SAN ANTONIO, Tex. – Magnetic resonance imaging (MRI) is a poor predictor of low back pain (LBP) prognosis and should be reserved for a differential diagnosis in cases where there is a high suspicion of neurological injury, infection, or malignancy, according to Eugene Carragee, MD, director of the Orthopedic Spine Center at Stanford University, California, who presented at the American Pain Society's 25th Annual Meeting.

"Instead of reassuring the patient, aggressive diagnostic attempts may reinforce the suspicion of serious disease, magnify the importance of nondiagnostic findings, and label patients with spurious diagnoses, implying the need for specific treatment." —Eugene Carragee, MD
In a plenary address, Dr. Carragee, who is well-known for challenging the widespread use of lumbar fusion for LBP, also said, "Combined cognitive behavioral and conditioning programs with medical support may be the most effective treatment strategy [in patients with nonspecific diagnoses] and are probably of similar efficacy to surgical fusion or arthroplasty in the group as a whole."

 
"I think MRI is overused when looking for common degenerative changes as an explanation of LBP," Dr. Carragee told CIAOMed. "It is very good if the suspicion is for cancer or infection. For LBP without sciatica, MRI adds little to establishing a firm diagnosis if no infection or tumor is seen, and it gives many people a perception that there is a serious local disease in the spine when the report reads all these common degenerative findings are present. [However,] these do not correlate well with who has serious problems," he said.

According to Dr. Carragee, the "overwhelming majority" of patients with LBP do not have serious pathology on imaging studies. Most, like most subjects who do not have LBP, show signs of disc degeneration, anular disruption, and facet arthrosis.

"Prospective studies of MRI in subjects without serious LBP problems at baseline found that the subsequent development of LBP problems correlated poorly or not at all with baseline MRI findings. Rather, future LBP is most strongly predicted by psychological factors, social or occupational factors, or other chronic pain processes. New MRI findings that have developed over time were not well correlated with the development of new symptom type or severity," Dr. Carragee said. He warned that imaging done early in the course of an LBP episode is unlikely to improve either clinical or economic outcomes.

"Instead of reassuring the patient, aggressive diagnostic attempts may reinforce the suspicion of serious disease, magnify the importance of nondiagnostic findings, and label patients with spurious diagnoses, implying the need for specific treatment," Dr. Carragee asserted.

Attempts to identify and treat occult, local "pain generator" areas in the spine have not been very successful, and Dr. Carragee suggested that the difference between subjects who report no or only occasional LBP and those with similar imaging findings who claim severe pain and disability is due to central pain processes, psychological factors, social disincentives, and poor coping strategies, among other factors.

"Treatment and prevention according to this approach would be directed at restoring function and supporting adaptive techniques, as opposed to medical or surgical treatment of the common spinal changes," Dr. Carragee concluded. He told CIAOMed that the cognitive behavioral approach should consist of more than analgesics and conditioning. 

"The key is to reorient the patient to understand that LBP is very common and not dangerous, and the spine does not need to be overprotected. A poor coping attitude and fear avoidance behavior seem to be important obstacles to overcome," he said.

Reference

  1. Carragee E. Diagnostic evaluation of low back pain and disc degeneration. Presented at: The American Pain Society 25th Annual Meeting; May 3–6, 2006; San Antonio, Tex.