Do I Need an MRI?

With healthcare costs skyrocketing and most insurance policies transitioning to a high deductible, determining medical necessity has growing importantce. As physical therapists, we are frequently asked, “Should I get an MRI?” Believe it or not, the common answer is no. Most orthopedic clinicians (MD’s, PT’s, DO’s) use an MRI to confirm a diagnosis after an examination. In the future you’ll likely see less MRI utilization as the expensive test rarely influences your course of conservative treatment. In fact, the addition of an MRI, especially too early on in treatment, increases medical costs while having minimal to no effect on your treatment program or outcome.(1)

Most patients express the need to know “what’s going on” with their back, neck, shoulder, etc. You’ll assume that the test would not only rule out the bad stuff (cancer), but also help your physical therapist decide the best course of treatment. We appreciate how debilitating and frightening an acute injury can be; however, your thought process should focus on early treatment, not postponing treatment until your imaging has been completed. In a study focusing on back pain patients, one month of conservative treatment, physical therapy for example, coupled with the body’s natural healing process was enough to heal 50% of cases alone.(2) In fact, another study found that low back pain patients seen within two weeks of onset had lower rates of advanced imaging (30% lower), another MD referral (28% lower), injections (10% lower), opioid use (7% lower), and lumbar spine surgery (5% lower).(3)

Seeing a physical therapist for low back pain within the first two weeks after onset decreases your total cost of care by $2,700(3)

You’ll need to buy into the fact that the MRI doesn’t drive your course of treatment. Treatment is always based on evaluation, as your PT moves you or asks you to perform guided movements. Two unique patients who both suffer from low back pain may have MRI confirmed disc herniations; yet, treatment for these two individuals will likely differ. A study by Webster et al confirmed that MRI’s, especially early MRI’s (received within the first month), do not provide information that improves treatment decisions or outcomes.(1) On the other hand, MRI’s have been found to lengthen the healing process, increase medical costs, and increase the chance of premature surgery.(1)

Now, it is not to say that MRI’s are irrelevant. When examining a patient, the clinician may suspect a “red flag.” These red flags are cues to the examiner that something more serious may be present. For example, an MRI is needed to rule out less common pathologies, like cancer. An MRI can also be used if conservative treatment is not progressing as suspected. It’s important to remember that an early MRI increases surgery rates not only at the lower spine, but also elsewhere. Recent research by Yim et al found that after a two year follow up between patients undergoing surgical repairs of meniscus tears (knee surgery) and patients receiving conservative treatment, there was no significant difference between knee function or patient satisfaction.(4) Again, I’m not preaching that surgery is never indicated, but conservative treatment should remain top of mind for regaining function.

Part of being a patient is being patient. Carve out four weeks before for conservative treatment before deciding on surgery or advanced imaging. You never know, your physical therapist may agree that you’re a surgical candidate or require an MRI, but at least you pursued the cost effective, less invasive avenue first.

References

1. Webster, Barbara S., et al. “Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain.” Spine 38.22 (2013): 1939-1946.
2. Vroomen, Patrick CAJ, M. C. T. F. M. De Krom, and J. A. Knottnerus. “Predicting the outcome of sciatica at short-term follow-up.” British Journal of General Practice 52.475 (2002): 119-123.
3. Fritz J, Childs J, Wainner R, Flynn T. Primary Care Referral of Patients With Low Back Pain to Physical Therapy. SPINE (2012): 1-8.
4. Yim, Ji-Hyeon, et al. “A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus.” The American journal of sports medicine 41.7 (2013): 1565-1570.

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