MRI for Regional Back Pain: Title and subTitle BreakNeed for Less Imaging, Better Understanding

In this issue of THE JOURNAL, Jarvik and colleagues¹ detail the benefits and costs that accrued when rapid MRI (magnetic resonance imaging) was substituted for the more traditional radiographs physicians have used when evaluating patients with regional back pain. Rapid MRI is an adaptation of standard MRI, but provides adequate images more rapidly and at considerably less cost. The study shows that substituting rapid MRI neither saved money nor led to improved clinical outcomes. Rather, the data suggest that substituting rapid MRI increases cost in part because it predisposes patients to undergo surgical intervention.

As a result of this randomized controlled trial, rapid MRI joins the ranks of appealing innovations that have proved illusory. Modern medicine is conditioned to be swayed by such a result, as is society at large, and is less conditioned to question the reasoning that generated the experiment in the first place. The results reported by Jarvik et al demand careful reflection before anyone rushes to develop a more rapid MRI. Why is it so important to define the anatomy of the lumbosacral spines of patients with regional back pain?

The patients in this study were recruited from 4 clinics, where they were under treatment for regional back pain, most for recurrent back pain. Health care agencies in 11 countries have published evidence-based guidelines for the management of such patients; all agree that radiographs are not useful.² As Jarvik et al point out in their introduction, low specificity limits the diagnostic utility of MRI scans as much as it limits that of radiographs. Magnetic resonance imaging cannot be used to predict back pain.³ Magnetic resonance imaging is not even sensitive to anatomical changes that might correlate with new symptoms.⁴ Cost has little to do with cost-effectiveness if imaging is ineffective.

None of this is lost on the investigators, the funding agencies, or probably the primary care physicians who ordered the studies. Yet the physicians treating the patients in this study thought imaging was indicated. This may reflect their concern that the evidence is based on an experience that might not encompass their patients' presentation.⁵

Such a stochastic rationale aside, imaging the spine is the proclivity of medical practitioners and the expectation of their patients for generations. Imaging might not facilitate return to well-being, but it certainly contributes to patient satisfaction.⁶ Is this a valuable outcome? Or is this sense of satisfaction contributing to the persistence of illness? The discourse that follows imaging always relates to the demonstrable pathoanatomy. That discourse may be satisfying, but it is associated with an exacerbation of pain.⁷ That discourse, particularly as it relates to MRI, is also associated with an increased likelihood of surgery,⁸ which, for regional back pain, is no more supportable on evidentiary grounds than is imaging.⁹ Imaging is not serving as a diagnostic modality in this setting. It is one element of a complex treatment act that endows patients with unfounded notions of pathophysiology and enriches their narrative of with the private vocabulary of the treating practitioner. Patients are forever changed by these experiences, too few for the better.¹⁰ Whatever "satisfaction" is derived from undergoing imaging studies does not stop a third of primary care patients with back pain from using multiple providers.¹¹ Imaging is not a diagnostic modality in this context; it is symbolic of the flawed logic that renders the prognosis for the return to a sense of well-being so dismal.

These primary care patients are the tip of the iceberg of morbidity from regional low back pain. Community-based surveys ¹² show that virtually everyone is repeatedly challenged by self-limited regional musculoskeletal disorders that occur without extraordinary precipitants.¹³ Back pain is joined by neck, arm, and knee pain as well as headache, heartache, heartburn, and much more to form the patchwork of morbidity with which everyone must cope.¹⁴ Feeling well demands the sense of invincibility that we can, indeed, cope. Being well symbolizes the triumph of having the wherewithal to cope with the last episode for as long as it took for that episode to remit, cope so well that the episode is barely memorable, if at all. Being well does not symbolize avoiding challenges like regional musculoskeletal disorders; that is not possible. That is the enigma of health.¹⁵

Coping with regional back pain is always a challenge and involves several key considerations. There is the personal effect to process: How and how much is function restricted? How and how much is comfort compromised? What vocational and personal activities are compromised or precluded? There are the options to consider: Is the back pain simply bearable? Do the symptoms require use of any of the myriad pharmaceuticals (agents, unctions, and potions) and devices that have been widely purveyed and forcefully marketed to prejudice the decision? Is professional assistance needed in coping? The menu of professionals who will provide assistance, for a fee, has always been considerable. How do patients choose between purveyors?

It is common sense that the press to any recourse is driven by the physical intensity of the predicament. The more severe the pain, the more likely it will be memorable, will result in use of analgesics, will cause work incapacity, and will lead to seeking professional health care. Epidemiology has put this common sense to the test; it is no longer tenable. The common denominator that drives all this choosing is a compromise in the wherewithal to cope.^{16 - 17} Workplace-¹⁸ and community-based^{19 - 20} cohort studies have probed associations with the recall and reporting of incident axial pain, as well as arm and knee pain. Psychological distress, aspects of illness behavior, and other somatic symptoms come to the fore. Furthermore, psychosocial confounders to coping are as important in rendering back pain to be persistent as they are in rendering back pain to being reportable in the first place.²¹

This insight has great implications for clinical treatment whether or not it is orchestrated by a medical practitioner. The narrative of distress of a patient with regional back pain should be probed as a surrogate complaint.²² "My back hurts" is likely to mean "My back hurts, but I'm really here because I can't cope with this episode right now." However, for 3 centuries²³ physicians, nearly all other health care professionals, and society at large have not conceptualized the complaint "My back hurts" in this fashion. The possibility that back pain is the last straw is counterintuitive, and the suggestion can be tantamount to the accusation "It's in your mind." The accepted notion is that back pain is simply the manifestation of an important underlying disease just as coughing purulent sputum is a manifestation of bacterial pneumonia. Any compromise in coping is a consequence of back pain, not the reason back pain is less tolerable. Disease is the culprit that must be palliated if it can not be expunged.

All health care professionals have theories of causation on which they formulate their treatment and purvey putatively therapeutic modalities. Most theories hold that something, somewhere in or near or about the back has gone terribly wrong. For regional back pain, no theory has withstood scientific testing. As for the modalities, none has proven a match and very few have any demonstrable effectiveness. Rather than question the premise, clinicians and patients are wont to cast about for variant theories and variant modalities. Imaging only serves to bolster the notion that back pain is nothing more than the symptom of an underlying disease. This is a social construct that nurtures an enormous treating enterprise far more than it helps the patient.

Today, individuals with regional back pain might fare less poorly by managing as best they can on their own,²⁴ perhaps with some lay advice,²⁵ than if they choose to be primary care patients. If only the statement "I can't cope with this backache" were parlance and the customary complaint when patients needed to seek care, perhaps they would fare better.