Association between Ordering Provider Type and Overuse of Spine MRIs for Cord Compression in the Emergency Department

Rates of spine MRIs being performed for cord compression in the emergency department (ED) have markedly increased during the past several years. In this study, we evaluate the order, volume, provider type ordering spine MRIs, and the rate of study positivity during the past 6 years.

This retrospective, institutional review board-approved study was performed at a single institution. All adult patients presenting to the ED of our institution who underwent a total spine cord compression survey MRI between 2018 and 2023 were included. Patient examinations were excluded if they had motion/other MR artifacts preventing an assessment. MRI reports were reviewed, and findings were stratified into 4 acuity categories: 0) negative/no actionable findings; 1) chronic degenerative changes with no greater than mild spinal/foraminal stenosis; 2) nonemergent findings that could account for patient symptoms, including moderate/severe spinal canal/foraminal stenosis; and 3) acute/emergent findings requiring admission/surgical decompression (eg, cord compression). Basic demographic data including patient age and sex and ordering ED provider type (attending, resident, nonphysician practitioner [NPP]) were collected and analyzed using a multiple logistic regression analysis. Additionally, data were stratified into 3 distinct timeframes including a pre-coronavirus disease 2019 (pre-COVID) pandemic cohort (before March 1, 2020), a height of COVID-19 pandemic cohort (March 1, 2020, to January 30, 2021), and a post-COVID-19 pandemic cohort (February 1, 2021, to December 2023).

A cord compression survey MRI was performed on 1384 included patients. The mean age was 55.8 (SD, 19.5) years, with 652 women (47%) and 732 men (53%). An MRI acuity score of 0 was encountered in 703 patients (51%); 1, in 391 patients (28%); 2, in 150 patients (11%); and 3, in 140 patients (10%). Physicians had significantly higher ORs of positive acuity examination findings compared with NPPs with an OR of 3.9 (95% CI, 2.9-5.3) (P < .001). Use of the cord compression survey increased in the postpandemic era from 161 cases performed in 2018 to 453 cases performed in 2023 (281% overall increase, 212% per month increase).

A 281% increase was noted in the number of cord compression MRI examinations ordered from the ED during a 6-year period with significantly higher odds of examinations with positive findings ordered by physicians compared with NPPs.