Good morning, everyone! With technology advancing at a faster and faster rate, I think it’s appropriate that today I discuss imaging and its role in the diagnosis and management of various musculoskeletal conditions.
Often times, a new patient will walk through my door and, upon introducing myself and asking the patient the nature of his visit, he will thrust a CD or a report at me and say confidently, “I have a bulged disc. Here’s the MRI”, or, “My x-ray says I have a ton of arthritis.” Now, don’t get me wrong, as a primary health care practitioner and a diagnostician, the more information the patient provides to me, the easier it is to properly diagnose and formulate a treatment plan. It is my job to evaluate all the information in front of me. However, it is also my job to discern which information is clinically significant, contributing to the patient’s chief complaint, and which information is irrelevant. And here is the kicker:
Just because an abnormality appears on imaging, doesn’t mean it is causing your abnormal signs and symptoms.
So what does that mean? Well, applying this statement to the scenario above, just because someone’s MRI shows a bulged disc, does not mean that that bulged disc is what is causing your back pain.
Often when I explain this to patients, they stare at me in disbelief and I can just picture the thoughts running through their heads. “But…isn’t an MRI a picture of what’s going on inside of me? That doesn’t make any sense. A bulged disc doesn’t just show up on imaging if it doesn’t exist inside me.”
And so I clarify. “I never said that the bulged disc doesn’t exist. Its existence is not what is causing your back pain, though.”
In order to wrap our heads around this concept, it is important to know what a bulged disc is. Here is a brief explanation: There is one disc between each vertebra throughout the spinal column. They act as shock absorbers. These discs are made up of cartilage; a harder cartilage on the outside, called the annulus fibrosis, and a liquid, more gel-like form of cartilage on the inside, called the nucleus pulposis. The inside material is highly inflammatory. Think of discs as jelly-filled donuts. Over time, it is common for these discs to start compressing, especially if one is sedentary at a desk all day. This flattening of the disc causes an increase in circumference. It is only when this disc impinges on the nearby spinal nerve roots that one can then get sciatica, or shooting nerve pain down the leg. And depending on which nerve root is affected, the patient will feel this sciatica in specific areas of the buttock, leg, and or foot.
You have just learned that discopathy at different levels of the spine may produce symptoms, and if it does produce symptoms, they symptoms are highly specific in pattern. Thus, if John presents me with an MRI of an L4/5 disc bulge on the right, and yet he is complaining of a slight twinge on the left side of his back at L1/2, then it is highly unlikely that this disc bulge is the culprit. If this seems confusing to you, just imagine going to your mechanic because your transmission isn’t working and him saying, “Ah, the problem is that the button that closes your sunroof doesn’t work.” Not relevant information, right? If that still doesn’t hit home, how about this: Did you know that according to studies, as many as 40% of completely asymptomatic patients’ MRIs showed bulged discs. 40% and yet they had zero symptoms. This is why it is extremely important to correlate imaging findings with clinical findings.
I am not saying that MRIs are useless or that they lie. MRIs are fabulous and are a wonderful aid to doctors in all specialties. MRIs also do not lie. However, a good chiropractor will first take a thorough history, then perform a thorough physical examination, and then examine the imaging to see if it matches up clinically to the patient’s presenation. If the clinical findings do not match up with the imaging findings, then the source of pain is from something else. To not work in this order risks being led down the wrong path as a clinician, which can cause an inappropriate plan of management, leaving both patient and doctor frustrated when results aren’t being achieved with therapy.
I hope this (lengthy) post sheds some light on the significance of clinical skills and their application to interpretation of imaging. Don’t let a picture dictate your fate!
Until next time,
Dr. Julia Viscomi
Active Back to Health
#302 Chinook Professional Building 6455, 6455 Macleod Trail SW, Calgary, AB T2H 0K9
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