Inappropriate Ultrasound Testing

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Inappropriate Ultrasound TestingStephen Barrett, M.D.Ultrasound testing (commonly called sonography or ultrasonography) is done with a device that transmits sound waves through body tissues, records the echoes as the sounds encounter structures within the body, and transforms the recordings into images that can be viewed on a television screen, recorded on videotape, and printed. Recent developments have greatly increased the variety and usefulness of diagnostic ultrasound procedures. However, some practitioners -- medical as well as chiropractic -- are using sonography as a money-making endeavor, claiming that it is useful for diagnosing muscle spasm or inflammation and for following the progress of patients treated for back pain.
Standard medical textbooks, radiology organizations, and even mainstream chiropractic leaders do not regard ultrasound testing as useful for these purposes. The 1993 Mercy Consensus Conference report, which reflects the opinions of chiropractic academicians, stated that such use is not established [1]. In 1995, the American Institute of Ultrasound Medicine (AIUM) issued the following official statement:

The AIUM recognizes that diagnostic ultrasound is a valuable tool in certain neonatal, fetal, perinatal, pediatric, neurologic and musculoskeletal disorders. Intraoperative spinal ultrasound is valuable in selected clinical situations.
There is insufficient evidence in the peer-reviewed medical literature establishing the value of diagnostic spinal ultrasound. Therefore, the AIUM states that, at this time, the use of diagnostic spinal ultrasound (for study of facet joints and capsules, nerve and fascial edema, and other subtle paraspinous abnormalities) for diagnostic evaluation, for evaluation of pain or radiculopathy syndromes, and monitoring of therapy has no proven clinical utility.
Diagnostic spinal ultrasound should be considered investigational. The AIUM urges investigators to perform proper double-blind research projects to evaluate the efficacy of these diagnostic spinal ultrasound examinations. [2]

That same year, the American College of Radiology concluded that diagnostic ultrasound had "no proven clinical utility as a screening, diagnostic or adjunctive imaging tool" for evaluating pain, fluid in the tissues, nerve disorders or other subtle abnormalities adjacent to the spine [3]. The American College of Chiropractic Radiology took a similar position in 1995 that was ratified in 1996 by the American Chiropractic Association's House of Delegates:

The application of diagnostic ultrasound in the adult spine in areas such as disc herniation, spinal stenosis and nerve root pathology is inadequately studied and its routine application for these purposes cannot be supported by the evidence at this time.

In 1998, a radiology research team reported on their study of ultrasound images of 15 patients with neck pain, 21 patients with low-back pain, 23 patients with both neck and back pain, and 23 symptom-free persons who served as controls. After the images were recorded, four board-certified radiologists who knew nothing about the patients' symptoms interpreted the images independently. No relationship was found between the radiologist's reports and the patients' symptoms [4].
That same year, an American Academy of Neurology Report (1998) on spinal ultrasound for the evaluation of back pain and radicular disorders concluded:

Currently, no published peer reviewed literature supports the use of diagnostic ultrasound in the evaluation of patients with back pain or radicular symptoms. The procedure cannot be recommended for use in the clinical evaluation of such patients [5].

When to Suspect Fraud
Inappropriate sonography is most prevalent in cases involving personal injury cases. In 1998, I reviewed the case of a young man who had suffered minor injuries and attended a "rehabilitation clinic" operated by a chiropractor and a medical doctor. The clinic submitted insurance claims for ultrasound examinations of three parts of the spine and two other areas -- a total of 12 tests performed over a 7-week period. The fees totaled more than $3,000. None of these tests appeared to have any relevance to the patient's treatment.
In rare cases, a single ultrasound examination could conceivably be useful for investigating a serious muscle injury or a large blood clot (hematoma). However, spinal ultrasound examinations that are done routinely (on most patients), that involve many different parts of the body, or are repeated "to follow the patient's progress" after an accident, have no scientific rationale and should be considered financially motivated.
References

• Haldeman S and others (editors). Guidelines for Chiropractic Quality Assurance and Practice Parameters. Gaithersburg, MD: Aspen Publishers, Inc., 1993.
• American Institute of Ultrasound in Medicine. Official statement: Diagnostic spinal ultrasound, Oct1995.
• American College of Radiology. Ultrasound: Not effective in diagnosing spinal injuries. ACR Bulletin 2-96.
• Nazarian LN and others. Paraspinal ultrasonography: Lack of accuracy in evaluating patients with cervical or lumbar back pain. Journal of Ultrasound Medicine 17:117-122, 1998.
• American Academy of Neurology. Review of the literature on spinal ultrasound for the evaluation of back pain and radicular disorders. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 51:343-344, 1998.
  

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