BBC Health carries an article about a review of six trials covering 1800 patients which concluded that MRI scanning does not help in the management of normal low back pain and should be reserved for specific conditions such as nerve root lesions, infections and tumours. The outcome of low back pain is not improved by the use of scans and there were no differences between the two groups, one group with typical management and the other having an MRI scan at some stage. This was the same for the early outcomes and for up to a year after the onset of acute low back pai
Patient expectations are a very strong driver of imaging for low back pain, either x-rays or magnetic resonance imaging, and many patients ask their doctors and surgeons for this, thinking it will indicate what is wrong with their backs. Scanning is something you can do but studies indicate that MRI rarely shows up an important finding in a person's back which was not already suspected. Communicating with the patients about the treatment plan and answering their questions is harder.
Because it is an easy technological intervention the rates of MRI scanning are increasing, leading to lots of misconceptions and awkward questions, let alone the communication errors which many medical professionals commit when explaining the findings to patients. Most patients would agree to have an x-ray or a scan if offered, illustrating the mismatch between what can realistically delivered by imaging and what patients want.
The patient history of the presenting condition and the physical examination should give a clear indication of the type of back pain being dealt with and MRI scanning should not routinely used to confirm this. Scanning should occur for nerve root pain or to investigate the possibility of a serious condition rather than just to have a look at what is there.
Patient education is a vital part of the management of back pain, explaining the reasons for pain, the reasons for not ordering a scan and the treatment path to follow, with a trial of manual therapy, acupuncture and a structured programme of exercise. A pain management programme may be necessary to address all the aspects of having long term and chronically disabling pain.
It's too easy to be offhand in communicating with the patient when we are explaining the scan, what it means for the spine and for the treatment choices. We should not give patients concepts without explanation in the sense that we tell them things they interpret and make part of their world view without a careful explanation and answering of any questions they might have about the new information. An incorrect explanation can create damaging images and beliefs which limit what a patient will do to help the self management of their pain.
Much of the explanation to patients comes under the category of what I call concepts without explanation. We give a concept, a way of seeing things, to patients but we don't give them the accompanying information they need to make sense of it and incorporate it helpfully into their view of their back pain and its management. This is a very bad idea and has very unhelpful consequences as the patient's interpretation of their condition informs their whole self-management.
Careful explanation must be given if we agree to scan a patient otherwise the answers we give will bring their own problems. Once we agree to scan someone there must be a plan for what we are going to do next. There should be an opinion we can access without delay as an MRI scan on its own has little relevance, it needs to be interpreted, explained and acted upon. Much of the frustration comes from the patient's expectation about what can be shown on the scan and when, as is overwhelmingly the case, little of diagnostic value emerges, there is a feeling of what's next?
