CT or MRI

[clubdeac]

I sometimes am not sure whether to get a CT or MRI.

I not infrequently see post traumatic acute neck pain patients. I know CTs are more sensitive for acute bony injury but less sensitive for stenosis or cord changes. Often times I’m not sure the best modality to get in these situations

Also in any of my post fusion patients who fall and come in with worsening pain, I debate whether to get a CT for better visualization of the hardware and bones or MRI for the soft tissue structures. Often times, MRIs in my post fusion patients have poor visualization at the levels of the hardware making them almost useless at these levels

What’s the best move in these scenarios or any others you can think of where CT may be better than MRI?

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[SSdoc33]

When in doubt, get the MRI. CT’s are easier to get in the ER, but there’s a lot of radiation and the neural structures are barely visible, that’s mostly what we care about and MRIs will catch most fractures

 

[au bon pain]

If they have fresh trauma and focal ttp over the SP and/or pt is otherwise old and/or decent mechanism get a CT to r/o Fx (or hardware failure if that’s a concern). Otherwise, MRI better for the other stuff.

 

[Ducttape]

initial images should be CT scan, plain films if CT not available, that should be done in the ER.

post ER, when they are home, then repeat cervical spine films and MRI scan.

the repeat xrays are to see if there is any ligamentous laxity that may not have been obvious or present after the original films. MRI also better for ligamentous injury that you cant rule out on plain films or CT.


for those with falls, i still generally favor MRI, but it kind of depends on where the worsening pain is. if it is purely anatomic, then maybe CT.

 

[RoloTomassi]

If the trauma is significant enough to potentially cause fx or hardware break, I order both at same time. Saves pt a trip back.

 

[Dr. Ice]

If the trauma is significant enough to potentially cause fx or hardware break, I order both at same time. Saves pt a trip back.

Then the insurance denies both and the patient has to do 6 weeks of PT 🤦🏽‍♂️

 

[RoloTomassi]

Then the insurance denies both and the patient has to do 6 weeks of PT 🤦🏽‍♂️

Yep. Unless your document suspected fx which I don't abuse too often

 

[lobelsteve]

Yep. Unless your document suspected fx which I don't abuse too often

Saw a patient today six weeks after an L3 kyphoplasty. Period Her care was delayed by two months as IR was fighting insurance who demanded six weeks of PT with a known fracture.

 

[RoloTomassi]

Saw a patient today six weeks after an L3 kyphoplasty. Period Her care was delayed by two months as IR was fighting insurance who demanded six weeks of PT with a known fracture.

Been there too. Several commercial policies require PT before kypho. I think they're hoping the fracture will heal if they stall long enough, regarding of what shape

 

[nvrsumr]

Have a 75 yo lady with 4 acute fractures. Humana won’t approve kypho without dexa to prove she has osteoporosis….She can barely get out of bed

 

[lobelsteve]

Have a 75 yo lady with 4 acute fractures. Humana won’t approve kypho without dexa to prove she has osteoporosis….She can barely get out of bed

The fx actually defines osteoporosis. Dexa useless.

 

[nvrsumr]

Yes. Maddening. Literally a money grab.

 

[au bon pain]

Curious to hear other folks charting styles to reflect when insurance is playing these games—anybody have any favorite phrases or other moves they play?

 

[nvrsumr]

Had another denied for retropulsion of 5mm in lumbar spine, mild stenosis last month. That was a new one. Humana advantage again. It’s a scam. Not following Medicare guidelines.

 

[SSdoc33]

Had another denied for retropulsion of 5mm in lumbar spine, mild stenosis last month. That was a new one. Humana advantage again. It’s a scam. Not following Medicare guidelines.

They don’t give AF. No repercussions

 

[bedrock]

They don’t give AF. No repercussions

Had another denied for retropulsion of 5mm in lumbar spine, mild stenosis last month. That was a new one. Humana advantage again. It’s a scam. Not following Medicare guidelines.

Sucks for this patient. However I do always mention to patients in various clinical scenarios that all of this would be covered by regular Medicare and they should switch back to it.

Saving $80 a month on premiums isn’t worth it if you can’t get proper medical treatment when you need it.

 

[knoxdoc]

What kind of special glasses does it take to read a plain CT and see a disc bulge? The radiologist calls a disc bulge with moderate stenosis and all I see is a bunch of gray throughout the spinal canal. Its like those old stereogram pictures you have to stare at for 20 minutes before you start to see a hazy silhouette of something.

 

[GoBeers]

Had another denied for retropulsion of 5mm in lumbar spine, mild stenosis last month. That was a new one. Humana advantage again. It’s a scam. Not following Medicare guidelines.

i thought retropulsion was a contraindication for kypho? is the concern overstated?

 

[lobelsteve]

i thought retropulsion was a contraindication for kypho? is the concern overstated?

If more than 50% canal with retropulsed bone, I would pass. Bealle has literature on topic and suggests that kypho can be safely done with even more.

 

[drrosenrosen]

Sucks for this patient. However I do always mention to patients in various clinical scenarios that all of this would be covered by regular Medicare and they should switch back to it.

Saving $80 a month on premiums isn’t worth it if you can’t get proper medical treatment when you need it.

They can switch back to regular Medicare, but will have eligibility issues for any supplements (pre-existing conditions) if it's been more than a year that they've been on Advantage plan. I tell people that the only advantage is to the insurance company

 

[clubdeac]

It sounds like from the comments y’all are as divided as I am with a few exceptions.

I guess if I have a patient s/p fall or MVA with continued neck pain and has only had X-rays, I’ll just get the MRI instead of CT and hope it won’t miss any significant fractures