So concludes a new study in which 380 adult patients with low back pain in the Seattle area were randomly assigned to receive either conventional radiographs (X-rays) or rapid MRI to evaluate the cause of their discomfort.
Dr. Jeffrey G. Jarvik, associate professor of radiology and neurosurgery and a member of the Center for Cost and Outcomes Research at the University of Washington at Seattle and colleagues conducted the study. A report on their findings appears in the June 4 issue of the Journal of the American Medical Association.
In an accompanying editorial written at the journal's request, Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill, wrote that 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," said Hadler, professor of medicine at the UNC School of Medicine. "Rather, the data suggest that substituting rapid MRI increases cost in part because it predisposes patients to undergo surgical interventions."
Hadler is a rheumatologist with research interest in back pain -- a nearly universal problem -- and other regional musculoskeletal ailments.
Twelve months after the tests, Jarvik and colleagues evaluated functional disability among 337 of the 380 back patients assigned to the two groups. They and found little differences in disability and no significant differences in pain intensity, pain frequency or in physical functioning.
"Ten patients in the rapid MRI group vs. four in the radiograph group had lumbar spine operations," the authors wrote. "The rapid MRI strategy had a mean cost of $2,380 vs. $2,059 for the radiograph strategy."
Both patients and physicians preferred the rapid MRI scan, "but there may be a higher surgical rate among patients undergoing MRI scan, and overall societal costs may be higher as well," they said. "A major impetus for this work was the concern that substituting radiographs with rapid MRI scans would result in worse patient outcomes because incidental abnormalities would foster increased interventions and unnecessary morbidity. Our study suggests that substituting rapid MRI scans for radiographs is likely safe but may in fact result in more specialist consultations and operations."
In his editorial, Hadler wrote: "As a result of this randomized controlled trial, rapid MRI joins the ranks of appealing innovations that have proved illusory. ... The results reported by Jarvik 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?"
Health-care agencies in 11 countries have published guidelines for managing patients with low back pain, he said. All agree that X-rays are not useful. By looking at the images radiography and also MRI create, doctors cannot predict who will and who will not suffer the sometimes debilitating pain and often cannot reliably ascribe anatomical changes to current symptoms. Still, patients have expected X-rays, or more recently MRI, for many years, and doctors usually have obliged them.
"Imaging might not facilitate return to well-being, but it certainly contributes to patient satisfaction," Hadler wrote. "Is this a valuable outcome? Or is this sense of satisfaction contributing to the persistence of illness?"
Not uncommonly, imaging for low back pain leads to surgery, he said. But no more evidence exists that surgery successfully relives that pain than exists that imaging shows what causes it.
"Community-based surveys show that virtually everyone is repeatedly challenged by self-limited regional musculoskeletal disorders that occur without extraordinary precipitants," Hadler wrote. "Today, individuals with regional back pain might fare less poorly by managing as best they can on their own, perhaps with some lay advice, than if they choose to be primary care patients."
By DAVID WILLIAMSON
UNC News Services
Note: Copies of the paper and editorial are available from the American Medical Association by calling (312) 464-5374. Hadler can be reached at (919) 966-0566, Jarvik through Pam Sowers at (206) 543-3620.
Journal
JAMA