Guidance Statement:

Referral for routine open or upright magnetic resonance imaging (MRI) in all indications is considered of low priority and will only be commissioned by the NHS on an individual case basis. Clinicians need to apply to the Individual Funding Request panel for approval of funding.

Urgent open/upright MRI requests in cases with red flag symptoms or signs should be made urgently by the referring clinician directly to the IFR panel and a decision will be communicated within 5 working days.

MRI radiographers are very skilled at getting patients through MRI even when they claim to be claustrophobic.

Patients need to have documented evidence of failure to tolerate MRI before oral sedation is recommended.

General anaesthetic (GA) is only suitable if there is no alternative imaging modality. The most common example would be that patients unable to tolerate MRI lumbar spine even with oral sedation should have a CT spine (if appropriate) rather than GA MRI unless there are clinical reasons why CT is inappropriate. GA is expensive, carries its own clinical risk and is a critically limited resource we need to preserve for biopsies, ablations and so on.

Patients with the following may be eligible for funding:

Funding requests for open or upright or wide bore MRI should be submitted by the referring clinician stating clearly the clinical question and reason for exceptionality, as well as the proposed intervention.

It is the responsibility of referring and treating clinicians to ensure compliance with this guidance.

Open/upright MRI

• Patients who are unable to tolerate conventional MRI due to claustrophobia despite conservative management of anxiety (including noise-cancelling headphones, visual aids and scanning feet first if possible) AND the use of sedation has been considered, and if clinically appropriate, offered. If sedation is not considered to be an appropriate option, the reason should be documented.

OR

• Patients who are unable to fit in a conventional MRI scanner, e.g. due to obesity or inability to lie flat.

OR

• Patients with debilitating symptoms which are thought, by the patients consultant, to be due to weight bearing pathology, where previous conventional MRI has shown no pathology.

Wide-Bore MRI

• Patient’s habitus (weight or girth) should be the only criteria for request of wide bore MRI.

MRI for diagnosing weight-bearing pathology:

Traditional MRI involves patients lying in the supine position in a noisy enclosed space for up to 90 minutes. This may be difficult for patients who are morbidly obese or those who suffer from anxiety secondary to claustrophobia. It has also been asserted that the image in the supine position in standard MRI scans may not always reveal pathology of weight-bearing joints and open/upright MRI has been proposed as a solution. Although it uses a lower magnetic field strength compared to standard MRI and hence lower resolution, it has been claimed that the current strength of open/upright MRI is sufficient to give equivalent diagnostic accuracy for some conditions.

Evidence for the benefit of open MRI in patients with claustrophobia is mixed. There are no comparative diagnostic studies of open/upright MRI compared with standard MRI showing an advantage for diagnosing weight-bearing pathology. Therefore, since the cost of open/upright MRI is considerably higher than for standard MRI, these will only be funded where a patient is unable to undergo a standard MRI or where there is a case for exceptionality.