Paternalism in Radiology?

Letters to the Editor Letters to the Editor

Published online before print December 13, 2012, doi: 10.3174/ajnr.A3438
AJNR 2013 34: E8

R.T. Fitzgeralda
aNeuroradiology Division, Department of Radiology
University of Arkansas for Medical Sciences
Little Rock, Arkansas

I read with great interest the article “Vertebral Endplate Changes Are Not Associated with Chronic Low Back Pain among Southern European Subjects: A Case Control Study” by Kovacs et al.1 Their article demonstrates the challenges we face when attempting to correlate imaging findings with clinical symptoms in patients with back pain.

In their discussion, the authors state, “In the case of vertebral endplate changes, refraining from including this finding in radiologic reports or mentioning it as a finding that is associated with disk degeneration but is likely to be clinically irrelevant may be a way of protecting patients from unnecessarily aggressive forms of treatment or overtreatment.” Are the data strong enough to support the authors’ view? This opinion, potentially stemming from the personal experience of the authors and well-publicized articles examining the overuse of spinal fusion surgery,2 merits further examination and raises a general question on the role of paternalism in radiology.

What motivations lie behind the propensity to include or exclude certain findings in our reports? I suspect that all neuroradiologists, at one time or another, have downplayed what we perceived as inconsequential findings by our choice of wording or omission from the radiologic report. In fact, in most groups, some partners may be thought of as “overcallers” or “undercallers” based on their long-term pattern of reporting. We all want what is best for our patients and thus are undoubtedly influenced when we encounter the negative sequelae of surgical procedures performed for questionable indications. Are choices of what to include or omit from our reports always backed by scientific evidence? Although Kovacs et al1 provide robust data on the question of endplate changes and back pain, are these results conclusive enough to eliminate discussion of endplate changes in all of our patients referred for spine MR imaging in the setting of back pain? To what degree does the paucity or absence of relevant clinical information on examination requisitions confound how we apply significance to imaging findings? Does it constitute radiologic paternalism to under-report certain imaging findings on the basis of our own perception of clinical relevance? By our choice of whether to report a finding, are we truly “protecting patients from unnecessarily aggressive forms of treatment or overtreatment” as Kovacs et al suggest?

References

  1. Kovacs FM, Arana E, Royuela A, et al. Endplate changes are not associated with chronic low back pain among Southern European subjects: a case control study. AJNR Am J Neuroradiol 2012;33:1519–24 » Abstract/FREE Full Text
  2. Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery; the case for restraint. N Engl J Med 2004;350:722–26 » CrossRef » Medline

Reply

Published online before print December 13, 2012, doi: 10.3174/ajnr.A3444
AJNR 2013 34: E9

F.M. Kovacs, E. Arana, A. Royuela, A. Estremera, G. Amengual, B. Asenjo, H. Sarasíbar, I. Galarraga, A. Alonso, C. Casillas, A. Muriel, C. Martínez and V. Abraira for the Spanish Back Pain Research Network

We thank Professor Fitzgerald for his interest in our study and for sharing his reflections on one of our recommendations.1 The concerns he voices open a worthy debate.

We believe that radiologists’ decisions on the findings that should be included in their reports should stem from the evidence on clinical relevance and not from their reporting patterns or personal styles. This implies that the findings that should be reported may vary with time, following the appearance of new robust evidence.

The evidence currently shows the following:

  1. Vertebral endplate changes (VEC) are not associated with low back pain (LBP) and are found in most asymptomatic subjects older than a certain age.1,2

  2. The lifetime prevalence of LBP among the general population is >70%,3and >80% of subjects show VEC (irrespective of whether they report LBP or a history of LBP).1

  3. Spinal fusion is an aggressive form of treatment, while its effectiveness appears to be similar to that of intensive exercise.4

  4. Nevertheless, some surgical societies recommend spinal fusion for patients who present with VEC and report LBP5; if one takes into account points 2 and 3, this means that most of the population would qualify for spinal fusion at some point in their lives.

  5. In fact and despite the cumulative evidence in the past years,4 the rate of spinal fusion in the United States is very high, this rate is rising more rapidly than other types of surgery,6 and the rate of reoperation is not decreasing.7

  6. Failed back surgery syndrome is a serious and incapacitating condition, for which few treatments have been shown to be effective, and the most effective preventive measure is to avoid surgery when not indicated.8

  7. MR imaging identifies many findings that are clinically irrelevant9⇓–11 but that appear to be misinterpreted and lead to unnecessary spinal fusion.1,2,4,5

  8. Including epidemiologic data in radiologic reports underlines the clinical irrelevance of such findings and actually improves clinical management.12

Therefore, we think that including epidemiologic data or omitting clinically irrelevant findings from radiologic reports may contribute to protecting patients from aggressive unnecessary forms of overtreatment.1

It is indeed advisable for examination requisitions to include relevant clinical information, but its absence would not be an obstacle for these approaches because it is the responsibility of the medical referral personnel to assess the concordance between clinical and potentially relevant radiologic findings (eg, disk herniation or spinal stenosis).

Despite the available evidence,1,2,4 clinically irrelevant imaging findings are being considered an indication criterion for (inappropriate) spinal fusion,5 leading to overuse and unnecessary harm to patients.6⇓–8 In this scenario, it would be unethical to not address this situation.6⇓–8 We believe that the approach proposed, far from being paternalistic, is an evidence-based strategy that empowers patients to effectively participate in a well-informed, shared decision-making process.

References

  1. Kovacs FM, Arana E, Royuela A, et al. Vertebral endplate changes are not associated with chronic low back pain among Southern European subjects: a case control study. AJNR Am J Neuroradiol 2012; 33:1519–24 » Abstract/FREE Full Text
  2. Jensen TS, Karppinen J, Sorensen JS, et al. Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain. Eur Spine J 2008;17:1407–22 » CrossRefMedline
  3. Hoy D, Brooks P, Blyth F, et al. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24:769–81 » CrossRef » Medline
  4. Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline.Spine 2009;34:1094–109 » CrossRef » Medline
  5. Rutka JT, Callaghan JJ, Gretch CC, et al. BlueCross BlueShield of North Carolina Lumbar Spine Fusion Surgery “Notification.”www.spine.org/Documents/BCBSNC_Lumbar_Fusion_Response121510.pdf. Accessed July 9, 2012
  6. Rajaee SS, Bae HW, Kanim LEA, et al. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine 2012;37:67–76 » CrossRef » Medline
  7. Martin BI, Mirza SK, Comstock BA, et al. Are lumbar spine reoperation rates falling with greater use of fusion surgery and new surgical technology?Spine 2007;32:2119–26 » CrossRef » Medline
  8. Chan CW, Peng P. Failed back surgery syndrome. Pain Med2011;12:577–606 » CrossRef » Medline
  9. Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther 2011;41:838–46 » Medline
  10. Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 2009;373:463–72 » CrossRef » Medline
  11. Modic MT, Obuchowski NA, Jeffrey S, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology 2005;237:597–604 » Abstract/FREE Full Text
  12. McCullough BJ, Johnson GR, Martin BI, et al. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology 2012;262:941–46 » Abstract/FREE Full Text
Paternalism in Radiology?