Lower back or lumbar spine MRs exams are useful in diagnosing the cause of lower back pain, but researchers at the Stanford School of Medicine and Department of Veterans Affairs (VA) found that 30 to 50 percent of the exams conducted in the VA are unnecessary.

Low back pain affects at least 80 percent of people at some point in their lives and between 20 to 30 percent of people at any given time, according to the American Spinal Decompression Association. According to the researchers, however, the pain frequently resolves on its own or with exercise within weeks.

The study, published in The American Journal of Managed Care, examined all lumbar spine MR exams conducted in the entire VA system in 2012 and found that the findings on MR are often unrelated to the patients' symptoms and it can actually lead to unnecessary treatments that don't help the patient feel better. The additional exams also raise costs and lead to "inefficient allocation of resources."
Over-utilization of imaging exams is frequently linked to fee-for-service payment models and physicians practicing defensive medicine in order to reduce the chance of a lawsuit. In the VA's situation, however, because its physicians are paid on a salary basis and are protected from malpractice proceedings, those explanations don't hold water.

Among the cases in which physicians ordered MR for any reason to manage the lower back pain, the researchers found that 31 percent of the exams were inappropriate, which cost $13.6 million. When they limited the definition of "appropriate" to the cases where the physician appointment had a billing code for lower back pain, the amount of inappropriate scans dramatically increased to 53 percent. The researchers mentioned that the real figure is somewhere in between those percentages.

In order to curb this problem, organizations, including the American College of Physicians and American Association of Neurological Surgeons, have created the Choosing Wisely campaign.

CMS put guidelines in place to determine what condition requires an immediate MR exam, including HIV, trauma, cancer or spinal surgery, and what cases only require visits with a physician to evaluate and manage the condition, and physical therapy in the 28 to 60 days prior to ordering the MR exam.

But despite the efforts, it still remains an issue. The researchers think that the percentage of inappropriate lumbar spine MR exams is most likely even higher outside of the VA and recommend that other studies should investigate health care settings where financial incentives may make the problem worse.

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