low back pain disability worse with early MRI

 A systematic review and narrative synthesis was just published on the association between early MRI and length of disability in patients with acute lower back pain (see low back pain early MRI inc disability BMC2021  in dropbox,ordoi.org/10.1186/s12891-021-04863-9). Thanks to Pooja Raval for alerting me to this article 

 

Details: 

-- 7 US studies were included (3 used the same study population) that had good methodologic quality, comparing early MRI of the back versus guideline recommendations: 4 to 6 weeks of conservative management of acute low back pain if no clinical suspicion of serious underlying conditions (red flags: suspected fracture, tumor, infection, and neurological deficit)

-- the number of participants in the studies ranged from 98 to 59,360 people, with a total of 64,232 low back pain cases overall

-- mean age 40, 70% male

-- all studies included those with uncomplicated low back pain, as identified by ICD-9 codes, nature of injury codes, or combinations of body part and nature of injury codes

-- early MRI was defined as one done within 30 days of seeking medical care, with one study using 6 weeks

-- length of disability was defined as total number of days of continuous paid indemnity (lost wage replacement for temporary total or temporary partial lost days)

-- all studies used workers' compensation program administrative and medical billing databases

-- main outcome: length of disability (LOD), comparing those who had early MRI (eMRI) versus not,  according to guidelines as noted above

 

Results: 

-- length of disability (LOD):

    -- 3 retrospective cohort studies found that comparing having eMRI versus not, eMRI was associated with an increased LOD: increasing from 9.4 days (8.5-10.2) versus 13.7 days (13.0-14.5) at the end of one year of follow-up

    -- the remaining 4 studies found there was an increased hazard ratio of work disability in those receiving eMRI: results ranging from HR 1.75 (1.23-2.50) to HR 3.57 (2.33-5.56) versus those not having eMRI

 

-- One study controlled for potential MRI indication bias using the propensity of belonging to the eMRI group, based on demographic and severity indicators, with similar findings to the overall group

 

Commentary: 

-- low back pain ranks first globally among all diseases in terms of years lived with disability, with an estimated age-standardized point prevalence of 7.5% in 2017, and with costs per year in the US at more than $100 billion and increasing

    -- and the effects of low back pain are profound: clinical and social effects for the individuals involved as well as their families, community, and the workforce

 

-- a few documented issues around back MRIs:

    -- MRI findings of age-related degenerative changes are prevalent in people without any low back pain, including some pretty severe MRI changes found in asymptomatic people

    -- there is no apparent relationship between MRI changes in the lumbar spine and pain intensity, health-related quality of life, and depressive or anxiety symptoms

    -- in those with low back pain, lumbar imaging overall in uncomplicated acute low back pain does not improve clinical outcomes

    -- one study found an unadjusted increased length of disability of 102 days versus 13 days, comparing those with eMRI versus not

 -- and, based on abnormal eMRIs, there is likely unnecessary interventions including surgery, epidural steroid injections, physiotherapy, osteopathy, and hospital admission

    -- an observational study done earlier this year found early that ordering an early MRI after first weeks of a new episode of uncomplicated nonspecific low back pain was associated with a 13-fold increased risk of surgery, increased opioid use, subsequent increased pain, and cost (see http://gmodestmedblogs.blogspot.com/2021/02/low-back-pain-dangerous-to-get-early.html ) 

 

-- however, despite the guidelines and this array of documentation, eMRI has been reported in 27.7% of patients with acute low back pain (21.3-35.1%)

-- this study found a quite consistent relationship between eMRIs in patients with uncomplicated low back pain, including those who had radicular symptoms, with pretty profound differences in their length of disability

 

  

 Limitations: 

-- this study only used Workers' Comp databases, and did not include either workers who did not have access to Workers' Comp, non-work-related low back pain or other people who had low back pain, limiting generalizability to the broader population (common, since 70-80% of people have low back pain at some point in their lives, many of whom are workers but have low back pain disability from a non-work cause and would not be in these databases)  

    -- also, the calculated length of disability was taken from the Workers' Comp data, and was based on termination of wage replacement. But, wage replacement does not necessarily mean complete recovery or returned to work: many work (and need to work), so they go back to work with some disability and the databases would not reflect that)

-- There was no granular information on the level of functional disability, work accommodation, the demographics of the population, etc; all making it difficult to generalize the results to the individual patients we are seeing 

-- the study also used ICD-9 codes for uncomplicated low-back pain, which not might accurately reflect the true clinical conditions. Two studies in the meta-analysis used ICD-9 codes that reflected the nature of the injury (mild or major sprain/strain) to classify low-back pain as uncomplicated. 

-- there was no information on why certain patients had eMRIs done: was this because of clinician unawareness of the guidelines, patient’s insistence for an imaging study, litigation issues (especially since these were all Workers' Comp patients), or clinician unawareness of the discordance between eMRI findings and clinical outcomes

-- and, as with all meta-analyses, this combination of seven different studies does reflect different exclusion and inclusion criteria, or differences of the definition of eMRI (one study used six weeks, the others 30 days after seeking medical care). the timing of the eMRI was from initiation of care and does not necessarily reflect onset of symptoms, but probably mostly does. However, on plus in using the Workers' Comp databases is that it does create a more uniform population than is found in most meta-analyses

 

So, another study showing that early MRI, within 4 to 6 weeks after an uncomplicated acute low back pain episode seems to lead to increased length of disability. This complements the findings of a study earlier this year finding a dramatically increased risk of surgery, opioid used, subsequent increased pain, and cost with eMRIs: see http://gmodestmedblogs.blogspot.com/2021/02/low-back-pain-dangerous-to-get-early.html . And, these studies reinforce the obvious conclusion: low back pain is remarkably common, has huge associated disability to the patient and society, and there really needs to be important ergonomic workplace changes to minimize back pain injuries in the first place. And, there should be public health initiatives to increase the awareness of this problem in the community and encourage back stretching and strengthening exercises as well as techniques to minimize the risk (eg, learning to lift heavy objects by bending knees instead of stooping over…)

 

geoff

 

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