Inappropriate use of MRI leads to increasing interventions and surgeries for low back pain (LBP). We probed the potential effects of a routine MRI report on the patient’s perception of his spine and functional outcome of treatment. An alternate ‘clinical reporting’ was developed and tested for benefits on LBP perception.
In Phase-I, 44 LBP patients were randomized to Group A who had a factual explanation of their MRI report or Group B, who were reassured that the MRI findings showed normal changes. The outcome was compared at 6 weeks by VAS, PSEQ-2, and SF-12. In Phase-II, clinical reporting was developed, avoiding potential catastrophizing terminologies. In Phase-III, 20 MRIs were reported by both routine and clinical methods. The effects of the two methods were tested on four categories of health care professionals (HCP) who read them blinded on their assessment of severity of disease, possible treatment required, and the probability of surgery.
Both groups were comparable initial by demographics and pain. After 6 weeks of treatment, Group A had a more negative perception of their spinal condition, increased catastrophization, decreased pain improvement, and poorer functional status(p = significant for all). The alternate method of clinical reporting had significant benefits in assessment of lesser severity of the disease, shift to lesser severity of intervention and surgery in three groups of HCPs.
Routine MRI reports produce a negative perception and poor functional outcomes in LBP. Focussed clinical reporting had significant benefits, which calls for the need for ‘clinical reporting’ rather than ‘Image reporting’.
Majority of low back pain (LBP) patients will improve spontaneously, but a multitude of treatment modalities are increasingly employed with a higher incidence of surgery every year [1,2,3]. Lumbar spine surgery is expensive and has significant complications, including mortality and a 19% cumulative increase in reoperation in 10 years . The incidence of spine surgery has paralleled the increasing use of MRI [5,6,7,8,9]. MRI to assess LBP instead of X-rays resulted in three times increase in spine surgery with no difference in outcome at one year . A meta-analysis of six randomized trials showed that in both short- and long-term patients (n = 1804) without advanced imaging did as well as those who had MRI . MRI utilization accounts for 22% of the variability in spine surgery rates, which was more than twice accounted for by patient characteristics .
MRI can produce a nocebo effect as radiologists report on images often without clinical knowledge of the patient and describe incidental changes with alarming terminologies like degeneration, tears, ruptures, neural compression, etc., which makes the patient and surgeons feel that some intervention is required for the spine to become normal . Inappropriate use of MRI in LBP evaluation has been discussed, but an MRI report’s negative influence on the patient and the health care professionals (HCP) providing primary care to LBP patients has not been formally evaluated.
The purpose of this study was to (a) perform a randomized control trial to study the effect of routine MRI reports on the perception of the patient and treatment functional outcome; (b) to devise a Clinical method of MRI reporting avoiding words and phrases that cause fear and catastrophization in patients and (c) to carry out a blinded study to assess the effect of such reporting on the perception of the condition of the spine and decision making for various health care providers.
Materials and methods
The study was conducted in three phases (Fig. 1) with the approval of the Institutional Review Board.
In Phase-I, 44 patients with chronic non-specific mechanical LBP of minimum 12 weeks, with no red flags and GHQ-12 score of <10, were randomized to Group A who had a full factual explanation of the pathologies reported in their MRI, and Group B who were reassured that their MRI was completely normal with only incidental and age-related findings. No patient had significant pathologies such as tumour, infection, severe stenosis, instability, sacroiliitis, and disc extrusion. The severity of pain (visual analogue scale—VAS), the perception of their status of spine and disease (Pain Self Efficacy Questionnaire-PSEQ-2), and functional status (Short form Survey-SF-12) were measured at the first consult, after exposure to the MRI report, and at six weeks of similar conservative therapy (Fig. 2).
In Phase-II, a google search was performed to secure the online information available to patients on terminologies frequently used in MRI, and those causing concern and anxiety to patients were identified. An alternate method of ‘clinical reporting’ was evolved, avoiding these terminologies without losing scientific clarity.
In Phase-III, for MRI of 20 LBP patients, both routine and clinical reporting were obtained. Forty health professionals, ten each of spine surgeons (SS), general orthopaedic surgeons (OS), orthopaedic residents (OR), and physiotherapists (PT) involved in spine care, went through these reports in a blinded fashion and opined on three factors for each report—(1) their assessment of severity of the spinal condition (scale 0−10); (2) their choice of treatment between conservative therapy, injection and surgery; and (3) the probability of requiring surgery (scale 0−10). For the opinions generated by clinical reporting, a change from surgery to injection/conservative management was considered as a decrease in magnitude of invasiveness. A shift from conservative to injection/surgery was considered as an increase in magnitude.
Minimum sample size for Phase-I RCT was calculated with PSEQ-2 as the primary variable for a minimum clinically significant difference of 1.5 under 90% power. Comparison between two groups for VAS, PSEQ, and SF-12 was made by paired-t-tests, independent-t-tests, and Chi-square tests as applicable. In Phase-III, assessment for severity for degeneration and probability for surgery on a scale of 10 was analysed using paired-t-tests. Change in treatment opinion was analysed by comparing the percentage increase or decrease in levels from conservative to surgery using Fisher’s exact test. Significance was fixed at p < 0.05.
Patients in both groups were comparable in demographic and disease characteristics at first consultation (Table 1). However, following exposure and detailed explanation of the MRI report, Group A had a decrease in PSEQ score (from 8.19 ± 1.8 to 7 ± 2.04), showing a negative perception of disease and catastrophization. Group B had improved perception of their spine status (8.13 ± 1.7–8.9 ± 1.8) on reassurance. The difference in alteration of perception between the groups was more significant (p = 0.002).
Following similar conservative therapy for six weeks, differences within and between the groups in VAS, PSEQ-2, and SF-12 showed that Group A continues to have the deteriorating effect of a negative perception (Table 2). In Group A, VAS significantly increased to 6.19 ± 1.7 from 5.33 ± 1.4 (p = 0.006), whereas it decreased from 5.96 ± 1.1 to 2.43 ± 0.8 in Group B (p < 0.001). Similarly, the perception of illness deteriorated from PSEQ-2 of 8.19 ± 1.8 to 6.19 ± 1.9 (p < 0.001) in Group A compared to an improvement from 8.13 ± 1.7 to 10.87 ± 1.1 in Group B (p < 0.001). The functional status of patients in Group A deteriorated from SF-12-PCS of 43.8 ± 7 to 38.8 ± 8.8 and improved significantly from 41.9 ± 6.6 to 47.3 ± 6.5 in Group B. SF-12 MCS deteriorated from 44.7 ± 7.5 to 39.2 ± 8.8 in Group A compared to an improvement from 43.4 ± 5.5 to 49.6 ± 5.0 in Group B. The effect size was larger in MCS than in PCS, indicating that the mental effects were more significant than physical effects. The results document that patients who were not alarmed about their MRI report had a better perception of their spine condition and also showed greater functional improvement for the same treatment (Table 3).
Frequently used terminologies which produced concern to the patient, the most catastrophizing search result for the wording and responses for FAQ on that subject were documented (Table 4). An alternate method of reporting avoiding these terminologies without losing the critical clinically relevant findings was developed using more scientific words that gave precise information (Table 5). Modified Pfirrmann grading to substitute disc degeneration, dehydration, desiccation and bulge; Schizas grading for lumbar stenosis; high-intensity zone (HIZ) for annular tears and fissures; ‘close proximity without compression’ to indicate nerve root indentation/impingement or abutment were employed to eliminate terminologies causing fear. Four examples of such routine and clinical reports for the same MRI are seen in supplementary file 1.
All three parameters—assessment of severity of the spinal pathology; choice of treatment between conservative, injections and surgery; and the perceived probability of requiring surgery differed considerably between routine and clinical reporting for the same patient’s MRI when the four groups of health care providers studied the reports in a blinded fashion. Clinical reporting significantly reduced the severity assessment of disease in OS (5.68–4.99), OR (5.58–5.20), and PT (6.07 to 5.39) groups. No significant change was noted amongst SS (5.05–5.23) (Table 6, Fig. 3). Following clinical reporting, the choice of treatment shifted to a decrease in magnitude of invasiveness amongst OS (45%), OR (48%), and PT (44.5%) (Fig. 4). There was no difference noted with SS (23.5%). The assessment of the requirement of surgery also dropped following clinical reporting in OS (5.9–4.8), OR (5.8–4.7), and PT (6.3–5.1) with no difference amongst SS (4.9–4.6) (Table 7, Fig. 5). Overall, the perception of severity, the need for invasive approach, and probability of the disease progressing to surgery showed a significant decrease following clinical reporting.
The global burden of LBP is continuously on the rise prompting a ‘call for action’ of all nations and governments for concerted action [11,12,13]. Although the lifetime incidence of LBP is 85%, the natural history is one of spontaneous remission, and only very few will become chronic or require surgery . However, paradoxically the number and types of interventions and the incidence of surgery is alarmingly on the rise [3, 5,6,7, 9, 15, 16].
The increasing use of MRI has been pointed as an important cause of the conversion of LBP symptom to a disease that requires intervention and surgery [17,18,19,20,21,22]. Considerable variability in lumbar spine surgical rates up to 20 times has been observed. Though direct causality was not established, a strong association was demonstrated between rates of MRI and surgery rates [3, 6, 7, 9]. MRI use accounted for 22% of the variability in spine surgery rates; twice, the variability accounted for the difference in patient characteristics . Although in four trials involving 399 patients, MRI did not reveal any serious condition  and in another study including 200 patients, 90% of individuals without LBP had significant image findings, the usage of MRI has increased by 50% in 15 years . 50% of MRI requests for LBP are inappropriate and an economic drain . However, surgeons continue to order more and more MRIs either because of a lack of knowledge, financial gains, or to satisfy the patient compounding the problem .
While the above studies have focused on inappropriate and wasteful usage of MRI, this study has demonstrated the nocebo and harmful effects of an MRI report on LBP patients and even on HCPs (Fig. 6). In Phase-I, patients with similar demographics and pain during the first consultation were treated similarly, the only difference being Group A was aware of the descriptive findings of their MRI and also had a factual explanation of all the morphological changes, while Group B were told that their MRI was within normal limits and all reported findings were age-related changes and incidental. After 6 weeks of the same therapy, the perception of back condition (measured by PSEQ-2), their perception of ability to return to normal (PSEQ-2), pain severity (VAS), and functional outcome (SF-12) were significantly worse in Group A (Table 2). Changes in PSEQ-2 have been documented to reflect anxiety and catastrophization of the disease . Knowledge of their MRI reports and the many changes in the MRI made these patients convinced that there were structural damages in the spine, which could be serious. The fact that MCS was more significantly different showed that the functional outcome was more affected by the mental perception than the actual physical status of the patient . Tissue damage and pain are deeply embedded in the patient’s mind as a cause and effect relationship . The negative perception of having spine damage can lead to the persistence of pain and inadequate response to treatment. Patients in Group A failed to get better and were also keen for an intervention mentioning that although they could live with their pain, they were keen to get a procedure to avoid possible deteriorations and future complications. Our study clearly proves that a misinterpretation of the patient’s spinal condition’s status through the MRI report leads to a negative impression of his spine.
Patients uncertain of their health seek opinions from patient peers and, more frequently, the Internet . It is now established that 80% of patients secure and counter check their health information from online searches . Table 4 shows our Phase-II search results of frequently used terminologies in a routine MRI report and related FAQs. It is obvious that these explanations can be fear-creating and severely catastrophizing to the patient. Cyberchondria (a tendency to check one’s health status on the Internet, excessively) is now well known  and is associated with an increased tendency to self-diagnose, heightened anxiety, increasing symptom severity, distress levels, functional impairment, and increased health care utilization. This was obvious in Group A patients with deteriorating PSEQ-2 values. Such patients believe that intervention is required to become normal and become a willing and easy target for spinal manipulations, footwear adjustments, injections, magnetotherapy, traction, different protocols of physiotherapy, and even spine surgery . This can also explain the strong association between advanced spine imaging and three to four times increase in the rates of lumbar spine surgery (Fig. 6).
In Phase-III, we went one step further to assess if the influence of an MRI report extends beyond the patient to healthcare professionals (HCP) also. We generated both ‘routine’ and ‘clinical’ reporting for MRIs of 20 chronic LBP patients. Terminologies causing anxiety and fear in routine reporting, such as degeneration, tears, fissures, nerve compression, etc., were replaced by alternate terminologies in clinical reporting (Table 5). We found that the effect of clinical reporting was significant in orthopaedic surgeons, orthopaedic residents, and physiotherapists as for the same MRI, they perceived lesser severity of the disease, prescribed conservative treatment in more number of patients, and also assessed lower probability of surgery. The difference in effect between the two forms of reporting was high in orthopaedic residents and physiotherapists and least in spine surgeons. Spine surgeons were able to read and interpret MRI by themselves and did not depend so much on the report in contrast to orthopaedic residents and physiotherapists. This is very important as in the USA and many other countries, the general practitioner, physiotherapist, and residents form the primary contact and care provider for LBP patients . They are also empowered to order an MRI before referring to a spine surgeon. More often than not, they are not trained to read and interpret an MRI and entirely depend on MRI report for educating the patient about his spinal condition . Our study shows the deleterious effects of a routine MRI on the medical person, which, in turn, medicalizes the largely innocuous LBP into a spinal disease.
Since MRI plays such a strong influence on patient’s perception and medical decisions, our results call for a conceptual change in the way MRIs are requested by clinicians, reported by radiologists and their reports interpreted to the patients (Fig. 7). In the absence of red flags, clinicians must use MRI wisely and request imaging only to confirm the diagnosis when an intervention is planned . They should be aware that unnecessary image may do much harm than good and resist from habitual ordering or doing a ‘scan to diagnose’ . Radiologists must move away from routine reporting and usage of terminologies that imply structural damage with possible catastrophization to the patient and adopt ‘clinical reporting’ . A catalogue-like description of image changes (image reporting) should be avoided, and a focused report relevant to the referred condition of the patient, which amounts to a sub-specialty consultation must be done. More importantly, MRI reports must not be openly available to the patient, where he is led to interpret the information through online search leading to cyberchondria . Our study proves that appropriate requests of an MRI, clinical reporting by a radiologist, and the proper education and reassurance about incidental findings in MRI by a responsible physician must be done. It is estimated that 30–50% of our health care spending is wasted and the wasteful spending in the USA alone is more than one trillion . Our proposed pathway of responsible MRI usage and clinical reporting will go a long way in reducing the unnecessary pandemic of low back pain disease.
Our study does have the limitation of being a single centre study and will have more value when done in multicentre to overcome any observer bias. Though terms used in clinical reporting are less prone for fear and anxiety, the reliability, reproducibility and adequacy of the terms may need to be validated through future studies.
Our study has documented that a routine MRI report without proper assurance leads to misinterpretation and catastrophization with poor functional results. This can be one of the important causes of LBP’s growing pandemic and an increasing number of interventions and rates of lumbar spine surgery. An alternate method of clinical reporting produced significant benefits in the way that four different health care professionals perceived the status of the spine and advised treatment. Our study calls for a conceptual shift in how advanced imaging is used in LBP and a plea to move from ‘image reporting’ to ‘clinical reporting’.
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All authors had significant contribution for the study. SR conceptualised and oversaw the study with writing of the manuscript. DCR was involved in conducting the study and preparing the manuscript. PBT was involved in Phase-II and Phase-III and was instrumental in devising enhanced method of reporting. RMK and APS provided the clinical inputs and participated in manuscript preparation.
The project was funded by Ganga Orthopaedic Research & Education Foundation (GOREF 2016–07).
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The authors declare that they have no conflict of interest.
The study was performed after approval of the IRB committee.
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Rajasekaran, S., Dilip Chand Raja, S., Pushpa, B.T. et al. The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials. Eur Spine J 30, 2069–2081 (2021). https://doi.org/10.1007/s00586-021-06809-0
- Low back pain
- MRI reports
- Clinical reporting
- Nocebo effect