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

Key Points

1. MRIs can lead to greater healthcare utilization but without improved outcomes.
2. Changing the reporting of MRIs to include an element of reassurance had a large positive effect over factual reporting.
3. Changing the terminology of MRIs had an effect on health care practitioner’s behavior towards interventions.

BACKGROUND & OBJECTIVE

Lumbar spine surgery is more frequently being used to treat low back pain (LBP), and the utilization of surgery has mirrored an increase in the use of magnetic resonance imaging (MRI). Despite comparable outcomes at one year (1), use of MRI over x-ray to assess LBP has been shown to result in three times the number of spine surgeries. Furthermore, patients who do not receive an MRI do as well as those who do receive one in both the short and long-term (2).

MRI has been associated with a nocebic effect potentially due to alarming terminology. MRI reporting without a clinical knowledge of the patient can potentially contribute to invasive interventions to normalize any spinal defects. MRIs negative influence on patients has not been formally investigated. Therefore, the aim of this paper was to:

• Study the effect of routine MRI reports on the perception of the patient and treatment outcome.
• Devise a clinical method of MRI reporting avoiding words and phrases that could cause fear and catastrophization in patients.
• Carry out a blinded study to assess the effect of such reporting on the perception of the condition of the spine and decision-making.

Use of MRI over x-ray to assess LBP has been shown to result in three times the number of spine surgeries.

The way in which MRI reports are described to patients appears to have a large effect on outcomes.

METHODS

The study was conducted in three phases:

Phase 1

44 patients with chronic non-specific mechanical LBP of minimum 12 weeks were randomised to group A (n=21) who received a full factual explanation of the pathologies reported in their MRI, or Group B (n=23) who were reassured that their MRI was completely normal with only incidental and age-related findings. All patients had no significant pathologies on MRI.

Outcome measures used were severity of pain (VAS), pain self-efficacy questionnaire (PSEQ), and SF-12 to measure functional status. The groups were then compared at 6 weeks after similar conservative therapy.

Phase 2

An alternate method of ‘clinical reporting’ was evolved avoiding terminologies that caused concern or anxiety. A google search was used to identify this terminology that is available to patients.

Phase 3

20 MRIs were reported by both routine and alternative (clinical reporting) methods. The effect of this was then tested on four categories of health care professionals (ten each of spine surgeons (SS), general orthopaedic surgeons (OS), orthopaedic residents (OR), and physiotherapists (PT)). These clinicians were blinded on their assessment of the severity of the spinal condition, then rated their choice of treatment between conservative therapy, injection, and surgery; and the probability of requiring surgery.

RESULTS

Phase 1

For both the VAS and the PSEQ, the effect size between group A (factual reporting) and group B (reassurance) was large in favor of the reassurance group following the 6-week conservative care program. At 6 weeks the between-group effect size for VAS was 2.8499 and the PSEQ 2.998. This large between-group difference in favor of the reassurance group was due to deterioration in group A scores over the 6-week time period, as well as improvements in group B scores.

The authors describe the PSEQ as a measure of a negative perception of disease, however the strict definition of the PSEQ measures confidence in the person’s ability to perform activities despite pain. Therefore, it could be argued that the person’s perception of their body and pain worsened following the exposure to the factual MRI report (3).

Phase 2

An alternate method of reporting avoiding potentially problematic terminology without losing the critical clinically relevant findings was developed using more scientific wording. This included: 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.

Phase 3

All three measures – assessment of severity of the spinal pathology; choice of treatment between conservative, injections, and surgery; and the perceived probability of requiring surgery – changed significantly between routine and clinical reporting for the same patient’s MRI.

LIMITATIONS

This study was a single-centre design and therefore may benefit from a larger multi-centre trial to replicate the results in a wider population and reduce observer bias.

CLINICAL IMPLICATIONS

The clinical implications of this paper are clear for the first phase of this study. The way in which MRI reports are described to patients appears to have a large effect on the outcomes at 6-weeks following a program of conservative care. The primary outcome measure of the PSEQ was double the minimal clinical important difference at 6 weeks.

The second and third phases provide an interesting insight into healthcare professionals behaviour in regard to MRI reporting, with a decrease in the invasiveness of the suggested approach following the change in the reporting of the MRIs. This shows that it is not just patients but also healthcare professionals who are influenced by the way in which terminology is used in healthcare.

For clinicians, helping patients to understand the meaning and implications of MRI reports can be a key aspect of good care. This can involve explanations of the terminology, expanding on patient concerns, and also highlighting the frequency of similar findings in asymptomatic populations. These findings also have to correlate with the clinical assessment and not just be taken in isolation, in line with a modern multifactorial understanding of painful spinal conditions.

+STUDY REFERENCE

Rajasekaran S, Dilip Chand Raja S, Pushpa B, Ananda K, Ajoy Prasad S & Rishi M (2021) 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. European spine journal: Advance online publication.

SUPPORTING REFERENCE

1. Verrilli D, Welch HG (1996) The impact of diagnostic testing on therapeutic interventions. JAMA 275:1189–1191
2. Chou R, Fu R, Carrino JA, Deyo RA (2009) Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet.
3. Nicholas MK. The pain self-efficacy questionnaire: Taking pain into account. Eur J Pain. 2007 Feb;11(2):153-63. doi: 10.1016/j.ejpain.2005.12.008. Epub 2006 Jan 30. PMID: 16446108.