Hey folks, once again I didn’t write this, but I think this discussion needs to happen. Too many patients of mine want an MRI at the first sign of pain.
The actual link to this article is http://www.dotmed.com/news/story/10496#
MRI Availability Linked to Possibly Unnecessary Back Surgery
October 20, 2009
by Brendon Nafziger, Writer
Ready availability of MRI scanners is linked with MRI use and controversial surgeries to ease lower back pain.
In a report published online in Health Affairs last week, researchers at Stanford Medical Center found, after poring over 666,000 Medicare claims drawn from a seven-year period, that areas with a high per capita concentration of MRI machines had a slight uptick in the number of patients undergoing MRI scans and back surgeries for nonspecific lower back pain.
The problem, the researchers say, is that the emerging scientific consensus suggests that MRI scans and surgery are unnecessary for lower back pain that has no obvious cause.
“Most low back pain, at least new onset, that is not really severe will get better by itself,” Laurence Baker, co-author of the study and a professor of health research and policy at Stanford, tells DOTmed News. “Surgery has lots of complications, and it doesn’t always work.”
And MRI scans are discouraged, too, because of their tendency to register false positives.
“One of the most interesting pieces of information on low back pain,” Dr. Baker says, “is if you scan a bunch of people with a healthy back, one in five… will have something on their MRI that looks like a problem to their doctor.”
Numbers are small but worrying
In their report, the researchers suggest that, according to their data, each additional MRI scanner in an area results in 40 additional lower-back scans, and living in a high-MRI density area would increase your chances for undergoing an unneeded scan by around two percentage points.
While that might not sound like a lot, if the results are extrapolated to the whole Medicare population, it translates to around 6,400 more scans in the period studied than there would have been if all areas had low-MRI density, the researchers say. And because MRI scans for this condition are so closely linked to back surgeries, the researchers argue that almost 3,500 of the seemingly superfluous surgeries would have been prevented if everyone lived in MRI barren regions.
Why does the link exist?
Dr. Baker believes the MRI-surgery connection for lower back pain comes from what he calls the “treatment cascade.”
In this scenario, the patient goes to his doctor with lower back pain. If the doctor is in an area with easy access to MRIs, he might be more likely to order a scan of the patient’s lower back. During the scan, he discovers something abnormal.
“You don’t know if [the abnormality] is causing [the pain], but you have the scan,” Dr. Baker says. “You have a thing to do. And having a thing to do becomes a fairly powerful motivator.”
“The MRI creates the information,” he adds, “and certainly creates the foundation for surgery.”
Thank you Charles. From your link:
“Approved a change in status for the Dartmouth Medical School Section of Neurology to Department of Neurology.”
Hot off the press.
Just in case “former res” needs a little clarification (note publication date):
http://www.dartmouth.edu/~news/releases/2008/11/08.html
I wouldn’t say my comments are “awaiting moderation.”
More like they “failed moderation.”
Hello moderators – kindly post my post #14 – and go ahead and delete this one. thanks.
I was searching for the mystery man you described at Dartmouth and, not knowing his name – attempted to search by department – and yes – no dept of neurology is listed in the link I sent you. If you have other information, kindly send it along. Otherwise, there’s no evidence it exists. Think outside your little box.
If they guy you mentioned is an MD – then you didn’t tell a “whole truth” and your statement misrepresented his credentials. Aside from a degree in chiropractic, he may also have been an Eagle Scout. He’s an MD and that would be expected. The rest is not relevant. (Yes I know about multiple degrees – many MDs are also MBAs too.)
And I do expect others to support their statements. Why should I do your research? Prove your own point – which you have failed to do. And see what you actually learned when you did it? That’s he’s an MD – though he may also have taken a basket weaving class in high school! Who cares?!
How does Brian like his coffee?
You really should do your own research before speaking. I mean, seriously, you need proof that there is a Dept of Neurology at Dartmouth College’s School of Medicine? I really don’t feel the need to go tit-for-tat on this type of thing with someone like you but I might as well finish you for good.
I do feel the need to apologize, however, as I was mistaken on one point before. The chiropractic physician at Dartmouth is actually the chair of the Dept of Anatomy at Dartmouth College’s School of Medicine. I trust you’ll agree a medical school would have a dept of anatomy without my providing proof, correct? His name is Dr Rand Swenson. He also has an MD and PhD. In his bio you’ll see he recieved his DC degree at NHSU back in 1975 before continuing his education and also getting a Phd and then MD. Quite a learned and brilliant scholar. In higher academic circles it is quite common to get multiple degrees. I guess you can look at his link here if you need someone else to do the research for you after you speak first.
http://dms.dartmouth.edu/faculty/facultydb/view.php?uid=1888
Now moving on. I will not bother to provide the links to the piles of studies showing the efficacy and cost effectiveness of spinal manipulative therapy as they are readily available on any lit search engine. Do your own research before hanging your assumptions out for all of us to see.
Regarding just a few of the prestiguous positions held by chiropractors in the country I will help you along a little and hopefully quiet you down a a bit. There are many more than these but you can start here as all of them have appeared prominently in national media.
Rand Swenson, DC, PhD, MD, Chair, Dept of Anatmoy, Dartmouth College School of Medicine
Bill Morgan, DC, Attending Physician, US Capitol Health Services Unit and Bethesda Naval Hospital
Michael Reed, DC, Medical Director, US Olympic Committee
Anthony Lisi, DC, Chair, Department of Veteran Affairs, Department of Chiropractic, oversees chiropractic physicians at 30 VA hosptials.
Brian Nathanson, DC, extraordinary blogger.
So, there ya have it.
I sent you a link showing the departments. You’ve provided no links to support anything you’ve said here. Surely you can provide a link to this faculty member. If he exists that is.
I called your bluff. Sorry if that upsets you. All you want to do is talk but never provide anything to back it up.
Go to the Dartmouth website and show me the link to the chiropractor – head of neurology. It isn’t rocket science. (I looked for it and couldn’t find it.)
There is no neurology department at the Dartmouth school of medicine? Think about what you just said. You may want to fact-check your staement with “StraightDope.”
Defensive? Read my posts very carefully. You start attacking a very credible and responsible chiropractor for absolutely no reason and I merely set your distorted and factless comments straight. I encourage you to keep speaking. It only helps my side of this debate.
There is no department of neurology at Dartmouth Medical School. I won’t bother attempting to verify your other “talking points.”
http://dms.dartmouth.edu/about/academics/
As far as there being many studies “verifying” the value of chiropractic – you guys are understandably on the defensive. Me thinks you protest too much.
Mr/Ms “former res”- Still, why not identify yourself?
Anyway, there is ample evidence that chiropractic is safe, effective and less costly in the management of most musculoskeletal conditions. Did you know there are 4 times more studies demonstrating the efficacy of spinal manipulative therapy than there are regarding the treatment of dental caries by dentists. Are you familar with recent Mercer study that demonstrated the clinical and cost effectiveness of chiropractic? It was done by a Harvard medical researcher obviously without any chiropractic bias.
Did you know the US active military and Verterans Affairs programs employ chiropractic physicians in their hospitals? Did you know there is a chiropractic physician treating members of Congress in the health services unit at the US Capitol? Did you know the Medical Director for the US Olympic program is a chiropractic physician? Did you know the Chairman of the Dept of Neurology at Dartmouth Medical School is a chiropractic physician? I bring this up because you seem to think we lack some level credibility. Between these facts and the ever growing research I think we are able to demonstrate otherwise.
To answer your question about the hypertension study I really am not surprised by it but since it was a small and only preliminary study done at the University of Chicago school of medicine I really cannot get too excited about it. A responsible chiropractor would not hang their hat on that study yet.
I would suggest, however, you use more credible sources that “striaght Dope.”
Please continue.
“That is the problem we fix very well.”
What evidence do you have to support this statement. If relief occurs following your “fix,” that does not prove a causal relationship. B following A does not prove that A caused B.
In other words, most back pain is self-limiting; like the common cold – it will clear in 5-7 days – no matter what you do.
It goes without saying that your being a chiropractor is your own bias. (I am not a physician.)
What did you think of the link/article I attached? I thought it was generally reasonable. Interesting about the hypertension.
Mr “former res”- It’d be nice if you had the courage to identify yourself. I am a chiropractic physician.
The subject article does not explore the true dynamics of lower back pain. It is study demonstrating the over reliance of advanced imaging in direct correltation with the absence of good clinical diagnostic skills by most medical providers.
Yes, often times an individual episode of lower back will resolve without treatment. However, the article does not take into consideration that most patients who seek treatment experience multiple progressive episodes that interfere with normal daily activities. Sure, each individual episode can, but not always, self remit eventually if left alone. Much like the flu. However, what the patient typically experiences are multiple and progressive individual episodes of pain and dysfunciton that begint o blur together and seriously interfere with normal daily life. That is the problem they want fixed. That is the problem we fix very well.
So, if a patient were to have 2-3 episodes of the flu per month and there was a very effective, safe, and inexpensive way to fix the problem you would not advocate for that? Even though each individual episode of the flu would likely eventually self remit without treatment? Do you see a little clearer now?
Your bias is actually not helpful in this discussion. You would rather advocate for poor public health policy for the sake of your own bais and because you seem personally threatened in some way. I’m left wondering why?
I was up-front about my background and bias. Do we assume Dr Kane is not an MD?
As the article suggests, most low back pain resolves without intervention.
Can we agree this is fair article?
http://www.straightdope.com/columns/read/2771/is-chiropractic-for-real-or-just-quackery
Great post Dr Nathanson. Knowing that patients use your site for current information it is wise to continue to set the record straight when it come to conservative physical medicine. I think this study demonstrates what we have always seen in practice.
Patients with lower back pain tend to go to their primary care docs who almost always have no clue so they over-rely on advanced imaging such as MR. The results some back with a disc bulg that they immediately assume os the soruce of pain and the diagnosis gets in the system. A referral is made to an ortho or PT for eval and treatment of the disc bulge. All the while the literature (that most PCP’s and your friend “former res” are totally unfamiliar with) clearly shows a high prevalence of disc bugles in asymptomatic populations. Conversely many people with symtoms have no disc bulges. At the same time a completely different functional likely is creating the pain and dysfunction than what the MRI shows.
Now the patient is on the medical merry-go-round being treated for an MRI finding that many times, according to the peer reviewed literature, is totally irrelevant. The patient makes no progress with tens of thousands of dollars of useless physical therapy, drug therapies, and invasive procedures such as epidurals and sometimes even dangerous surgical procedures.
Once exhausted, battered, broken and drained of their cash they make their way to a good chiropractor and the problem is fixed in a few weeks. Why? Because the other providers were stuck staring at an irrelevant MRI finding and totally missing the functional deficits found during a good differential diagnostic examination.
And oh, Mr. “former res”…your bias is showing.
“Is that behavior any better that the chiropractors that you believe keep pitching for unnecessary treatments?”
No it isn’t any better. Is that the standard? You’re no worse than the other guys?!
“…unnecassary treatments?” It would appear so.
According to the study’s co-author, ““Most low back pain, at least new onset, that is not really severe will get better by itself.”
So, what do you bring to the table, beside googling and posting self-serving articles?
Funny, you are more intent on bashing chiropractic than the content of the article. What is your agenda? I regularly send patients for MRI when indicated. You seem to have an axe to grind with some very dated and fractured thinking. I have patients bring me MRI’s from surgeons who want to operate on asymptomatic bulging discs. Whats the point? If orthopedic tests and red flags are negative, why cut? Is that behavior any better that the chiropractors that you believe keep pitching for unnecessary treatments?
And again, doc, how could your patients’ getting an MRI possibly benefit your practice? Not at all. On the contrary – they’re continuing to visit you – and avoiding medical evaluation – is the best result for you and your business.
This is really a great deal. You don’t seem to have to write anything original – simply post things you find on the internet – and you get to advertise your business for free? Is that correct? I can’t really say I blame you for taking advantage of this gig.