Patients ask: Is my MRI accurate?

Prolotherapy Knee articular cartilage repair without surgery

Ross Hauser, MD
Is your MRI reporting hindering your pain treatments? In this article Ross Hauser, MD discusses the over-reliance of doctors on MRI dictating what could be inappropriate treatments.

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MRI or Magnetic Resonance Imaging is a science of rapidly developing technology. Every day new wonders are discovered. So when commenting on MRI accuracy, one needs to make sure that the latest research is cited to give accurate updates. This helps us answer patient’s questions on MRI accuracy.

September 2017: Doctors at Yale New Haven Health at Bridgeport Hospital and Boston University School of Medicine write in the journal Radiologic clinics of North America that:

  • With technologic advances and the availability of sophisticated computer software and analytical strategies, imaging plays an increasingly important role in understanding the disease process of osteoarthritis.
  • Radiography has limitations in that it can visualize only limited features of osteoarthritis, such as osteophytes (bone spurs) and joint space narrowing, but remains the most commonly used modality for establishing an imaging-based diagnosis of osteoarthritis.
  • Clinical relevance of MRI findings related to osteoarthritic joints remains unclear due to the high prevalence in asymptomatic patients.1

July 2017: Doctors at Queen Elizabeth Hospital in the United Kingdom and the University Medical Centre, Rotterdam, The Netherlands write in the European journal of orthopaedic surgery and traumatology:

The assessment of a patient with chronic hip pain can be challenging. Magnetic resonance imaging (MRI) arthrography of the hip has been widely used now for diagnosis of articular pathology of the hip. Our study conclusions are MRI arthrogram is a useful investigation tool in detecting hip labral tears, it is also helpful in the diagnosis of femoro-acetabular impingement. However, when it comes to the diagnosis of osteoarthritis’ chondral changes, defects and cartilage delamination, the sensitivity and accuracy are low.2

In a 2016 study doctors writing in the Archives of physical medicine and rehabilitation 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.3

The simple understanding to that research is: 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

MRI Knee MeniscusIn a 2015 study from doctors at leading medical universities in South Korea was published in the medical journal Knee Surgery and Related Research. The paper reviewed 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.

The conclusion of this research:

  • approximately one-quarter of patients visiting a knee clinic (after visiting other clinics) had pre-obtained knee MRI (came to the clinic with an MRI).
  • The doctors at the clinic viewed the MRIs and deemed more than 40% of them useless in selecting treatment options.
  • In particular, knee MRI was less likely to be useful in patients with degenerative joint disease or nonspecific knee pain.
  • This study suggests clinicians need to reconsider and consult with patients the expected usefulness of knee MRI in making the correct diagnosis and selecting proper treatment options before getting an MRI. 4

The above research should not be particularly shocking to a patient with chronic knee pain. We see many patients with MRIs, and for many of those patients, the MRI has failed to come up with a good treatment plan for them. That is why they are visiting us.

Not shocking, it agrees with early research published in 2014 from Mount Sinai Hospital and Women’s College Hospital researchers who say while knee MRI is highly accurate in evaluation of internal derangements (structural damage) of the knee, 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”5

In other words – the MRI pointed out the obvious, but it had difficulty pointing out the less obvious. It could not offer help if the image was too difficult to interpret, or were of no use at all for recommending a treatment plan.

MRI for ACL?

In a 2015 study, University researchers in Turkey published their research calling into question MRI accuracy in ACL readings.

The found that 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.

MRI False Positive Rates

The researchers concluded: “In cases where there is uncertainty regarding ACL integrity in degenerative knees, although standard MRI provides additional information on ACL status, it is not of sufficient diagnostic value.” 6

So as you can see an MRI can sometimes be detrimental to designing a treatment program for the patient, especially a surgical treatment program.

What do researchers say going to ACL surgery? Let a doctor examine your knee NOT the MRI

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 primary component of our initial consultation. Now it is considered a sound scientific device in recent research comparing taking a patient history to MRI accuracy.

Doctors in Korea writing in BioMed Central Musculoskeletal Disorders examined whether MRI findings are of value in predicting the degree of knee joint laxity as measured using two typical physical examinations, i.e., the Lachman (physical manipulation to test the laxity of the ACL) and pivot shift tests (physical manipulation to test the ACL and PCL Posterior Cruciate Ligament).

  • They concluded that their analysis of the associations between MRI findings and the grade on physical examinations in patients with symptomatic ACL injury suggests that MRI has limited value for predicting the grade of laxity. 7

False positives sending the British sailors to surgery

Now here is another study on the problems of surgery selections based on MRIs. This comes from doctors of the British Navy publishing in their Journal of the Royal Naval Medical Service

  • False-positive MRI scans may lead to unnecessary surgery for meniscus damage.
  • The false-positive patients who went to surgery prevented 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).8

MRI will send you to knee replacement, a doctor after physical examination may have other thoughts

Getting back to the discussion of MRI for knee osteoarthritis and the subsequent use of MRI imaging to send patients to possible unnecessary knee replacement surgery, we find that a lot of 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:

Writing in the medical journal Arthritis, doctors in Turkey wrote:

“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.”9

  • 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.

In both our opinion and that of certain researchers, physical examination and patient history are superior to the current MRI technology.

MRI or physical examination?

MRI vs. Thumb

Published in May 2013 research from Boston University School of Medicine suggests that assessing the patient’s symptoms through a physical examination is likely to be more informative for understanding, treating, and potentially preventing functional limitations than radiographic assessments in osteoarthritic patients.

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.”10

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 Arthritis Research United Kingdom Primary Care Centre doctors had to 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.”

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:

  1. assessment of chronic joint pain,
  2. patient’s ideas and concerns,
  3. exclusion of red flags,
  4. examination,
  5. provision of the diagnosis and written information,
  6. promotion of exercise and weight loss,
  7. initial pain management and
  8. arranging a follow-up appointment.

This study has enabled the priorities of the doctors and patients to be identified for a model Osteoarthritis consultation.11

The study did not say – look at the film and treat.

Ankle MRIs

Doctors at The Steadman Philippon Research Institute writing in the medical journal Foot and Ankle International examined MRI readings in the ankle. Doctors looked at a group of patients:

  • 95% reported pain as the primary reason for seeking medical attention

and secondarily

  • 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.”12

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 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.13

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.14

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.

1 Hayashi D, Roemer FW, Jarraya M, Guermazi A. Imaging in Osteoarthritis. Radiologic Clinics of North America. 2017 Jun 12. [Pubmed] [Google Scholar].
2 Rajeev A, Tuinebreijer W, Mohamed A, Newby M. The validity and accuracy of MRI arthrogram in the assessment of painful articular disorders of the hip. European Journal of Orthopaedic Surgery & Traumatology. 2017:1-7. [Pubmed] [Google Scholar]
3 Gade V, Allen J, Cole JL, Barrance PJ. Upright Magnetic Resonance Imaging Tasks in the Knee Osteoarthritis Population: Relationships Between Knee Flexion Angle, Self-Reported Pain, and Performance. Arch Phys Med Rehabil. 2016 Jul;97(7):1107-14. doi: 10.1016/j.apmr.2015.12.007. [Pubmed] [Google Scholar]
4. 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.[Pubmed] [Google Scholar]
5. 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.  [Pubmed] [Google Scholar]
6. 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. [Pubmed] [Google Scholar]
7.  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. [Pubmed] [Google Scholar]
8. 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. [Pubmed] [Google Scholar]
9. Cubukcu D, Sarsan A, Alkan H. Relationships between Pain, Function and Radiographic Findings in Osteoarthritis of the Knee: A Cross-Sectional Study. Arthritis. 2012;2012:984060. [Pubmed] [Google Scholar]
10. 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. [Pubmed] [Google Scholar]
11. 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. [Pubmed] [Google Scholar]
12. 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. [Pubmed] [Google Scholar]
13. 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. [Pubmed] [Google Scholar]
14. 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. [Pubmed] [Google Scholar]

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