Understanding Patient Non-Compliance with Spinal Imaging and Ensuring Follow-Up
Why the Brain MRI Was Completed but Spinal Imaging Was Not
The most likely explanation is that the patient prioritized the brain MRI due to greater perceived urgency or fear of serious intracranial pathology, while viewing spinal imaging as less critical—a common pattern when patients face multiple imaging orders without clear explanation of their relative importance.
Patient-Level Barriers to Completing Spinal Imaging
Scan burden and fatigue: When multiple imaging studies are ordered simultaneously, patients often complete what they perceive as most urgent and defer or abandon additional studies, particularly if they involve separate appointments, additional time commitments, or copayments 1
Lack of understanding: Patients may not comprehend why both brain and spine imaging are necessary, especially if the clinical rationale wasn't explicitly explained—for example, in suspected spontaneous intracranial hypotension, both brain and spine MRI are required to localize potential CSF leaks 2
Logistical challenges: Spinal MRI often requires longer scan times (particularly for complete spine protocols), may need separate scheduling, and can be more uncomfortable due to positioning requirements, leading patients to postpone or avoid completion 3
Symptom improvement: If the patient's pain improved between the time imaging was ordered and when appointments were scheduled, she may have felt the spinal imaging was no longer necessary 4
System-Level Factors Contributing to Non-Completion
Poor care coordination: When pain management and neurology order imaging separately without coordinating with each other or the patient, confusion about which studies are truly necessary can lead to selective completion 5
Delayed access: Long wait times between scheduling and appointment dates (>21 days) significantly increase the likelihood of cancellation or no-show—patients waiting longer than 3 weeks are 2.3 times more likely to cancel or fail to attend 1
Inadequate communication: If the ordering provider didn't clearly explain that spinal imaging is essential for diagnosis and treatment planning (not optional), the patient may have viewed it as discretionary 6
Ensuring the Patient Returns for Neurology Follow-Up and Completes Necessary Imaging
Immediate Actions to Take
Direct phone outreach: Have a nurse or care coordinator call the patient within 48 hours to schedule both the neurology follow-up and the outstanding spinal imaging, explaining why both are medically necessary 4
Expedite scheduling: Prioritize appointment availability within 21 days, as delays beyond this threshold dramatically increase ED utilization (6.6-fold increase) and appointment cancellation rates 1
Consolidate imaging: If possible, schedule the spinal MRI at the same facility and ideally the same day as any other required studies to reduce patient burden 2
Communication Strategy
Explain the clinical rationale explicitly: Tell the patient that spinal imaging is not optional—it is required to identify the source of her pain and guide treatment decisions, particularly if infection, inflammation, or neoplasm is suspected 3, 7
Address specific concerns: Ask directly why she didn't complete the spinal imaging and address those barriers (cost, time, fear, confusion about necessity) 5
Clarify the care plan: Explain that neurology and pain management are working together, that both specialties need the spinal imaging results, and that without it, treatment will be delayed or suboptimal 6
Preventing Future Non-Compliance
Use a single point of contact: Designate one care coordinator to manage all imaging orders, scheduling, and follow-up to prevent confusion from multiple providers ordering studies independently 4
Provide written instructions: Give the patient a clear, written summary of what imaging is needed, why it's needed, where to go, and when to schedule it 5
Implement reminder systems: Use automated phone calls, text messages, or patient portal messages to remind the patient of upcoming appointments and outstanding imaging 1
Consider alternative pathways: If the patient continues to have barriers to completing MRI, discuss with neurology whether alternative imaging (CT) or clinical evaluation could proceed first, though MRI remains the gold standard for suspected infection, inflammation, or neoplasm 3, 7
Addressing the Neurology Referral Specifically
Confirm the referral was received: Verify that the neurology office received the referral and that the patient is on the schedule—referral management systems sometimes triage patients to alternative pathways (advice, telephone consultation) rather than face-to-face visits 4
Check for triage decisions: Some neurology practices screen referrals and decline to schedule patients they deem inappropriate for face-to-face consultation, instead recommending follow-up with primary care or pain management—this happens in up to 32% of referrals 5
Facilitate direct communication: If the patient hasn't been scheduled, contact the neurology office directly to advocate for the patient and clarify the clinical urgency, particularly if there are red flags such as progressive symptoms, neurologic deficits, or suspected serious pathology 2, 5
Common Pitfalls to Avoid
Don't assume the patient is simply non-compliant: Investigate system-level barriers (scheduling delays, poor communication, lack of coordination) before attributing non-completion to patient factors alone 1, 4
Don't order imaging without clear indication: Ensure that spinal imaging is truly necessary based on clinical suspicion for infection, inflammation, neoplasm, or other serious pathology—unnecessary imaging contributes to patient burden and healthcare costs 3, 7
Don't allow fragmented care: When multiple specialists are involved, establish clear communication about who is responsible for coordinating imaging, interpreting results, and following up with the patient 5, 6
Don't ignore access delays: If neurology appointments are delayed beyond 21 days, the patient is at significantly increased risk of ED visits, cancellations, and lost to follow-up 1