To MRI or not to MRI? That is the question.

The use of MRI as a means of imaging the body has become very common practice. Between 2014 and 2019 there has been a 16% increase in the use of imaging within the NHS. ^1. Most health insurance policies include a free MRI every year and even if paying for one themselves, the cost of an MRI has reduced to a point where it is no longer prohibitive for many patients. Believe it or not though, this may not be a good thing!!!

Regularly we get patients attending the clinic requesting an MRI on their initial appointment without having given conservative management (physiotherapy, activity modification, exercise) a proper chance. This is especially relevant when dealing with lower back pain. In 2011 Baras Sreirbati and Baker showed that access to MRI is strongly correlated with patients receiving MRI and having an MRI increased the chances of having surgery by 34%.

Cuff et al (2020) in their review estimated that a quarter of patients with lower back pain presenting to primary care will undergo diagnostic imaging and that the rate of imaging in primary care and in A&E departments has increased two-fold. But crucially, no difference has been seen one year down the line between those who have had a scan and those who haven’t when pain, function or quality of life are assessed.

They recommend that imaging only be used if serious pathology is suspected. The say that routine imaging is not recommended for patients with suspected arthritis or when following up with people who are known to have arthritis. If someone is not responding to treatment, then imaging can be considered but conservative management should be attempted first.

Horga et al (2020) performed MRI on 230 uninjured and asymptomatic knees and showed 97% of them to have abnormalities. Wasserman et al (2018) looked retrospectively at spinal MRI on 100 Olympic athletes who competed in the Rio Olympics. 52 of them showed moderate to severe spinal disease and yet were competing at the highest level.

The message is that imaging is a great tool but should be used wisely. It is currently overused and can lead to needless surgery, injections, consultations and not to mention big costs. The results of imaging regularly do not reflect the presentation of the patient. Considerable degenerative changes can be noted on an image, but the patient may have no pain and may have good function and vice versa. It is crucial that imaging be used strategically and as part of the overall picture and not as an isolated examination. It is also crucial that the language used to report on imaging be chosen carefully so as not to elicit catastrophising behaviour in patients.

If you have any questions on this topic or wish to discuss a specific problem you have with us please feel free to contact us.

John Casey MSICP MScSportsMed

References.

1. Cuff et al (2020) Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder: A scoping review, Musculoskeletal Care, 1-10.
2. Baras Shreibate & Baker (2011) The relationship between low back pain, magnetic resonance imaging, surgery and spending: Impact of physician self-referral status, Health Services Research, Oct., 46: 5.
3. Horga et al (2020) Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI, Skeletal Radiology, 49: 1099-1107.
4. Wasserman et al (2018) Evaluation of spine MRIs in athletes participating in the Rio de Janeiro 2016 Summer Olympic Games, BMJ Open Sports Exerc Med, 4, 1-7.