Should a lumbar spine MRI be approved for a patient with degenerative disc and joint disease, lateral recess stenosis, and current symptoms of tingling and numbness, without prior MRI results for comparison?

MRI Approval for Lumbar Spine with Lateral Recess Stenosis

The lumbar spine MRI should be approved for this patient with documented lateral recess stenosis, new neurological symptoms, and failure of conservative management.

Clinical Assessment of the Case

The patient presents with:

• History of multilevel degenerative disc and joint disease in the lumbar spine from a 2018 MRI
• Documented lateral recess stenosis at several levels, most pronounced at left L3-4
• New symptoms of tingling and numbness down the right leg and numbness on the bottom of the right foot
• Chronic low back pain without sciatica
• Gastrointestinal side effects from NSAIDs (bloody stools)
• No focal neurological deficits on examination

Rationale for MRI Approval

1. New Neurological Symptoms

   • The patient has developed new radicular symptoms (tingling and numbness) in a distribution different from the previously documented lateral recess stenosis (right leg vs. left L3-4)
   • These symptoms suggest possible progression of disease or new pathology

2. Guideline Support

   • The ACR Appropriateness Criteria for Low Back Pain (2021) supports MRI imaging for patients with persistent symptoms and neurological findings 1
   • MRI without contrast is recommended for evaluating soft tissue abnormalities, including disc herniation and nerve root compression 2
   • The patient's symptoms of tingling and numbness in the leg are consistent with potential nerve root compression that requires imaging evaluation

3. Failed Conservative Management

   • Patient reports inability to take NSAIDs due to GI side effects (bloody stools)
   • Considering transition from opioids to gabapentin, which requires accurate diagnosis of the underlying pathology

Addressing the Specific Question

The request asks whether this meets MCG repeat imaging criteria for "prior imaging results of specific area or structure with same imaging modality documented and available for comparison."

While the provider has not sent a copy of the previous MRI, they have:

1. Documented the year of the prior study (2018)
2. Provided specific findings from that study (multilevel degenerative disc and joint disease, lateral recess stenosis most pronounced at left L3-4)
3. Noted new symptoms that differ from the previous presentation (right-sided symptoms vs. previously documented left-sided pathology)

Recommended Imaging Approach

• MRI lumbar spine without contrast is the most appropriate next step
• This will allow evaluation of:
  • Progression of previously documented degenerative changes
  • New or worsened lateral recess stenosis
  • Potential disc herniation causing the new right-sided symptoms
  • Nerve root compression or irritation

Important Considerations

• The patient's symptoms of tingling and numbness in a radicular distribution represent a change from their baseline chronic low back pain
• The development of new neurological symptoms in a patient with known spinal stenosis warrants reassessment with imaging
• The inability to use NSAIDs due to GI side effects limits conservative management options
• Proper imaging is necessary to guide appropriate treatment decisions, including potential epidural steroid injections

Conclusion

Based on the ACR guidelines and the patient's clinical presentation with new neurological symptoms, the MRI request should be approved despite the absence of the actual previous MRI images. The provider has adequately documented the findings from the previous study, and the new right-sided symptoms represent a significant change warranting reassessment.