The common pathway for individuals with low back or neck pain is to get an MRI, be referred for surgical referral, receive spinal injections and then surgery. This article reminds you that this pathway leaves out conservative, non surgical options that are cost effective.

The article “Patterns of Care After Magnetic Resonance Imaging of the Spine in Primary Care SPINE Volume 38, Number 1, pp 51–59 2012” reviews whether or not an MRI indicating degenerative disk disease, stenosis or herniation will lead to spine surgery. That is because spinal MRI is considered the “gold standard” in diagnosis of spinal degeneration. Meaning that in order to diagnose any of these conditions you must have an MRI.

It would be expected that after your MRI findings it would be clear what intervention would be best for you, i.e. exercise, rest, NSAID’s, chiropractic, acupuncture, injections, surgery. This study shows that the use of MRI doesn’t change what treatment is recommended to the patient.

Of the 647 patients who had a lumbosacral MRI, 44.5% saw an orthopedic surgeon or neurosurgeon, and 6.5% received spine surgery during 3 years of follow-up. Of the 373 patients who had a cervical MRI, 44.0% were seen in consultation by an orthopedic surgeon or neurosurgeon, and none had spine surgery during 3 years of follow-up. Patients with severe disc herniation or severe spinal stenosis were more likely to undergo subsequent surgery.

“However, many patients with these MRI abnormalities did not receive surgery, and the absence of these MRI findings did not significantly lower the likelihood of subsequent surgery.” MRI scans almost always contain abnormal imaging findings, referral for surgical assessment is frequent, and subsequent surgery is infrequent.

Because of the lack of correlation between MRI findings and treatment the authors concluded that non-surgical spine specific physicians like chiropractors are the most effective way to manage these patients. in the event that these first line treatments don’t work then surgical care is warranted.

If you have had an MRI and have found the presence of degenerative disk disease, stenosis or herniation please contact us for our expert opinion on your best options. You can set up a free ten minute consult with our experienced doctors here.

1. Luo X , Pietrobon R , Sun SX , et al. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States . Spine (Phila Pa 1976) 2004 ; 29 : 79–86 .
2. You JJ , Purdy I , Rothwell D , et al. Indications for and results of outpatient computed tomography and magnetic resonance imaging
in Ontario: a population-based study . Can Assoc Radiol J 2008 ; 59 : 135–43 .
3. Tu JV , Pinfold SP , McColgan P , et al. Access to Health Services in Ontario . 2nd ed . Toronto, Canada : Institute for Clinical Evaluative Sciences; 2006 .
4. Baras JD , Baker LC . Magnetic resonance imaging and low back pain care for Medicare patients . Health Aff (Millwood)
2009 ; 28 : w1133–40 .
5. Rampersaud YR , Fernandes A , Persaud O . Wait-time effects on spinal patients . Can J Surg 2011 ;54:S4.
6. Braybrooke J , Ahn H , Gallant A , et al. The impact of surgical wait time on patient-based outcomes in posterior lumbar spinal surgery . Eur Spine J 2007 ; 16 : 1832–9 .
7. Sarro A , Rampersaud YR , Lewis S . Nurse practitioner-led surgical spine consultation clinic . J Adv Nurs 2010 ; 66 : 2671–6 .
8. Kim JSM, Dong JZ , Brener S , et al. Cost-effectiveness analysis of a reduction in diagnostic imaging in degenerative spinal disorders. Healthc Policy 2011 : e105–21 .
9. Gooch KL , Smith D , Wasylak T , et al. The Alberta Hip and Knee Replacement Project: a model for health technology assessment
based on comparative effectiveness of clinical pathways . Int J Technol Assess Health Care 2009 ; 25 : 113–23 .
10. Frank C , Marshall D , Faris P , et al. Essay for the CIHR/CMAJ award: improving access to hip and knee replacement and its quality by adopting a new model of care in Alberta . CMAJ 2011 ; 183 : E347–50 .
11. Phelan EA , Deyo RA , Cherkin DC , et al. Helping patients decide about back surgery: a randomized trial of an interactive video program. Spine (Phila Pa 1976) 2001 ; 26 : 206–11 .
12. Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 1994;331:69–73.
13. Boden SD , Davis DO , Dina TS , et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation . J Bone Joint Surg Am 1990 ; 72 : 403–8 .

14. Boden SD , McCowin PR , Davis DO , et al. Abnormal magneticresonance scans of the cervical spine in asymptomatic subjects. A
prospective investigation . J Bone Joint Surg Am 1990 ; 72 : 1178–84 .
15. Bederman SS , McIsaac WJ , Coyte PC , et al. Referral practices for spinal surgery are poorly predicted by clinical guidelines and opinions of primary care physicians . Med Care 2010 ; 48 : 852–8 .
16. Rampersaud YR , Alleyene J , Harvey B , et al. Understanding primary care physicians’ challenges, barriers, and priorities in caring
for patients with low back pain . Can J Surg 2011 ;54:S4.
17. You JJ , Levinson W , Laupacis A . Attitudes of family physicians, specialists, and radiologists about the use of computed tomographyand magnetic resonance imaging in Ontario . Healthc Policy 2009 ; 15 : 54–65 .
18. Cheng F , You J , Rampersaud YR . Relationship between spinal magnetic resonance imaging fi ndings and candidacy for spinal surgery. Can Fam Phys 2010 ; 56 : e323–30 .
19. Bederman SS , Mahomed NN , Kreder HJ , et al. In the eye of the beholder: preferences of patients, family physicians, and surgeons for lumbar spinal surgery . Spine (Phila Pa 1976) 2010 ; 35 : 108–15 .
20. Huynh T, Karimzad Y, Kashani H, et al. Appropriateness of Lumbar Spine MRI in the Toronto Central LHIN. Abstract presented
at: Canadian Agency for Drugs and Technologies in Health Annual Symposium; April 16, 2012; Ottawa , Ontario, Canada .
21. Weinstein JN , Tosteson TD , Lurie JD , et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis . N Engl J Med
2008 ; 358 : 794–810.

22. Weinstein JN , Lurie JD , Tosteson TD , et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis . N Engl J Med 2007 ; 356 : 2257–70 .
23. Weinstein JN , Lurie JD , Tosteson TD , et al. Surgical versus nonoperative treatment for lumbar disk herniation: the Spine Patient
Outcomes Research Trial (SPORT) observational cohort . JAMA 2006 ; 296 : 2451–9 .
24. Weinstein JN , Tosteson TD , Lurie JD , et al. Surgical versus nonoperative treatment for lumbar disk herniation: the Spine Patient
Outcomes Research Trial (SPORT): a randomized trial . JAMA 2006 ; 296 : 2441–50 .
25. Speciale AC, Pietrobon R, Urban CW, et al. Observer variability in assessing lumbar spinal stenosis severity on magnetic resonance
imaging and its relation to cross-sectional spinal canal area. Spine (Phila Pa 1976) 2002 ; 27 : 1082–6 .