004- Where MRI and Referrals Meet

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Hello, happy holidays and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Today we're going to look at a piece of research released in the year 2012. It was released by Spine Journal and it's titled Patterns of Care After MRI Imaging of the Spine in Primary Care. MRI is a big source of contention in my opinion within chiropractic. Some chiropractors rely very heavily on MRI findings and shooting and ordering MRIs. Others are frightened by just the term MRI itself. Today's research that we're going to dive into looks a bit into the patterns of care regarding after an MRI is taken in primary care. Very important information for us to know as chiropractors because we're typically going to be co managing patients with their primary care providers when they come into our office as we do every week. I'd love to say a few words about Rock Tape before we get started. First, Rocktape is proud to be a sponsor of the evidence Based Chiropractor. Rock Tape offers the world's best kinesiology tape, pain relief, topicals, mobility tools and functional fitness accessories. New from Rock Tape is rocksauce Chill, a powerfully cool pain relief topical and a convenient roll on with 6% menthol. It's stronger than the freeze competition. Rocktape, most importantly as always, is more than a tape company. They are truly a movement company. Learn more and get access to your medical discount by visiting rocktape.com now back to the research. This piece of research released by Spine Journal, again titled Patterns of Care After Magnetic Resonance Imaging of the Spine in Primary Care was released in the year 2012. The use of spinal MRI has been a topic of increasing popularity in the last few years due to its gold standard diagnostic reputation. Again, to me, when I look at mri, there are some physicians who are very reluctant to order MRIs. They'll practically as chiropractors practically refer out before ordering MRI. Other chiropractors that I know order MRIs each and every day on perhaps a majority of their patients. This study from Spine shows that the use of MRI has minimal significance on the clinical decision making of primary care physicians and and ultimately minimal correlation with the subsequent intervention. The authors suggest that the use of non surgical spine specific physicians may be the most effective way to manage patients. Due to the evidence based evaluation, treatment protocols, relationships with orthopedic and neurosurgeons, and a focus on spine chiropractors are the logical choice to fill this role for many primary care providers. The authors of this study found specific findings on the index MRI scans I.e. degenerative disc disease, disc herniation, spinal stenosis, etc. Were not very predictive of subsequent consultation with a spine surgeon. They also found among patients who received an MRI scan in the primary care setting, MRI scans almost always contain abnormal imaging findings, referral for surgical assessment is frequent and subsequent surgery is infrequent. These two quotes really go in line with what we know about mri. When an MRI is taken, the foundation of what you'll see are normal findings. Second to that is truly incidental findings. They might be deemed pathological in terms of a degenerative change or in terms of an endplate change, but they're not necessarily the primary reason for pain or the primary complaint for which a patient's coming in. So while a plethora of information is gleaned from any MRI report, it's usually far more robust than the conditions of why the patient is presenting to the office. As I always say, in terms of any spine care, you really want to treat the patient, not the image. The image is typically going to always have more robust findings. These researchers also found MRI scanned results do not discriminate very well between those who will and will not undergo surgery, suggesting that alternative models for the assessment of patients with spine complaints in a primary care setting should be explored. Finally, they found alternate models of healthcare delivery for individuals with spinal complaints, such as multidisciplinary spine assessment centers staffed by highly trained personnel, could potentially result in a more targeted use of MRI testing may provide more optimal pathway to transition patients from general practice to surgical care. Now, from a chiropractic perspective, of course we're not very eager to transition patients from general practice or from a chiropractic office to surgical care. But I think it emphasizes the point that MRIs scale could be done perhaps with a little bit more tact at times. From a primary care provider perspective, often what I see is that after, let's say four to six weeks duration of minimal improvement, which falls within evidence based care guidelines, they're going to be ordering that MRI scan, which is okay. The challenges that I've seen, and I think a lot of members of the evidence based chiropractor, the physicians that they've built relationships with, that we often see, is that at that Time, if the physician sees that there's a nerve root entrapment, foraminal encroachment, spinal stenosis, they get a little bit more itchy as far as referral for surgical consultation, even when their initial examination, evaluation and case history led them to believe that spinal stenosis or nerve root entrapment as perhaps the primary pathology of what's going on with the patient and why they're presenting to the office. My history and what I've seen has been that upon the confirmation of that by an MRI scan, physicians again tend to be a little bit more itchy to make that referral for a surgical consultation. The flip side of that is we're going to be touching on a piece of research in the next few weeks here where chiropractic adjustments or spinal manipulation actually are equivalent and in some cases outperformed a microdiscectomy in terms of reduction of pain and disability secondary to radiculopathy, secondary to a disc herniation. From an everyday clinical practice perspective, this research really puts into perspective the importance of how and why chiropractors need to be able to and be comfortable with ordering and reading MRIs and making recommendations based off of them. Even if the recommendations are continued care in your practice, your recommendations and patient expectations ultimately may be different on a strain sprain injury than, let's say, a lumbar disc herniation that's producing radiculopathy. Your plans of care might be different, and therefore your expectations regarding that care might be set a little bit differently. That communication is gonna be very important if that patient goes back to their primary care doctor, and their primary care doctor is also giving them a recommendation based off of those MRI findings. So being able to head that at the pass, so to speak, or being able to live read those films with confidence with a patient, I think is extremely, extremely imperative from a practice management perspective because it'll help you better expectations regarding that patient's recovery regarding your plan of care and where you stand in that. Now to get up to speed at home, Dr. Bill Morgan, a chiropractor in the VA system, I believe, came out with an absolutely awesome book for the reading of MRI for chiropractors. I highly recommend it if you want to get up to speed locally, and I'll link that in the show notes here. Additionally, we started last month, but throughout 2016, I'm going to be traveling to a variety of states and conferences presenting MRI essentials for the practicing chiropractor. The goal of that program is to enable you to be able to live read films with a patient to feel comfortable doing so. So please check that out and certainly there'll be more information about that as time comes on and you'll be able to find that across the evidence based chiropractor platform. However, the most important thing about this piece of research, again, in my perspective, is really knowing that primary care providers, when they see stenosis, when they see disc herniation and radiculopathy, they are going to be very much in the vein and in the thought process of referring that patient for a surgical intervention. Furthermore, this research also shows that very few of those patients undergo eventually any sort of surgical intervention. Even more important for you as a chiropractor to build relationships with surgeons in your community or interventional spine docs in your community, because this piece really frames the fact that patients may be coming into their office in a very small percentage, maybe 5%, perhaps even less, are ultimately going to undergo a surgical intervention or any intervention in their office. So these are going to be patients that those providers are going to be looking to refer to other providers to help manage without that surgical intervention. What better place than a chiropractic office? Again, as we go through each and every single week, the depth and breadth of chiropractic research on efficacy, safety, cost effectiveness is growing by leaps and bounds. When we're able to bridge that gap, inform, educate and provide value for the other practitioners in our community, we set ourselves up for the best practice possible. We set our patients, our friends, our neighbors up for the best care possible. And ultimately we make impacts that can change our communities, our country and ultimately the world. So if you are a chiropractor who's a little bit intimidated by MRI findings, by ordering MRIs and or by reading MRIs, please use the resources you have available to get up to speed. I think it will greatly serve your practice. Secondarily. We're coming in on the closing of 2015 here and we are looking forward to an Absolutely fantastic 2016. It's a great time to be a chiropractor. Have an awesome week in practice and we'll see you back here next week on the Evidence Based Chiropractor.

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