spine surgery and measured their impact on the entire lumbar spine literature. Here is what they found: The most cited paper was “the classic paper” from 1990 that described magnetic resonance imaging (MRI) findings in individuals without back pain, sciatica, and neurogenic claudication (impairment), showing that spinal stenosis and herniated discs can be incidentally found when scanning patients. (2)

The word “incidental” meant that the patient had no pain. The purpose of the paper was to examine why people with no back pain show abnormalities on MRI. More than a quarter of a century later, doctors are still citing the paper and asking the same question: “Why does this patient have clear problems on MRI but no back pain?” And the secondary question: “Should we send this patient to surgery?”

The second most cited (and far more recent) study similarly showed that patients who had no symptoms of back pain who underwent lumbar spine magnetic resonance imaging frequently had lumbar degeneration and disease.(3)

The two most cited research papers in relationship to spinal surgery are studies on why patients had absolute and clear spinal problems on MRI and yet showed no signs of pain or expressed any problems.(4)

I often see patients who have severe back pain and show me an MRI, X-ray, and/or scan that was inconclusive. For instance, a patient can have muscle spasm from a simple back strain, which can cause excruciating pain and may limit the ability to walk or even stand. Conversely, a large herniated disc may be completely painless. Yet the patient with the large herniated disc may be sent to surgery. Why do we see so many failed back surgery patients? Because lower back pain is one of the most difficult complaints to accurately diagnose and treat. The reason for the insurance diagnosis code of “Failed Back Surgery Syndrome” is that so many back surgeries fail.

As the research above has shown, magnetic resonance imaging (MRI) for back pain remains controversial because a considerable proportion of patients may be classified incorrectly by MRI for lumbar disc herniation and spinal stenosis.

Not only that, but doctors writing in the European Journal of Pain reported that while the importance of MRI findings remains controversial, best evidence does not support the use of any prognostic test in clinical practice in selecting patients for lumbar spinal fusion.

This supports recent findings that despite doctors frequently requesting MRIs for the lumbar spine, the imaging performs poorly and is not likely to identify the anatomical structures that are the
source of pain.(5) This is why a physical examination, not an MRI, is the main diagnostic tool I employ. While MRI is used as an ancillary confirmation, it is most often wrong when used solely on its own as a diagnostic tool.(6)

Recently, doctors in Canada found that more than half of lower-back MRIs ordered at two Canadian hospitals were either inappropriate or of questionable value for patients. And family doctors were more likely to order these unnecessary tests compared to other specialists. The findings are important, because in some parts of Canada, MRI tests for the lower back account for about
one-third of all MRI requests. Across the country, wait times for MRIs are long, and patient access is limited.(7)

From another study from the University of Connecticut Health Center: “More than 85% of patients seen at primary care practices 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.”(8)

This evidence confirms that clinicians should refrain from routine, immediate lumbar imaging in patients with nonspecific, acute or subacute lower back pain with no indications of underlying serious conditions. Specific consideration of patient expectations about the value of imaging was not addressed here; however, this aspect must be considered to avoid unnecessary MRI imaging while also meeting patient expectations and increasing patient satisfaction.”(9)

In another recent paper, researchers concluded that at present, best evidence does not support the use of any prognostic test in clinical practice in selecting patients for lumbar spinal fusion.(10)

But MRI Is Suggesting Fusion Surgery for Sacroiliac Joint Dysfunction—Shouldn’t I Get the Surgery?

In one research paper, doctors concluded that sacroiliac joint spinal fusion for the management of chronic lower back pain is “murky,” and that the consequences of the unsupported enthusiasm for surgical management of disc-related back pain negatively impacts the public perception of spinal surgeons.(11)

There is a further double jeopardy for patients—new research questions whether or not MRI has any value in determining sciatica treatment or diagnosis.(12) We now have a possibly misleading MRI sending a patient for a procedure that may not work, causing the patient more problems.

As noted in the above recent study, researchers have shown that diagnosis of sacroiliac joint dysfunction is flawed.(13, 14) This misdiagnosis is why doctors say that the sacroiliac joint spinal fusion for the management of chronic lower back pain is “murky” and can lead to Failed Back Surgery Syndrome.

One of my patients is a woman in her early seventies. She presented with her husband after not one, but two sacral fusions, one on the right and one on the left. You might be appalled if you saw the amount of metal that was used to do the fusion. Huge screws, too. Because of continued pain on the left side, her surgeon wanted her to redo the left fusion. She came to me for advice. During examination, I pressed on her gluteus muscles, away from the fusion site and she winced in pain. I immediately told her that her pain was not coming from the sacroiliac joint, and that she simply
had a strain where the muscles were attached to the pelvis. I asked her if the surgeon actually examined this area and to my astonishment, her answer was, “no.” She and her husband looked like deer in headlights, confused as to what I was telling them. How could her pain not be related to the joint, and the subsequent fusion, when she had surgery for that issue. I told them I was sorry, but the surgery never needed to be done if this is where the pain had been. It took about a half hour for them to digest this information, and we proceeded to inject PRP though the muscles down to the bone interface. We call that the enthesis. She returned two weeks later, and was about 50% better. I injected again, and expect full recovery with one more series of injections.

This is the most common scenario in my office. Not necessarily the same area, but almost all areas of the body. Please remember, elective surgery means you, the patient, get to elect whether or not to proceed to surgery. It is your body. You own it. You decide, not the doctor.

If It Isn’t the Discs, Then What Is Causing Your Back Pain?

A recent study in the medical journal Pain Medicine questions the prevailing thought that discs are a major culprit in back issues. The researchers wrote: “Between 26% and 42% of chronic low back pain is attributed to internal disc disruption of lumbar intervertebral discs (i.e., a disc problem in the lower back). These prevalence estimates and data characterizing discogenic pain originate largely from research conducted 20 years ago. With few studies since, their concordance with rates in community practice has rarely been addressed.”

The researchers had some doubts about these numbers. In conducting their own tests, they found that discogenic pain was not as prevalent but was still within the confidence intervals previously
reported (meaning in the ballpark), owing to the fact that they discovered discs as being responsible for pain 21% of the time.(15)

If this is the case, then it can be said that something else is causing your back pain 79% of the time. As we have discussed, one of the great challenges in treating back pain is identifying the source of the patient’s pain. As I indicated above, the majority of patients believe that the source of their pain has been identified by their MRI. However, in many patients the picture of disc degeneration is not an accurate profile of the cause of pain. Most often, I find that it is the spinal ligaments that are involved—in other words, the pain is being caused by a simple “sprain.” I ask patients
whether they have ever had a sprained ankle. Most say yes, and that it hurt quite a bit. I then tell them that they have the equivalent of a sprained “ankle” in their back, and nothing more, regardless of what the MRI or other films show. Do people get surgery for a sprained ankle? Of course not!! This is not to say that surgery may be needed for a tendon or ligament rupture, or fracture.

This is difficult for people to understand, because they see their MRI with an apparently “obvious” abnormality that requires surgical intervention. However, once they have had a physical examination and are shown where the pain is being generated, patients come to understand that their back pain may be based on ligament irritation at the point where the ligaments attach to bone (enthesopathy). A treatment plan with realistic expectations can then be discussed using regenerative medicine injections.

1. 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.
2. Steinberger J, 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. doi: 10.1097/BRS.0000000000000847.
3. Wassenaar M, van Rijn RM, van Tulder MW, et al. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J. 2012 Feb;21(2):220-7. Epub 2011 Sep 16.
4. Steinberger J, 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. doi: 10.1097/BRS.0000000000000847.
5. Steffens D, Hancock MJ, Maher CG, Williams C, Jensen TS, Latimer J. Does magnetic resonance imaging predict future low back pain? A systematic review. Eur J Pain. 2013 Nov 26. doi: 10.1002/j.1532-2149.2013.00427.x.
6. Balagué F, Dudler J. [Imaging in low back pain: limits and reflexions.] Rev Med Suisse. 2013 Jun 26;9(392):1351-2, 1354-6, 1358-9.
7. Emery DJ et al. Overuse of magnetic resonance imaging. JAMA Intern Med. 2013 May 13;173(9):823-5. Doi: 10.1001/jamainternmed.2013.3804.
8. 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.
9. Andersen JC. Is immediate imaging important in managing low back pain? JAthl Train. 2011 Jan-Feb;46(1):99-102.
10 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 orthopaedica. 2013 Feb 1;84(sup349):1-37.
11. Shaffrey CI, Smith JS. Editorial: Stabilization of the sacroiliac joint. Neurosurg Focus. 2013 Jul;35(2 Suppl):Editorial. doi: 10.3171/2013.V2.FOCUS13273.
12. el Barzouhi A, Vleggeert-Lankamp CL, Lycklama à Nijeholt GJ, Van der Kallen BF, van den Hout WB, Koes BW, Peul WC; Leiden-Hague Spine Intervention Prognostic Study Group. Predictive value of MRI in decision making for disc surgery for sciatica. J Neurosurg Spine. 2013 Dec;19(6):678-87. doi:10.3171/2013.9.SPINE13349. Epub 2013 Oct 18.
13. Rupert MP, Lee M, Manchikanti L, Datta S, Cohen SP. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician. 2009 Mar-Apr;12(2):399-418.
14. Hansen H, Manchikanti L, Simopoulos TT, Christo PJ, Gupta S, Smith HS, Hameed H, Cohen SP. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2012 May-Jun;15(3):E247-78.
15 Verrills P, Nowesenitz G, Barnard A. Prevalence and characteristics of discogenic pain in tertiary practice: 223 consecutive cases utilizing lumbar discography. Pain Med. 2015 Aug;16(8):1490-9. doi: 10.1111/pme.12809. Epub 2015 Jul 27.



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