“Pictures can be deceiving”. In the world of social media, it is hard to judge the reality of a person and situation by looking at their pictures online. Similarly, in the medical world, it is often hard to judge the symptoms, the extent of the diseases, and their relevance just by looking at the MRI film.
The purpose of this blog is not to demonize MRIs but to question their relentless use and excessive reliance in modern healthcare.
MRIs do hold some importance for eg: learning the extent of anatomical damage in cases of traumatic injuries, and neurological disorders and ruling out sinister pathologies like tumors, etc. But, these cases account for a smaller population.
In many common and painful conditions like low back pain, knee pain, etc, the relevance of MRI is quite questionable. Hence, it is important to consult a healthcare practitioner and avoid self-diagnosis.
“Please correlate clinically” is a statement written at the end of every investigation which means that the changes seen on an MRI or other investigations should be consistent with the symptoms a person presents with. Unfortunately, in many instances, the investigation is given priority over the patient’s presentation leading to biomedicalization, ignoring that these MRI findings might be present way before the current onset of pain aka incidental findings.
However, on the bright side, It is perfectly normal to find MRI abnormalities in people with no pain or disability, which questions its necessity, specifically in orthopedic conditions. While the majority of the low back cases are nonspecific meaning that we don’t have a determined cause for the pain and it is likely a result of multiple intertwined factors.
The authors of this study quote, “Progression of subclinical common backache or acute back pain to serious disabling LBP illness appears to be associated with various nonstructural issues such as emotional distress, poor coping strategies, compensation disputes, and other chronic pain problems. These associative conditions make determining clear structural causes of serious LBP illness problematic.”
The authors also hypothesized that “when subjects with no significant LBP problems develop acute and serious symptoms, MR imaging will commonly demonstrate new findings. This close temporal association would support a causative relationship between specific structural changes and the development of serious LBP illness. They were also interested in determining if such new findings were more likely to be seen after minor trauma, supporting an ‘‘injury’’ model of LBP development.”
Regardless, the results turned out to be contradictory. Subjects having MR imaging within 12 weeks of a serious LBP episode uncommonly had new findings or progression of old findings. The most common new finding, a progressive loss of disc signal intensity, is primarily an aging phenomenon poorly correlated with symptoms. Furthermore, it is suggested that disc and spinal degeneration seen on imagining might begin early in life depending on factors like genetics, nutrition, activity levels, etc, with psychological factors being a better predictor of disability caused by low back pain than the factors mentioned above.
A meta-analysis of six randomized trials showed that both short- and long-term patients (n = 1804) without advanced imaging did as well as those who had MRI. Astonishingly, patients with acute low back pain who received an MRI had a longer length of disability as compared to the no MRI group.
Even though most of the patients with low back pain see spontaneous improvement in their symptoms, irrespective of their MRI findings, various invasive procedures and surgeries are used as a resort to treat the MRI findings (instead of the patient). Despite the advertised ease of surgeries in today’s world, they come with accompanying complications. Moreover, if low back pain improves despite the failure of reversal of MRI changes, it further questions its significance.
Research by Modic et al. suggests that early MR imaging may be associated with a lesser sense of well-being despite benign findings. This study further demonstrates the nocebic and harmful effects MRI findings produce in people with low back pain. “In Phase-I, patients with similar demographics and pain during the first consultation were treated similarly, the only difference being Group A was aware of the descriptive findings of their MRI and also had a factual explanation of all the morphological changes, while Group B was told that their MRI was within normal limits and all reported findings were age-related changes and incidental.
After 6 weeks of the same therapy, the perception of their back condition, their perception of ability to return to normal, pain severity, and functional outcome was significantly worse in Group A. Knowledge of their MRI reports and the many changes in the MRI made these patients convinced that there were structural damages in the spine, which could be serious. The fact that MCS was more significantly different showed that the functional outcome was more affected by the mental perception than the actual physical status of the patient.”
“Tissue damage and pain are deeply embedded in the patient’s mind as a cause-and-effect relationship. The negative perception of having spine damage can lead to the persistence of pain and inadequate response to treatment. Patients in Group A failed to get better. They were also keen for an intervention mentioning that although they could live with their pain, they were keen to get a procedure to avoid possible deteriorations and future complications. Our study proves that a misinterpretation of the patient’s spinal condition status through the MRI report leads to a negative impression of his spine.”
Furthermore, the imprecise accuracy of MRIs makes them unreliable as an independent diagnostic tool, especially if used as an indication for surgery. In this popular study, the researcher attempts to discover the variability and interpretive errors in MRIs of a 63-year-old woman with a history of low back pain and right L5 radicular symptoms scanned at 10 different MRI centers over 3 weeks. The researcher concluded, “This study identified marked variability in the reported interpretive findings and an alarmingly high number of interpretive errors in the lumbar MRI reports. Concerning variability, no interpretive findings were reported in all 10 study examinations and only one finding was reported in 9 out of 10 study examinations. Of the interpretive findings, 32.7% only appeared once across all 10 of the study examinations’ reports.”
The low back pain guideline by the National Institute for Health and Care Excellence (NICE) recommends constraints against the use of imaging in a non-specialist setting and its avoidability when referred for a specialist opinion or the use of imaging in a specialist setting if the result is likely to change management for people with LBP with or without sciatica.
Well, this exploitation of MR imagining and its questionable necessity isn’t just limited to low back pain. Many people like athletes also display these “abnormal” changes and yet still are pain-free and engaged in their sports. In contrast, abnormal MRI changes are seen on the opposite non-painful limb of the same individual with unilateral pain as well.
For instance:
A high percentage of professional soccer players have asymptomatic intra-articular knee changes, with the cartilage of both knees being affected in 97.9% of soccer players. Grade 2 cartilage lesions were the most prevalent, and grade 4 lesions were detected in 12.7% of joints. Among meniscal lesions, grade 2 lesions were the most prevalent, being detected in 71% of the cases. Grade 3 lesions were detected in 13.8% of the joints. The posterior horn of the lateral meniscus was the most common site of meniscal lesions (affected in 95.7% of the joints).
This cohort comprised 230 knees of 115 asymptomatic uninjured sedentary adults with the MRI showing abnormalities in most (97%) of knees.
In a study examining 50 elite climbers (20-60 years of age), the authors found MRI evidence of tendinosis of the rotator cuff, subacromial bursitis, and long head of the biceps tendonitis was exceptionally common, at 80%, 79%, and 73%, respectively. Labral pathology was present in 69% of shoulders, and discrete labral tears were identified in 56%.
Well, all these MRI changes can also be equated to changes on the outside of your body like the silent scars, bruises, and wrinkles on your skin that develop unknowingly over time, though are harmless!
In conclusion:
MRI is not necessary to make a diagnosis. Not all scans reveal a "cause" and not all "abnormalities" explain the clinical picture.
MRI findings in people in pain are also present in people without pain.
MRI findings might be present way before the current onset of pain (incidental findings).
Pain and function can improve despite the changes seen on an MRI, whereas, early scans can potentially become a reason for impaired coping, unhelpful beliefs, and increased length of disability.
Treatment for many conditions wouldn’t change irrespective of the MRI finding.
You are not your scan. Don’t let an image stand in the way of your recovery, keep moving!
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