How unnecessary Xrays, mri’s and ct scans make you stupid

Just this week it hap­pened again.

A new patient came in for an ini­tial con­sul­ta­tion. He had low back pain that spread down his right leg.

I per­formed an exam­i­na­tion that included pal­pa­tion of his spine and eval­u­a­tion of the func­tion of the sci­atic nerve. There was an extremely ten­der, com­pressed spot in his low back. One of his reflexes was dimin­ished and some of the mus­cles of his right foot were slightly weak.

Based on the exam, it was clear he had reduced func­tion of his sci­atic nerve. The most likely expla­na­tion was a bulging disc pinch­ing the nerve roots.

What’s The Treat­ment Plan, Doc?

Most doc­tors would agree on the basic out­line of the treat­ment plan for this patient. It has two main parts:

  • Con­trol the irri­ta­tion of the area, so swelling doesn’t worsen and pinch the nerve even more.
  • Improve the bio­me­chan­i­cal func­tion­ing of the low back to allow the spine to move freely with­out adding to the nerve pressure.

Though agree­ing on the impor­tance of thees two goals, doc­tors might dis­agree on the best ways to achieve them.

Some might sug­gest the use of anti-inflammatory drugs (NSAIDs) to con­trol the swelling. Oth­ers, who are more vig­i­lant about the pos­si­ble neg­a­tive side-effects of NSAID’s, would pre­fer to use ice and pro­te­olytic enzyme sup­ple­ments to con­trol inflammation.

Some might have con­fi­dence that a doc­tor of chi­ro­prac­tic would be the most qual­i­fied to help the patient improve bio­me­chan­i­cal func­tion­ing. Other doc­tors might think a phys­i­cal ther­a­pist is more qual­i­fied. Most would agree that a pro­gram of reha­bil­i­ta­tive exer­cise is vital.

In other words, the details might vary, but the under­ly­ing prin­ci­ples would meet with wide agree­ment. Before long, the patient would be on the direct road to recovery.

Med­ical Merry-Go-Round

Unfor­tu­nately, my patient didn’t begin on that direct road to recov­ery. Instead, he set up an appoint­ment with a spine spe­cial­ist. That’s a rea­son­able step.

Of course, before he could even go to his appoint­ment, the doctor’s office required him to have low back Xrays so that the results would be avail­able to the physi­cian at the time of his visit.

On the sur­face, there’s noth­ing unrea­son­able about that. The spine spe­cial­ist wants to know what’s going on, and hav­ing the Xrays taken in advance will save an extra step of the process.

Then, based on his ini­tial exam­i­na­tion, the spine spe­cial­ist decided the patient needed MRI’s. Noth­ing wrong with that – after all, an MRI is con­sid­ered to be the best way to visu­al­ize the archi­tec­ture of the inter­ver­te­bral disc. If the poten­tial diag­no­sis was a bulging disc, wouldn’t an MRI be needed to con­firm the bulge?

While he was down at the radi­ol­ogy lab for his MRI’s they decided to throw in a CT scan at the same time. I’m not sure what the ratio­nale was for that, but he did have fairly sig­nif­i­cant sco­l­io­sis, and a CT scan is bet­ter than an MRI at depict­ing bone anatomy, so per­haps his spine spe­cial­ist thought it was impor­tant to look at his bones, too. Or maybe they were wor­ried that he might have bone can­cer. (That’s never impos­si­ble, though pri­mary can­cer of bone is rare for an adult – more often can­cer of the spine has sec­on­dar­ily spread from the prostate, bowel, breast, or lung.)

Are We Get­ting Enough Dumb For Our Money?

After he had all these tests, did any infor­ma­tion emerge to alter the basic out­line of his two part treat­ment plan?

Not really.

If for what­ever rea­son he’s unfor­tu­nate not to achieve relief with a con­ser­v­a­tive pro­gram of care, he could ulti­mately become a can­di­date for surgery. Then, the spe­cific infor­ma­tion obtained from these tests will become invaluable.

In the mean­time, after all his test­ing, he still has to find a way to achieve the orig­i­nal two goals: quiet inflam­ma­tion and improve bio­me­chan­i­cal function.

After a nice merry-go-round ride, he’s back where he started.

A lot has already been writ­ten about the huge cost the coun­try is pay­ing for unneeded med­ical tests.

Here’s an exam­ple -  a quote from Robert Lan­greth in Forbes Mag­a­zine:

A third cat­e­gory [of spend­ing waste] is MRI and CT scans. Nearly 100 mil­lion are done every year, at huge expense. Some aren’t nec­es­sary. …Scans can drive up costs in an insid­i­ous way. Instead of resolv­ing the mat­ter, more often than you would think they yield ambigu­ous results that lead to expen­sive, inva­sive tests.

Go Ahead — A Lit­tle Bit (of radi­a­tion) Won’t Hurt You

The unnec­es­sary expense is bad enough.  But that’s only the first of three rea­sons why these tests are dumb. The sec­ond rea­son – the radi­a­tion expo­sure is killing us.

Dis­cover mag­a­zine reported on this issue in Decem­ber 2009:

A sep­a­rate study, pub­lished in …the Archives of Inter­nal Med­i­cine — cited those radi­a­tion lev­els [gen­er­ated by CT scans] and the fact that CT scans have grown tremen­dously (from 3 mil­lion in 1980 to 70 mil­lion in 2007) to try to quan­tify the dan­ger. Exclud­ing scans per­formed after a can­cer diag­no­sis and within the last five years of life, they cal­cu­lated that the scans would con­tribute to about 29,000 can­cers in the next 20 to 30 years. They also esti­mate that half that num­ber could die.

Of the great­est sig­nif­i­cance to me, how­ever, is a third rea­son to avoid these unnec­es­sary tests.

Back to the Future

When I went to chi­ro­prac­tic school, CT scans were pretty new things, and MRI’s were just begin­ning to be used out­side the laboratory.

These two tech­nolo­gies are brilliant.

We can now gen­er­ate exten­sive, spe­cific infor­ma­tion about the archi­tec­ture of your injured inter­ver­te­bral disc. The impre­cise guess­work vocab­u­lary I learned back in school to describe disc prob­lems (bulges, her­ni­a­tions, pro­tru­sions, seques­tra­tions, etc.) can now be applied with seem­ing exactitude.

Are we any bet­ter off?

Back pain is still a prob­lem of epi­demic pro­por­tions. Prob­a­bly worse than 30 years ago.  Ortho­pe­dic sur­geons still get rich per­form­ing surg­eries, many of which aren’t necessary.

There have been a few real improvements.

  • For one, the idea of bed rest for back pain, already on the way out the door thirty years ago, is not only out the door but dead and buried.
  • The con­cept of core strength to pro­tect the low back, though often incor­rectly applied, has rightly become a main­stay of ther­a­peu­tic exer­cise programs.
  • The use of spinal exten­sion exer­cises (back­ward bend­ing) has become a respectable com­po­nent of reha­bil­i­ta­tive exer­cise, sup­ple­ment­ing or in some cases sup­plant­ing pelvis tuck­ing or spinal flexion.
  • If you do need surgery, the sur­gi­cal pro­ce­dures are better-targeted and less invasive.
  • The method­ol­ogy of trac­tion, now renamed “decom­pres­sion,” has been upgraded and proven to be effective.
  • The role of exces­sive sit­ting as a major con­trib­u­tor to back prob­lems has become recognized.

That’s about it. Of course, other doc­tors would add things to this list. But all would agree on one thing: despite these advances, the state of low back care in this coun­try is still a mess. A big, $100 bil­lion per year mess.

Pay No Atten­tion To The Man Behind the Curtain

The third impor­tant rea­son to avoid unnec­es­sary CT scans and MRI’s is that they dis­tract us from more valu­able insights.

The bio­me­chan­i­cal func­tion­ing of your low back is the key to low back health. And guess what? Scans and MRIs don’t tell you any­thing about the way your spine is working.

  • What’s the flex­i­bil­ity of the low back?
  • How do you engage your core muscles?
  • What’s the joint play avail­able in your bio­me­chan­i­cal chain to dis­trib­ute phys­i­cal loads evenly through­out your system?
  • What pos­tural habits stress cer­tain body structures?
  • How vul­ner­a­ble are your spinal mus­cles to fatigue?  To get­ting knot­ted up?

These ques­tions and oth­ers like them are the real meat and pota­toes of low back care. As a patient, you have the oppor­tu­nity to get to the root of them just by pay­ing atten­tion to your own body and the way it’s mov­ing. And a physi­cian has the chance to under­stand some of these fac­tors by the use of old fash­ioned pal­pa­tion, and mus­cle and move­ment testing.

Those unneeded CT scans and MRIs? They’re just dumb­ing us down.


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