Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 20 - Spine Medical Treatment Guidelines › Subchapter A - Cervical Spine Injury › Section I-2007 - Follow-Up Diagnostic Imaging and Testing Procedures

Current through Register Vol. 50, No. 6, June 20, 2024
A. One diagnostic imaging or testing
					 procedure may provide the same or distinctive information as does another
					 procedure. Therefore, prudent choice of a single diagnostic procedure, a
					 complement of procedures, or a sequence of procedures will optimize diagnostic
					 accuracy, and maximize cost effectiveness (by avoiding redundancy), and
					 minimize potential adverse effects to patients. All imaging and testing
					 procedures have a degree of specificity and sensitivity for various diagnoses.
					 No isolated imaging test can assure a correct diagnosis.
B. Clinical information obtained by history
					 taking and physical examination should form the basis for selecting an imaging
					 procedure and interpreting its results. Clinical updates must demonstrate the
					 patient's current status to document the need for diagnostic testing or
					 additional treatment. A brief history, changes in clinical findings such as
					 orthopedic and neurological tests, and measurements of function with emphasis
					 on the current, specific physical limitations will be important when seeking
					 approval of future care. The emphasis of the medical treatment schedule are
					 that the determination of the need to continue treatment is based on functional
					 improvement, and that the patient's ability (current capacity) to return to
					 work is needed to assist in disability management.
C. Magnetic resonance imaging (MRI),
					 myelography, or computed axial tomography (CT) scanning following myelography,
					 and other imaging and testing procedures may provide useful information for
					 many spinal disorders. When a diagnostic procedure, in conjunction with
					 clinical information, provides sufficient information to establish an accurate
					 diagnosis, the second diagnostic procedure will become a redundant procedure.
					 At the same time, a subsequent diagnostic procedure can be a complementary
					 diagnostic procedure if the first or preceding procedures, in conjunction with
					 clinical information, cannot provide an accurate diagnosis. Usually, preference
					 of a procedure over others depends upon availability, a patient's tolerance,
					 and/or the treating practitioner's familiarity with the procedure.
1. Imaging studies are generally accepted,
					 well-established and widely used diagnostic procedures. In the absence of
					 myelopathy, progressive neurological changes or incapacitating pain, imaging
					 usually is not appropriate until conservative therapy has been tried and
					 failed. Six to eight weeks of treatment are usually an adequate period of time
					 before an imaging procedure is in order, but the clinician should use judgment
					 in this regard. Early testing may be indicated for patients who demonstrate
					 they cannot tolerate a trial of conservative therapy or who have a significant
					 acute objective neurologic deficit that requires immediate imaging. When the
					 findings of the diagnostic imaging and testing procedures are not consistent
					 with the clinical examination, clinical findings should have preference. There
					 is good evidence that in the over 40 asymptomatic population, the prevalence of
					 disc degeneration is greater than 50 percent. Disc degeneration, seen as loss
					 of signal intensity on MRI, may be due to age-related biochemical changes
					 rather than structural deterioration, and may not have pathological
					 significance. Disc bulging and posterior disc protrusion, while not rare, is
					 more commonly symptomatic in the cervical spine than in the lumbar spine due to
					 the smaller cervical spinal canal. Mild reduction in the cross-sectional area
					 of the spinal cord may be seen without myelopathy in patients older than 40,
					 therefore, clinical correlation is required. The studies below are listed in
					 frequency of use, not importance.
a. Magnetic
					 Resonance Imaging (MRI) is the imaging study of choice for most abnormalities
					 of the cervical spine. MRI is useful in suspected nerve root compression, in
					 myelopathy to evaluate the spinal cord and/or masses, infections such as
					 epidural abscesses or disc space infection, bone marrow involvement by
					 metastatic disease, and/or suspected disc herniation or cord contusion
					 following severe neck injury. MRI should be performed immediately if there is a
					 question of infection or metastatic disease with cord compression. MRI is
					 contraindicated in patients with certain implanted devices.
i. In general, the high field, conventional,
					 MRI provides better resolution. A lower field scan may be indicated when a
					 patient cannot fit into a high field scanner or is too claustrophobic despite
					 sedation. Inadequate resolution on the first scan may require a second MRI
					 using a different technique. All questions in this regard should be discussed
					 with the MRI center and/or radiologist. Repeat MRI testing may be needed in
					 cases that involve a change in exam or symptoms or for contemplated surgical
					 intervention.
ii. Specialized MRI
					 Scans
(a). MRI with Three-Dimensional
					 Reconstruction. On rare occasions, MRI with three-dimensional reconstruction
					 views may be used as a pre-surgical diagnostic procedure to obtain accurate
					 information of characteristics, location, and spatial relationships among soft
					 tissue and bony structures;
(b).
					 Dynamic-Kinetic MRI of the Spine. Dynamic-kinetic MRI of the spine uses an MRI
					 unit configured with a top-front open design which enables upright,
					 weight-bearing patient positioning in a variety of postures not obtainable with
					 the recumbent images derived from conventional, closed unit MRI systems.
					 Imaging can be obtained in flexion, extension, and rotation of the spine, as
					 well as in erect positioning. There is a theoretical advantage to imaging
					 sequences obtained under more physiologic conditions than in the supine
					 position. There is currently ongoing research to establish whether the
					 theoretical advantages of positional and kinetic MRI result in improved
					 sensitivity and specificity in detecting spine pathology. Currently it remains
					 investigational, and is not recommended until the correlation with clinical
					 syndromes is firmly established.