(Kiosk 8) Framing Effect: An “incidental” Cause of Neck Pain: A Case Report

Case Diagnosis: An incidental finding on a radiology report indicating an unusual cause of neck pain; a diagnosis of Calcium Pyrophosphate Deposition (CPPD) in the cervical spine.

Case Description or Program Description: An 85-year-old male with hypertension, OA and several vertebral compression fractures after a mechanical fall requiring lumbar laminectomy and decompression without complication. Initial CT cervical spine without acute findings. Patient began seeking follow-up care with Physiatry for continued neck pain and decreased ROM.

Setting: An outpatient PM&R practice in Metro Detroit.

Assessment/Results: Cervical MRI revealed multilevel disc-spur complexes with neuroforaminal stenosis and an incidental finding of calcifications and degeneration at C1-2 consistent with CPPD. Given this report, the Physiatrist treated the patient for presumed arthritic changes of the spine, though failing all conservative treatments including: physical therapy, osteopathic manipulative medicine, oral and topical NSAIDs, epidural, trigger point, and facet injections. Ultimately, the Physiarist pivoted to treatment of presumed CPPD and the patient achieved symptomatic improvement with oral steroids.

Discussion (relevance): Reviewing radiology reports is important to patient care. Incidental findings and the language utilized in reports has a significant impact on the clinician’s evaluation of patient symptoms. In this case, with a history of known trauma (a risk factor for CPPD), the phrase “incidental finding” influenced the assessment of the patient’s symptoms and subsequent treatment plan.

Conclusions: Though a radiology report may classify a finding as “incidental”, this should not create clinician framing effect bias. This bias is the tendency for the brain to infer different conclusions in regards to the same information depending on the way the information was presented. Had the radiology report not included the phrase “incidental finding”, the clinician may have interpreted the results differently and the treatment plan may have changed. Considering this bias is important in the evaluation of imaging reports, as seen in our patient.