Immediate routine use of imaging in patients with low back pain (LBP) is currently discouraged by some experts in this area [1
]. The reasons for this are that only few cases of serious pathology are found in the clinical population [2
], little is known about the clinical relevance of other spinal pathological or degenerative findings
and access to these images seems to have little or no influence on treatment effect [7
Magnetic Resonance Imaging (MRI) is increasingly replacing other imaging modalities in the diagnosis of LBP but the routine use of "up-front" MRI is not recommended [1
]. An up-front MRI is an MRI which patients receive on a routine basis prior to the clinical examination.
From the patients' perspective, knowledge of various anomalies - many of which are normal degenerative findings - are, by some, thought to induce anxiety and dependence on health care services in those who are ill informed, which in turn could cause ill-advised medical interventions [8
]. Others suggest that early use of MRI has a reassuring effect [7
From a societal perspective, the cost of an MRI examination is high. Also, detailed visualisation of various abnormalities, such as a disc protrusion, could result in overzealous referral for surgery [7
]. This could have both adverse economic consequences (because of the high cost of surgery) and negative personal consequences (because of the higher risk of serious side effects with surgery as compared with conservative treatment).
An additional perspective, however, is the growing trend for patients to distrust or disregard expert advice [11
] as many clinicians have observed. Also, the medical profession is losing its traditional hold on the role of gate-keeper with full control over the management of the entire clinical course
Today, many patients view health personnel in a given health field as just one of many sources of information and providers of services [16
]. Therefore, if one health practitioner refuses to refer a patient for advanced imaging, the patient might continue his/her search for full information until an MRI has been obtained. This is possible because many patients have private insurance or may even pay themselves, and if the public system is uncooperative, there are private clinics that may be less restrictive in their criteria for proceeding with imaging.
On the one hand, this may have the positive effect of stopping the continued search for an MRI, but on the other hand, if the patient gets an unsuitable explanation, where findings are not explained in relation to the patient's specific spinal complaint, it may not result in an improvement of e.g. well-being, fear avoidance beliefs and avoidance of everyday activities [17
As a consequence of this new development, which has accelerated in Denmark over the past few years, a new approach has been introduced into our specialised, out-patient public clinic. All patients with LBP referred to the clinic, who fulfil certain inclusion criteria, have since June 2006 received an up-front routine MRI examination on the first visit. This occurs before being examined by a clinician, rather than on a perceived needs basis.
The introduction of this new approach was based on the assumption that up-front access to an MRI report will have an anxiety-reducing effect when the patient learns that there is nothing seriously wrong. Also, if there is no effect of the treatment, consisting of exercise-based conservative therapy, the duration of treatment at the clinic does not have to be prolonged while waiting for the required MRI that might enlighten the clinician further. Having the anatomical facts at hand is thought to make it easier for both patient and clinician to accept the situation for what it is. This in turn is thought to effect the duration of treatment, reduce the risk of chronicity and sick-leave, and hence save society unnecessary costs. A quicker turn-over of patients will also have the benefit of reducing the waiting lists at this specialised clinic.
Nevertheless, to our knowledge, these potentially positive aspects of up-front routine MRI in patients with prolonged LBP have not been studied. For this reason, we made use of the standardised records available in the clinic, and performed a study that compared the present system with that previously used. We were able to retrieve information on, and compare the duration of, treatment, number of contacts with clinicians, and referral for surgery that occurred before and after the practice of routine MRI. However, we did not have access to information on any relevant psychosocial data, making it impossible to study patients' personal reactions and indirect costs. Nevertheless, the direct costs relating to the MRI and the subsequent visits to the clinic could be identified. A crude analysis was therefore performed comparing these costs in the two groups.