How early to order CT or MRI for back pain?

[injuryupdate]

Just found the following very interesting free full text article on the web:

http://radiology.rsnajnls.org/cgi/co...full/231/2/343

Basically concludes that for chronic back pain, the influence of ordering a CT scan or MRI scan is that:

(1) Management doesn't really change
(2) However, despite (1), patients have a slightly improved outcome in terms of pain.

Therefore treatment is the same, but because the explanation to the patient of what is going on has been better with the scanning, they are generally happier with treatment and therefore improve a bit quicker.

Conclusion: Should this management therefore be routine?

In an ideal world, yes. But is it cost effective?

[hhh]

I think it comes down to this.
* If you have even the most tiny ounce of EBM running through your veins, don't order the imaging.
* If you have no inclination to EBM, current evidence or best practices, order the imaging.

[Unregistered]

The Gilbert paper seems to be the first EBM which really does show a benefit for ordering MRI or CT scan - it is an RCT which does show improved pain scores (significantly) in the intervention group. However, there may be an 'imaging placebo' effect. Hard to do a control without an imaging placebo (?maybe send to a Chiro and get the 'alignment' of the lumbar spine assessed).

Another good free web paper which is more sceptical about imaging:

http://www.racgp.org.au/afp/download...601yelland.pdf

[South Sydney Sports Med]

This is also not a bad review (of management) although technical in Bogduk's typical style:

http://www.mja.com.au/public/issues/...og10461_fm.pdf

[hhh]

To save everyone reading the Bogduk paper, I'll summarise. No therapy works. Live with it or refer to me for blocking procedures which I have proved in a non-randomized trial. That's the gist of it.

[Dr J]

I will soon be introducing to injuryupdate an ID system where you will need 100 points of ID to secure the user name you wish to use (Doug Stewart, yours arrive in the mail today). There has been reports that there are people on this website impersonating other individuals and medical clinics through falsification of user name. It is extremely unlikely that a Bogduk, Bahr, Mafulli or Olympic Park Sports Medicine Centre would ever waste their time on this site, so if you see their name floating about, take their opinion with a grain of salt.

Dr J

[hhh]

The differences between the group are minimal and do not reach a p<0.01 value, which for a study of this size should be the gold standard. Furthermore this is a difference between "statistically significant" and "clinically significant". There is no mention of the score change required to prove clinical efficacy. There was virtually no change in the quality of life, which is an important measure of chronic pain scenarios. Lastly have a look at the cost for change in QoL - $2124! (which coincidently, if you did send to a chiro this is probably the fees they would get charged). So it depends how you look at the paper, half full or empty. A fair assessment of it could be that imaging produced no clinically significant change and cost a truck load.

The Gilbert paper seems to be the first EBM which really does show a benefit for ordering MRI or CT scan - it is an RCT which does show improved pain scores (significantly) in the intervention group. However, there may be an 'imaging placebo' effect. Hard to do a control without an imaging placebo (?maybe send to a Chiro and get the 'alignment' of the lumbar spine assessed).

Another good free web paper which is more sceptical about imaging:

http://www.racgp.org.au/afp/download...601yelland.pdf

[injuryupdate]

In case anyone hasn't noticed, we have a 2-tier health system in Australia. The summary of the Gilbert paper should be:

In the Medicare bulk billing FOC health system - imaging of moderate chronic back pain doesn't change management so not worth doing.

In the private health user pays out of pocker system - if you want an MRI of your back, it will probably result in you getting a better understanding of why you are in pain, which might help you get over it more quickly, although it is going to cost you $250 out of pocket for this peace of mind.

[hhh]

Although there are other factors in good patient management...

Hirsh AT, et al. Clinical Journal of Pain. July/August 2005; Vol. 21, No. 4, pp. 302-310.

Patient Satisfaction With Treatment for Chronic Pain: Predictors and Relationship to Compliance

Objectives: Patient satisfaction with treatment has been extensively researched in a variety of medical patients. However, satisfaction with treatment of chronic pain has received considerably less attention. The present study sought to identify the predictors of patient satisfaction with treatment of chronic pain. In addition, the relationship between patient satisfaction and compliance with treatment recommendations was explored.

Methods: One hundred eighty patients (84 men and 96 women) seeking treatment of chronic pain at University of Florida pain clinics were recruited for this telephone follow-up study.

Results: Satisfaction ratings were generally high, with ratings of satisfaction with care significantly higher (t(179) = 9.58, P < 0.001) than ratings of satisfaction with improvement. Aspects of the patient-provider interaction, pain relief, and anxiety at treatment onset predicted satisfaction with care. These same variables, with the exception of anxiety, also predicted satisfaction with improvement. Those patients who were more satisfied with their improvement were also more compliant with treatment recommendations, and this relationship was stronger for health care provider-rated compliance.

Discussion: Results suggest the importance of distinguishing between satisfaction with care and satisfaction with improvement in assessments. Satisfaction with treatment of chronic pain is not merely a matter of pain relief. To increase the probability of treatment success and satisfaction, attention to the interpersonal aspects of the health care provider-patient relationship appear critical. Explanations for satisfaction's stronger relationship to health care provider-rated compliance were discussed.

[Spedide09]

how much does an MRI scan cost in melbourne coz i may need to get one in about a month once i see the surgeon again towards end of september. Last time i had an MRI it cost me 60 coz i had a health care card. But now i dont have one and would like to know how much ill most likely be in for.

Also, is there much of a waiting list? or can you get in pretty quick?

thanks