Is my MRI accurate?
In a recent study doctors made this observation: (we saw) evidence that weight bearing MRI evaluations based on (current) imaging protocols are compatible with patients reporting mild to moderate knee osteoarthritis-related pain.1
Here is how to understand that: A patient reports knee pain, a doctor sends him/her to get an MRI. The finding? “MRI confirms what you told your doctor, you have knee pain.” This is the kind of research that indirectly confirms research like this: 43% of Knee MRIs are arguably useless.
Research says 43% of Knee MRIs are arguably useless
Recently, research appeared in the medical journal Knee surgery and Related Research, that looked at 185 knee MRIs and evaluated them as useful, too difficult to interpret, and arguably useless as a means of recommending a treatment program. The results?
- 43% were useless
- 18% were too difficult to interpret
- 39% were useful especially when it came to obvious injury as in sports injury and advanced degenerative joint disease.2
Not shocking, it agrees with other research which said that knee MRI is highly accurate in evaluation of internal derangements (structural damage) of the knee. However, a variety of potential pitfalls in interpretation of abnormalities related to the knee have been identified, particularly in evaluation of the meniscus, ligaments, and articular cartilage”3 In other words – the MRI pointed out the obvious, or could not offer help because image was too difficult to interpret, or were of of no use at all for recommending a treatment plan.
In another study ACL damage in degenerated knees was much more difficult to determine than an acute injury and in fact were:
- Moderately successful in GRADE 1 damage – intact ligament;
- POOR for Grade 2, partial tear with less than half of the ligament substance disrupted;
- POOR for Grade 3, partial tear with more than half of the ligament substance disrupted;
- FAIR for Grade 4, complete tear. 4
So as you can see an MRI can sometimes be detrimental to designing a treatment program for the patient, especially a surgical treatment program.
Now here is another study on the problems of surgery selections based on MRIs
- False positive MRI scans may lead to unnecessary surgery for meniscus damage.
- The false positive patients who went to surgery prevented the those with real meniscal tears from getting more prompt surgery because of a backlog. And by the way the false positive patients should have never been sent to surgery.
- It is also important for the surgeon to review the MRI scan itself, as well as the report. (Some surgeons did not even look at the MRI).5
We usually advise new patients that we do not require an MRI before his/her visit as when they do come in we will do a physical examination and talk to them about their pain challenges. Asking the patient questions about their pain has always been a main component of our initial consultation. Now it is considered a sound scientific device in recent research comparing taking a patient history to MRI accuracy. Here is the research to prove it: “MRI findings may have some usefulness for predicting the grade of knee instability in patients with symptomatic ACL injury, but its value is limited, especially in patients with a longer time interval between injury and the performance of MRI.” 6
Researchers say going to knee replacement surgery? Let a doctor examine your knee NOT the MRI
Research suggests that the decision to have knee replacement surgery should be made after a physical examination and consultation. Unfortunately many times the decision is left to the interpretation of a scan or X-ray that may not provide the doctor with an accurate assessment.
Late 2012 and 2013 research recommended to doctors that the determination of a patient’s knee pain was best left in the hands of an experienced examining physician – as opposed to patient scans:
“The use of MRI techniques to investigate tissue pathology (damage) has become increasingly widespread in osteoarthritis research. Semiquantitative assessment (this is defined as non precise – or subject to interpretation) of the joints by expert interpreters of MRI data is a powerful tool that can increase our understanding of the natural history of this complex disease.
Several reliable and validated semiquantitative scoring systems now exist and have been applied to large-scale, multicentre, cross-sectional and longitudinal observational epidemiological studies.
Such approaches have advanced our understanding of the associations of different tissue pathologies with pain and improved the definition of joint alterations that lead to disease progression. . . Although these new scoring systems offer theoretical advantages over pre-existing systems, whether they offer actual superiority with regard to reliability, responsiveness and validity remains to be seen.”
The study interpretation cast doubts that the latest MRI technology is actually helping the patient’s situation
The study interpretation cast doubts that the latest MRI technology is actually helping the patient’s situation. In other research, MRI based diagnosis was given another set back when doctors summarized: “Knee pain, stiffness, and duration of disease may affect the level of disability in the patients with knee osteoarthritis. Therefore treatment of knee osteoarthritis could be planned according to the clinical features and functional status instead of radiological findings.”7
The interpretation of the research suggests that it is better to ask the patient what hurts them as compared to telling them what hurts them based on scans.
Hopefully technologies of the future will assist in making a determination of the patient’s true cause of pain, but for today, in our opinion and that of certain researchers – physical examination and patient history is superior to the current technology.
It is not just Knee MRIs in question
And here is supportive research that examined MRI readings in the ankle. Doctors looked at a group of patients
- 95% reported pain as the primary reason for seeking medical attention
- 44% reported instability
- 42% loss of function
Also, almost as a sub note it was reported that 39% reported previous ankle surgery. Since these patients were seeking relief of pain it can be assumed that these were failed ankle surgeries.
The researchers noted that following a radiographic reading and confirmation by arthroscopic surgery – most of the false positives could be eliminated BUT “a high index of suspicion should be maintained in the appropriate clinical setting.”8
One could give an opinion that MRI and surgical confirmation must be balanced and checked by a physical examination in the clinical setting. One could also ask the question – why not just get the physical examination in the first place and put off the MRI and arthroscopic intervention?
How can talking and taking a patient history be more effective than technology? It is in preventing spinal surgery!
For one thing, a doctor has to ask the right questions and do a little investigation. When you ask the right questions you get “significant diagnostic value,” as reported in new medical literature on the diagnostic accuracy of history taking to assess lumbosacral nerve root compression.9
Why is talking to a patient considered a “significant diagnostic value,” because a lot of the other diagnostic methods DON’T WORK.
In trying to determine best testing methods for spinal fusion surgery success prior to the surgery, investigators had this to say:
Spinal fusion is a common but controversial treatment for chronic low back pain. In an effort to test whether any pre-fusion test could be performed to increase satisfactory surgeries and make fusion less controversial, different diagnostic tests including MRI were examined. In the end no tests in patients with chronic low back pain could be identified for whom spinal fusion is a predictable and effective treatment.
Best evidence does not support the use of current tests for patient selection in clinical practice.10
Please see this article on Failed Back Surgery Risks In this article I explain why MRI readings may lead to INCREASED incidents of failed back surgery syndrome.
The difference between a patient history and an MRI is that the MRI can be interpreted subjectively, open to interpretation, and often be a “roadblock,” in helping the patient heal. Our patients are incredibly well educated when it comes to their pain. That is why we think it is better to talk than look at films.
MRI or physical examination?
Published in May 2013 research which says that assessing the patient’s symptoms through physical examination are likely to be more informative for understanding, treating, and potentially preventing functional limitations than radiographic assessments in osteoarthritic patients.11
A recent study acknowledges this: In looking at the widespread use of MRI to identify joint disease, the study says that semiquantitative assessment (which is a non precise – subject to interpretation reading) of the joints by expert interpreters of MRI data is a powerful tool that can increase understanding of joint disease in osteoarthritis.
Using a tried and testing scoring system for different joint diseases, doctors can precisely diagnosis problems of the joint as seen on the MRI. BUT, the researchers warn – it is still not accurate!
“Although these new scoring systems offer theoretical advantages over pre-existing systems, whether they offer actual superiority with regard to reliability, responsiveness and validity remains to be seen.”
The entire study points to the use of MRI as a valuable tool until the end, which states in theory this should work, but that remains to be seen. In other words – there is a doubt that the latest in MRI enhancements help the patient’s situation.
Supporting this finding is another research paper: Incredibly the paper cites that there is not much by way of published literature to help a doctor to have a proper consultation.
Listen to what they say: “Osteoarthritis is a common condition managed in general practice, but often not in line with published guidance. The ideal consultation for a patient presenting with possible Osteoarthritis is not known. The aim of the study was to develop the content of a model Osteoarthritis consultation for the assessment and treatment of older adults presenting in general practice with peripheral joint problems.”12
An accurate MRI – lack of consensus
There is a lack of consensuses of how to perform the proper consultation in determining how to help a patient. Here is what these researchers came up with: The model Osteoarthritis consultation included 25 tasks to be undertaken during the initial consultation between the doctor and the patient presenting with peripheral joint pain. The 25 tasks provide detailed advice on how the following elements of the consultation should be addressed:
- assessment of chronic joint pain,
- patient’s ideas and concerns,
- exclusion of red flags,
- provision of the diagnosis and written information,
- promotion of exercise and weight loss,
- initial pain management and
- arranging a follow-up appointment.
This study has enabled the priorities of the doctors and patients to be identified for a model Osteoarthritis consultation.13 The study did not say – look at film and treat.
1. Phelan N, Rowland P, Galvin R, O’Byrne JM. A systematic review and meta-analysis of the diagnostic accuracy of MRI for suspected ACL and meniscal tears of the knee. Knee Surg Sports Traumatol Arthrosc. 2015 Nov 27. [Epub ahead of print]
2. Song YD, Jain NP, Kim SJ, Kwon SK, Chang MJ, Chang CB, Kim TK. Is Knee Magnetic Resonance Imaging Overutilized in Current Practice? Knee Surg Relat Res. 2015 Jun;27(2):95-100. doi: 10.5792/ksrr.2015.27.2.95. Epub 2015 Jun 1.
3. Mohankumar R, White LM, Naraghi A. Pitfalls and pearls in MRI of the knee. AJR Am J Roentgenol. 2014 Sep;203(3):516-30. doi: 10.2214/AJR.14.12969.
4. Altınel L, Er MS, Kaçar E, Erten RA. Diagnostic efficacy of standard knee magnetic resonance imaging and radiography in evaluating integrity of anterior cruciate ligament before unicompartmental knee arthroplasty. Acta Orthop Traumatol Turc. 2015;49(3):274-9. doi: 10.3944/AOTT.2015.14.0013.
5. Chambers S, Cooney A, Caplan N, Dowen D, Kader D.The accuracy of magnetic resonance imaging (MRI) in detecting meniscal pathology. J R Nav Med Serv. 2014;100(2):157-60.
6. Chang MJ, Chang CB1, Choi JY, Je MS, Kim TK. Can magnetic resonance imaging findings predict the degree of knee joint laxity in patients undergoing anterior cruciate ligament reconstruction? BMC Musculoskelet Disord. 2014 Jun 21;15(1):214. doi: 10.1186/1471-2474-15-214.
7. Verwoerd AJ, Peul WC, Willemsen SP, Koes BW, Vleggeert-Lankamp CL, El Barzouhi A, Luijsterburg PA, Verhagen AP. Diagnostic accuracy of history taking to assess lumbosacral nerve root compression. Spine J. 2013 Dec 7. pii: S1529-9430(13)01964-5. doi: 10.1016/j.spinee.2013.11.049. [Epub ahead of print]
8. Gatlin CC, Matheny LM, Ho CP. Diagnostic Accuracy of 3.0 Tesla Magnetic Resonance Imaging for the Detection of Articular Cartilage Lesions of the Talus. Foot Ankle Int. 2014 Sep 24. pii: 1071100714553469.
9. Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 2013 Feb;13(2):99-109. doi: 10.1016/j.spinee.2012.10.001. Epub 2012 Nov 3.
10. Nelson AE, Elstad E, Devellis RF, Schwartz TA, Golightly YM, Renner JB, Conaghan PG, Kraus VB, Jordan JM. Composite measures of multi-joint symptoms, but not of radiographic osteoarthritis, are associated with functional outcomes: the Johnston County Osteoarthritis Project.Disabil Rehabil. 2013 May 3. [Epub ahead of print]
11. Guermazi A, Roemer FW, Haugen IK, Crema MD, Hayashi D. MRI-based semiquantitative scoring of joint pathology in osteoarthritis. Nat Rev Rheumatol. 2013 Jan 15. doi: 10.1038/nrrheum.2012.223. [Epub ahead of print]
12. Porcheret M, Grime J, Main C, Dziedzic K. Developing a model osteoarthritis consultation: a Delphi consensus exercise. BMC Musculoskelet Disord. 2013 Jan 16;14(1):25. [Epub ahead of print]
13. Guermazi A, Roemer FW, Haugen IK, Crema MD, Hayashi D. MRI-based semiquantitative scoring of joint pathology in osteoarthritis.. Nat Rev Rheumatol. 2013 Apr;9(4):236-51. doi: 10.1038/nrrheum.2012.223. Epub 2013 Jan 15.