Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 20 - Spine Medical Treatment Guidelines › Subchapter B - Low Back Pain › Section I-2019 - 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 procedures and testing may provide useful information for
					 many spinal disorders. When a diagnostic procedure, in conjunction with
					 clinical information, can provide 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. Subsequent MRI may be indicated with a change in neurological exam,
					 change in symptoms or a contemplated surgical intervention.
1. Imaging studies are generally accepted,
					 well-established and widely used diagnostic procedures. In the absence of
					 myelopathy, or neurological changes, or history of cancer, 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. When indicated, imaging studies can be utilized for further evaluation
					 of the low back, based upon the mechanism of injury, symptoms, and patient
					 history. Prudent choice of a single diagnostic procedure, a complementary
					 combination of procedures, or a proper sequential order of complementary
					 procedures will help ensure maximum diagnostic accuracy and minimize adverse
					 effect to the patient. When the findings of the diagnostic imaging and testing
					 procedures are not consistent with the clinical examination, the clinical
					 findings should have preference. There is good evidence that in the
					 asymptomatic population, disc bulges, annular tears, or high intensity zone
					 areas, and disc height loss are prevalent 40 to 60 percent of the time
					 depending on the condition, study, and age of the patient. Therefore, the
					 existence of these anatomic findings should not be considered relevant without
					 physiologic and clinical correlation in an individual patient. The studies
					 below are listed in frequency of use, not importance:
a. Magnetic Resonance Imaging (MRI) is rarely
					 indicated in patients with non-traumatic acute low back pain with no
					 neuropathic signs or symptoms. It is generally the first follow-up imaging
					 study in individuals who respond poorly to proper initial conservative care.
					 MRI is useful in suspected nerve root compression, myelopathy, masses,
					 infections, metastatic disease, disc herniation, annular tear, and cord
					 contusion or severe incapacitating pain. MRI is contraindicated in patients
					 with certain implants.
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 who 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.
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 and outcomes is firmly established.