A patient saved money the other day after consulting with me for a single concern.
His question pertained to the necessity of having a certain type of diagnostic test that had been recommended by another doctor he had been seeing.
He wasn’t in critical condition. His low back problem responded decently to treatment but periodically returned.
Like many people who have testing, he was hoping the test would finally tell him what was wrong and help him get “fixed” for good.
So I asked him 4 questions that everyone should ask their doctor about any test that is suggested.
- What are you looking for?
- Why do you need to know this?
- How reliable is the test in telling you what you want to know?
- How will it change your recommendations or response to treatment?
As we reviewed answers to these questions, the lack of necessity became clear. Test reliability was poor. Treatment would not have changed.
His back pain may have improved but it would’ve only been due to him being $300 “lighter” in his wallet.
If ordered appropriately, testing for low back pain and/or sciatica should LOOK for 3 main things.
- Compression of spinal nerves causing leg pain, weakness, or severely decreased walking tolerance. It is not uncommon for some numbness or tingling to be present but intermittent numbness/tingling by itself is NOT a good reason for testing.
- Infection, cancer, or some other disease process that requires urgent detection and treatment.
- Fracture or severe structural spinal instability.
In most cases, the situations above will have tell-tale signs that are evident when a good history and clinical examination is performed. Unfortunately, in today’s hurried pace of many office visits, too many physicians jump right to testing, spending little time on properly identifying the cases where it is clearly needed.
Numerous studies have shown that early testing, without a clear reason for urgent necessity, leads to unnecessary expense, a greater chance of having surgery, and either no benefit or worse outcomes from treatment that was based on the test results.
A doctor would be looking to KNOW just a few things if his or her test was properly ordered.
- What structure is compressing or injuring a spinal nerve?
- How severe is the compression-injury?
- Should he or she look elsewhere (somewhere other than the spine) for an explanation of the problems experienced?
Back pain and sciatica can appear to be coming from the spine, but actually be due to something else. This is one of the most important things a doctor would need to know.
However, many doctors don’t have the necessary training and experience to recognize these non-spinal problems and this can lead to mis-directed treatment. For this reason, it is also important that any doctor ordering a test has the appropriate training and experience to order the RIGHT test and KNOW what to do with the result.
Many people fail treatment that is undertaken based upon a test having poor RELIABILITY. This is important to understand because no test is 100% perfect in finding what it is looking for.
- Some testing finds abnormalities that are completely irrelevant.
- Other tests may be normal, but do not reliably exclude the problem they were searching for.
Getting back to what I had discussed above, this is why any test needs to be based on a thorough history and clinical examination and only be used for specific reasons.
For example, it is common for people to have an MRI for low back pain and sciatica. However, studies have clearly shown that as many as 60+% of people who have NEVER had low back pain will have abnormalities on their MRI. Receiving treatment, based upon these abnormalities that may be irrelevant, can be dangerous and could partly explain the rising rate of low back surgical failures.
Another example relates to different types of injections. These are often used to “numb” an area, presuming that if pain improves, the part of the spine that was “numbed” is the cause of the problem. But, such injections have been found to be inaccurate around 50% of the time. “Flipping a coin” does not appear to be a good way to make a solid diagnosis.
Probably the most important question to ask is, “How will the test results CHANGE my treatment plan?” This is a logical progression from properly answering the other 3 questions.
For low back pain and sciatica, testing may CHANGE treatment in 3 main ways:
- Changing the diagnosis. The implications for requiring different treatment are obvious.
- Identifying a spinal problem that requires surgery, or sometimes avoidance of specific physically demanding activities.
- By suggesting that a particular type of injection may be helpful.
For example, finding a tumor causing sciatica would change the diagnosis and treatment. This is not common, but does occur. There are also many other non-spine causes of weakness, pain, and numbness into the legs and certain tests can help to identify these.
Re-stating what I had before, most of these other non-spinal causes have subtle clues in the history and examination that will be detected by an experienced physician. Again, this is why a physician familiar with such problems should be the one ordering the test.
Low back problems that require surgery are also different from low back problems where surgery is an option. As I had mentioned before, patients may fail to have surgical success if the surgery was based on an MRI finding that was unrelated to their back pain.
Lastly, don’t let YOUR test be someone else’s CASH COW.
More practices are developing what are called ancillary revenue centers. These often involve investing in other facilities providing a certain test or service or bringing something similar into their own practice. This can be much more convenient and expedient for a patient. But it can also can create a potential conflict of interest and lead to over-utlization for the purposes of revenue production. For example:
- A 1990 study by the Government Accounting Office found that Florida doctors ordered 3x more MRI’s and CT scans and 5x as many ultrasound studies if they were investors in the facilities providing those services. This was reinforced by a similar study performed by the GAO in 2008.
- Another researcher pointed out that imaging, epidural steroids, and even complex surgical procedures are recommended and performed much more frequently when physicians have a vested financial interest in these facilities. (Hospital Medical Care and Research, 2007)
In closing; diagnostic testing for low back pain and sciatica can be an integral part of making proper treatment decisions on a patient’s behalf. However, testing should be guided by a thorough assessment, have a specific goal, and only be ordered by a physician knowledgeable about what they are seeking.
By asking the 4 questions mentioned above, patient’s and doctors will avoid needless expense and the risk of ill-advised treatment based upon test results that could be irrelevant.