New Imaging Better Identifies Sources of Chronic Pain

By Pat Anson, PNN Editor

A new approach to diagnostic imaging that combines the use of positron emission tomography (PET) and magnetic resonance imaging (MRI) could help identify the causes of chronic pain better than current methods, according to a new study at Stanford University School of Medicine.

PET scans that identify increased glucose metabolism in the body – known as 18F-FDG PET -- are currently used by oncologists to detect where tumors are located. Stanford researchers say the same approach could also be used to more precisely locate inflammation in injured nerves and muscles.

"In the past few decades, we have confirmed that anatomic-based imaging approaches, such as conventional MRI, are unhelpful in identifying chronic pain generators," said Sandip Biswal, MD, an associate professor of radiology at Stanford University School of Medicine.

"We know that 18F-FDG PET has the ability to accurately evaluate increased glucose metabolism that arises from to acute or chronic pain generators. As such, in our study we examined PET/MRI as a potential solution to determine the exact molecular underpinnings of one's pain."

In the study, 65 chronic pain patients underwent 18F-FDG PET and MRI scans from head to toe. The PET/MR images were then evaluated by two radiologists to determine if more glucose uptake occurred in painful areas or in other parts of the body. Increased glucose metabolism was detected in 58 of the 65 patients.

One such patient was an adult male who lived with decades of chronic pain in his neck as a result of an injury experienced at birth. PET/MR scans — such as the image on the right — identified muscles in his right neck near a spinal nerve where there was elevated glucose uptake.

This finding encouraged a surgeon to explore the area. The surgeon found a collection of small arteries wrapped around the nerve. When the arteries were ablated (removed) by the surgeon, it relieved pressure on the nerve and the patient reported tremendous relief.

Cipriano, et al., Stanford University

As a result of PET/MR imaging, 40 patients in the study had their pain management plans modified, including some who had procedures that their doctor had not anticipated, such as surgery to relieve foot pain and the placement of blood patches to treat cerebrospinal fluid leaks.

"The results of this study show that better outcomes are possible for those suffering from chronic pain," said Biswal. "This clinical molecular imaging approach is addressing a tremendous unmet clinical need, and I am hopeful that this work will lay the groundwork for the birth of a new subspecialty in nuclear medicine and radiology.”

Biswal recently presented his findings at the annual meeting of the Society of Nuclear Medicine and Molecular Imaging. They’ve also been published in the Journal of Nuclear Medicine.

Researchers Question Value of Brain Imaging

By Pat Anson, Editor

An international team of researchers is recommending against the use of brain imaging as a diagnostic test for chronic pain, saying the tests are “inappropriate and unethical.”

"It's not possible at this point in time to say with any degree of certainty that a person does or does not have chronic pain based on brain imaging," said Karen Davis, PhD, senior scientist at the Krembil Research Institute and a professor at the University of Toronto.

"The only way to truly know if someone is in pain is if they tell you because pain is subjective and it is a complex experience. No brain scan can do that."

In recent years, technological advances in brain imaging have led to an increased use of functional magnetic resonance imaging (fMRI) to search for brain-based biomarkers for chronic pain.

Demand for brain imaging is also growing for legal purposes, including the development of a potential “lie detector” test for chronic pain.

"Use of such tools would be inappropriate and unethical," said Davis. "This technology is not foolproof. There are vast issues of variability between people and even within a person at different times. As a result, brain imaging must not be used as a lie detector for chronic pain."

Davis and her colleagues say brain-based biomarkers should only be used to supplement -- not replace -- a patient’s own reports of pain, even if testing is improved and valid protocols developed. Their recommendations were published in the journal Nature Review: Neurology.

"We are working towards biomarkers for chronic pain, but the goal is not as a lie detector test but rather to help provide personalized pain treatment options for patients," Davis. “People outside of the field of imaging might be disappointed, but the fact of the matter is the technology cannot be used to support or dispute a claim of chronic pain."

According to a 2015 study at the University of Michigan, one in eight visits to a doctor for a headache or migraine end up with the patient going for a brain scan. Often a doctor will order an fMRI to ease a patient’s fear that they may have a brain tumor or some other serious health problem. Doctors may also order a test to protect themselves in case of a lawsuit. About 1 to 3 percent of brain scans of patients with repeated headaches identify a cancerous growth or aneurysm.

University of Michigan researcher Brian Callaghan, MD, identified 74 neurological tests and procedures that are often unnecessary. Many involve the use of imaging.

“The two biggest areas that might be done more than they should are imaging for low back pain and imaging for headaches,” Callaghan said. “It’s a big problem and it costs a lot of money – we’re talking a billion dollars a year on just headache imaging.”

Other researchers believe brain imaging can be used as a valuable diagnostic tool. In a small study at the University of Colorado Boulder, researchers used fMRIs to discover a “brain signature” that identifies fibromyalgia with 93 percent accuracy. They found three neurological patterns in the brain that correlate with the pain hypersensitivity typically experienced with fibromyalgia.

Imaging Identified as Most Wasteful Medical Test

By Pat Anson, Editor

Should you get an MRI for your headache?

What about a CT scan for low back pain?

Or a bone-density scan for someone under the age of 65?

In most cases, the answer to all of those questions is no, according to the Choosing Wisely campaign of the ABIM Foundation, which seeks to reduce the use of hundreds of unnecessary and costly medical tests. Experts say an MRI or CT scan of the lower back can cost over $1,200 and does nothing to relieve your back pain.

Since Choosing Wisely was launched in 2012, over 370 wasteful procedures have been identified by over 70 medical societies, such as the American Academy of Sleep Medicine and the American Academy of Neurological Surgeons. Each organization was asked to identify an initial list of five medical services that may be unnecessary. Many societies went far beyond that, returning with two or even three lists.

A neurologist at the University of Michigan says the list of recommendations from the American Academy of Neurology (AAN) only scratches the surface. Brian Callaghan, MD, has identified 74 tests and procedures related to neurology that are often unnecessary. Many involve the use of imaging.

“The two biggest areas that might be done more than they should are imaging for low back pain and imaging for headaches,” Callaghan said. “It’s a big problem and it costs a lot of money – we’re talking a billion dollars a year on just headache imaging.”

According to a recent study at the University of Michigan, one in eight visits to a doctor for a headache or migraine end up with the patient going for a brain scan. Often a doctor will order a CT or MRI scan to ease a patient’s fear that they may have a brain tumor or some other serious issue causing their pain. Physicians could also order a scan to protect themselves legally in case of a future lawsuit.

In most cases, however, the brain scan will be useless. Previous research found that only 1 to 3 percent of brain scans of patients with repeated headaches identify a cancerous growth or aneurysm that's causing the problem. Many of the issues that a scan might identify don’t pose a serious threat or may not require treatment right away. There is also the risk of a false positive that could generate unnecessary fear and alarm.

“These are all areas where lots of physicians agree that you’re more likely to get harmed by doing the procedures,” said Callaghan, whose study was recently published in the journal Neurology.

Callaghan isn’t encouraging you to say no if your doctor wants to image your brain or lower back, but he hopes his research will inspire a thoughtful discussion between doctors and patients about the purpose of the test and its value

“Ordering an MRI for a headache is very quick, and it actually takes longer to describe to the patient why that’s not the best route,” Callaghan said. “These guidelines are meant for physicians and patients both, to trigger a conversation.”

Besides imaging, another treatment that is widely questioned is the use of opioid pain medication to treat headaches and migraine. The Choosing Wisely campaign recommends that opioids only be used as a last resort for severe headaches, including migraine. Overuse of any pain reliever – even over-the-counter medications -- are known to make headaches worse.

Study Finds Doctors Order Too Many Imaging Tests

By Pat Anson, Editor

Doctors are still ordering too many imaging tests for low back pain and headache, according to an early study of the effectiveness of the Choosing Wisely campaign, a national effort to reduce the number of unnecessary medical treatments and procedures.

In an analysis of seven clinical services with questionable benefit to patients, published in JAMA Internal Medicine, researchers found that the use of five procedures either increased or stayed the same; while there were only slight declines in the use of two others.

CT and MRI imaging tests for simple headache decreased from 14.9 percent to 13.4 percent, while cardiac imaging for patients with no history of heart problems dropped from 10.8 percent to 9.7 percent.

The prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) increased from 14.4% to 16.2% for hypertension, heart failure or chronic kidney disease. Testing for human papillomavirus (HPV) in young women also rose, from 4.8% to 6%.

Imaging tests for low back pain (53.7%), pre-operative chest x-rays (91.5%), and antibiotics for sinusitis (91.5%) remained stubbornly high.

The study was based on a database of insurance claims from 2013 for about 25 million members of Blue Cross and Blue Shield health plans.

“It remains an open question whether clinicians or consumers at large are aware of specific Choosing Wisely recommendations or have changed their attitude toward unnecessary tests and procedures,” wrote Ralph Gonzalez, MD, in a commentary published in JAMA Internal Medicine.

“In a fee-for services system, most delivery systems continue to get paid for tests and drugs. Payers are able to pass on these costs to employers and patients, creating a vicious cycle.”

The Choosing Wisely campaign was launched in 2012 by the ABIM Foundation (American Board of Internal Medicine) with the goal of reducing waste and unnecessary medical tests and treatments. It has grown to include a list of hundreds of frequently used procedures that have little value or may, in fact, be risky.

“Most people with lower-back pain feel better in about a month whether they get an imaging test or not. In fact, those tests can lead to additional procedures that complicate recovery,” Choosing Wisely states on its website.

“A study that looked at 1,800 people with back pain found that those who had imaging tests soon after reporting the problem fared no better and sometimes did worse than people who took simple steps like applying heat, staying active, and taking an OTC pain reliever. Another study found that back-pain sufferers who had an MRI in the first month were eight times more likely to have surgery, and had a five-fold increase in medical expenses.”

The Choosing Wisely campaign also discourages doctors from performing epidural steroid injections if a patient doesn’t show signs of improvement after one injection. A number of prominent pain doctors have told Pain News Network the shots are overused, with some patients getting dozens of injections.  

Imaging for Back Pain Often Doesn't Help Older Adults

By Pat Anson, Editor

Spending thousands of dollars on CT scans or MRI’s is often a waste of time and money for older adults with low back pain, according to a large new study published in JAMA.

Researchers at the University of Washington in Seattle say older adults with lower back pain who had spine imaging within six weeks of visiting a primary care doctor had pain and disability over the following year that was no different than other patients who did not have advanced imaging.

“Among older adults with a new primary care visit for back pain, early imaging was not associated with better one-year outcomes. The value of early diagnostic imaging in older adults for back pain without radiculopathy is uncertain,” said Jeffrey G. Jarvik, MD, a professor of radiology in the UW School of Public Health, who studies the cost effectiveness of treatments for patients with low back pain.

Jarvik and his colleagues studied over 5,200 adults aged 65 or older who had a new primary care visit for back pain at three U.S. health care systems. They followed up with the patients 12 months later, comparing pain and disability for those who received early imaging with those who did not. The imaging included radiographs (X-rays), computed tomography (CT scans) and magnetic resonance imaging (MRI) of the lumbar or thoracic spine.

Among the patients studied, 1,174 had early radiographs and 349 had early MRI/CT. At 12 months, neither the early radiograph group nor the early MRI/CT group differed significantly from controls on measures of back or leg pain-related disability.

When to image older adults with back pain remains controversial. Some guidelines recommend that older adults undergo early imaging because they are more likely to have serious underlying medical conditions, such as cancer or infections.

The American College of Radiology recommends early imaging with MRI for patients older than 70 with back pain, as well as patients older than 50 with osteoporosis. European guidelines say patients older than 55 with back pain should have imaging.

However, Jarvik says there is no strong evidence to support those guidelines.

“Despite the lack of evidence supporting routine imaging for older adults with back pain, guidelines commonly recommend that older patients with back pain undergo imaging,” he wrote. "Our study results support an alternative position that regardless of age, early imaging should not be performed routinely.”

Jarvik says adverse consequences from early imaging are more likely in older adults because they can lead to unnecessary treatments, including steroids injections and surgery.

Early imaging for lower back pain is not recommended for people at any age, according to the Choosing Wisely campaign, an initiative of the ABIM Foundation to encourage physicians and patients to make better choices about their healthcare treatment.

“Most people with lower-back pain feel better in about a month whether they get an imaging test or not. In fact, those tests can lead to additional procedures that complicate recovery,” Choosing Wisely states on its website.

“A study that looked at 1,800 people with back pain found that those who had imaging tests soon after reporting the problem fared no better and sometimes did worse than people who took simple steps like applying heat, staying active, and taking an OTC pain reliever. Another study found that back-pain sufferers who had an MRI in the first month were eight times more likely to have surgery, and had a five-fold increase in medical expenses.”

According to HealthCareBlueBook.com, an MRI of the lower back can range from $880 to $1,230, and a CT scan from $1,080 to $1,520.