A Normal MRI, Celebrating An Anomaly

We saw something today that most of us in this practice have seldom seen, a completely normal MRI. It also had a report attached that said it was a completely normal MRI, another anomaly.

Let’s talk….

There is a saying out there that, to paraphrase, we are all actually not living, but dying, each day. As we get older, our bodies start to break down from everything we do with, and to, them. Degeneration, especially in the joints and spine, is normal and can start showing up in tests such as MRI’s and CT scans in the early 20’s.

Also, very few people have a perfect structure. Spinal canals can be narrowed, there can be congenital defects throughout the body or people are injured in different ways at all ages. Radiologists are obliged to read everything they see, so even the “close to normal” MRI reports can scare a layperson into thinking there is something terribly wrong.

 This is why we treat patients, not MRIs. Something can show up on an MRI, but it could be normal for that person and be completely asymptomatic. It is also why we want to see films, not just reports. Every radiologist uses a different vernacular and level of importance to what they read. It may not be what we would consider important in relation to our patient’s symptoms.

So, if you get an abnormal MRI read, don’t panic. Your sympoms will be what is important, not a diagnostic test.

Citations

  • Jiang X, Chen D. Magnetic resonance imaging analysis of work-related chronic low back pain: comparisons of different lumbar disc patterns. J Pain Res. 2018;11:2687-2698. PubMed PMID: 30464586

Discussing news and issues in orthopedics and spine healthcare. This is Spine Talk. Hi, I'm Dr. John Shim, and today we're going to talk about a very interesting topic, and that's a topic about disc degeneration findings on MRIs of young military recruits of the Italian Air Force. There was a study published in June 2019 in one of the journals of spine, and it's about this very topic. Jason, I hope you can kind of enlighten us on the topic, and what they found. All right, so this the study very intriguing study that we looked at comes to us from Naples, Italy. It was a cross-sectional study in retrospective study of 350 Air Force cadets in Italy. The cadets ranged in age from 18 to 22 years old. All of them underwent an MRI the thoracic and lumbar spine - this was done over approximately a four year period. The study protocol had two radiologists reviewing the studies to look at curve abnormalities, structure abnormalities, spinal canal diameter, and degenerative and spinal cord abnormalities. And the findings of the study kind of probably surprised some is that 77% of the 350 cadets had some form of a structural abnormality. This includes 49% with a disc bulge, and 38% with some type of alteration of spinal curve, and 30% with disk desiccation. The authors of the study concluded that the imaging findings are similar to that of an adult population, and suggest the aging spine is morphologically appreciable in immediate post-adolescent period. So Dr. Shim, based on the kind of the findings of study - do the findings at all kind of surprise you in for this very young cohort? Well, for me it's not a surprise. People have to understand we see a very skewed population. People come to see a spinal specialist like me because they're having pain. They don't come to me because they're not having pain. So when we get tests it's almost rare that we ever see a normal MRI. What does give me pause is that no number of these young healthy cadets - age 18 to 22 actually has some sort of finding abnormal on the MRI - 77% that's 3/4 of the population who are not having concerns had these findings. Slightly higher than what I thought but this is more in light of what we kind of know now. The natural history's people develop these degenerative findings or these findings under MRIs, and we see them all the time. So, 77% of this population had an abnormal finding despite being asymptomatic. Yet we know that about 80% of the population adult population develops back pain at some point in their life. As a clinician, where do you draw the line and say that the changes that we see on an MRI are truly age-related versus some type of precipitating event causing them? Well, you know the statistic about 80% of people having some significant debilitating spinal concern in their life. That's a pretty much accepted principle. The question is how one how many of those complaints are actually related to a disc problem, or how much is related to normal wear and tear of arthritis to do up in the spine, or how much is it related to holes, and ligaments, and tendons, and muscles of the spine? I think there's a combination of all those things. MRIs are a very significant diagnostic study. It gives us a lot of information. The question is is it giving us information that's relevant to that person who's getting the MRI? If there's some sort of event that happened and you're really concerned - you get x-rays, you see findings - I think the MRI is very very helpful, and a physical exam will clue you in on should there be a major finding on the MRI. So I think you have to take the MRI findings - a little grain of salt. You have to put it together with what's going on with that person, what happened to that person, and what are the physical exam findings. Do they have numbness, do they have weakness to their muscles that we can detect, if they have reflex changes that we can detect. That would clue us in on are these MRI findings actually related to what's going on with that person right now. So for these the the purpose of the study here. So again it's really not clear from reading through the paper a couple times here kind of the the overall intended purpose of this. You know this kind of looks like they want to use this as a screening tool in this case for cadets going into the Air Force. So when you tell an 18 to 22 year old that you have some type of issue with your spine again they not haven't necessarily knee pain but there's findings on the MRI. What does this do for the long term? Meaning, are we gonna spend thousands and thousands of dollars we already know billions of dollars are spent yearly on healthcare for spine related disorders? Are those people more likely to be the ones that consume all the healthcare dollars because they know early in life there is a problem with their spine? Well, I mean you bring up a very interesting point in, and I'm not sure this has really been researched. Because most of the research that we have in medicine is geared towards trying to solve a problem. All right. A lot of the research is actually fostered by entities that produce pharmaceutical or medicines, produce devices to try to help people. So in a way a lot of these researchers are geared towards finding a problem that we can fix. What we're saying is there's a problem identified on a test that may not be the source of the complaint, but now have we embedded a potential source of anxiety? My goodness, I'm 22 years old and I have these findings in my spine. What's it gonna do to me long-term? Is that going to cause more utilization of healthcare services down the road? Is that gonna cause more angst and maybe increasing rates of disability and work injures and what not? I don't know if the data is really out there yet, but from a practical standpoint I think it probably does. There probably needs to be some longitudinal research on that being done, but I can't really say for sure if enough information has been provided for us to be able to make those conclusions. Now overall again it's very intriguing study that a lot of kind of questions this study can raise, but I think it's definitely some eye opening statistics that this group of authors came up with in looking at the MRI findings. Well, I'll tell you in the past historically in the 60's, we used to x-ray people's backs before they're hired for some manual labor jobs and whatnot. Well they stopped doing that because they realize x-ray findings that by themselves do not really have bearing on how well a person will perform in their job functions - even heavy labor functions. So, I'm not sure using this as a screening tool to take people out of contention for certain things actually makes sense. I don't know if this passed muster United States maybe a pass muster in Italy. What I do know is we still don't know a lot about the unintended consequences of testing. To give you an example there's a lot of information now on laboratory testing. We know if you get 20 laboratory test there's a 5% chance at any one of those laboratories being abnormal just because it's abnormal by testing. So one out of 20 findings is not going to be abnormal. Then you have to chase that finding to find out if that's real or not. Well it turns out we increase the level of anxiety for a lot of these folks, and there is studies showing that there's over utilization based on testing. So is that over utilization of MRI testing actually causing long-term costs? Which I think it does. More important, is it causing long-term psychologic anxieties, and predisposing people to be concerned about things they shouldn't be concerned about? These are very very important issues. I wish we had the answers. I think more studies need to be done. The question is who's going to fund those studies, and is there an incentive to fund those studies? Alright. So, this is Dr. Shim and Jason Mazza. We're talking about the study. It's called the High Prevalence of Spinal Magnetic Resonance Imaging Findings in Asymptomatic Young Adults Aged 18 to 22 Cadets to an Air Force Flight. This was published in the Journal of Spine in June of in the 2019. I found it kind of interesting. I hope you enjoyed watching the video. If you like to find out more information about our videos please subscribe to our station. Thank you.

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