Posts tagged MRI
Will my neck pain and MRI findings worsen with age?

Aging occurs in all of our body systems including the spine.  Similar to wrinkles and grey hair, the spine will demonstrate age related changes including disk bulges, herniations, facet and ligament changes, as well as, degeneration around age 30.  Interestingly, we find a high percentage of these changes in people with and without neck pain.  Thus, we need to be careful when interpreting MRI findings in the cervical spine to ensure the pathology in question matches a patient's clinical presentation.  An interesting study was just performed and questioned how changes on a patient's MRI correlated with their current symptoms.

Daimon and colleagues in this year's Journal of Bone and Joint Surgery followed pain free individuals over a 20 year period.  At the time of the initial MRI all 193 subjects were pain free and physicians documented the degree of cervical degeneration.  The authors reported these age related changes progressed in 95% of subjects and affected all spinal levels over the 20 year period.  As expected, the rates of spinal changes correlated directly with a patient's age.  Surprisingly, the authors reported no relationship between the progression of this degeneration and the onset of clinical symptoms.  One exception was narrowing of the canals (foramen) in the neck.  Narrowing of these canals correlated with upper extremity symptoms due to compression of the nerve root.  

This study adds to the vast amounts of data documenting the high rates of false positive spinal MRI testing.  The lack of specificity of these tests limits their utility unless they can be interpreted with the patient's current symptoms.  Most of these abnormal findings were there before you had neck pain and will be there after successful treatment by a Physical Therapist.  

What imaging pathologies are associated with shoulder pain?

MRI testing of the shoulder is no different than testing in other body regions.  Pathologies such as bursa changes, tendinopathies, labral and rotator cuff tears are very common in asymptomatic populations and tend to increase with an individual's age.  Many of these MRI findings do not contribute to a patient's current symptoms and may be reflective instead of the natural aging process in the shoulder.  Conversely, some pathologies such as rotator cuff tears may explain a patient's symptoms especially when these findings match the patient's subjective history or clinical examination.

Tran and colleagues sought to answer this question by reviewing the available evidence on shoulder MRI findings and a patient's symptoms and prognosis (Arthritis Care Res. 2018).  Authors reviewed 56 papers and found no significant association between most imaging findings and current symptoms.  One exception was enlarging rotator cuff tears which were shown to be associated with an increased incidence of symptoms.  In general, the majority of these studies were low in quality and authors called for high quality studies on this topic.  

High Percentage of Positive MRI Findings Among High Performing Olympians

In the absence of rare spine pathology the only abnormal low back MRI is a normal MRI.  After age 30 many of our spines will age and positive findings will become more common in patients with and without back pain.  MRIs have tremendous sensitivity and can find even the smallest amount of pathology, but their specificity is lacking in patients with low back pain.  Multiple studies have shown high rates of spinal pathology among asymptomatic groups of individuals.  A recent study highlighted the presence of spinal pathology among an elite group of athletes.  

Wasserman and colleagues retrospectively analyzed spinal MRIs of Olympic athletes from the 2016 Rio Summer Games (BMJ. 2018).  The authors reported 100 olympic athletes underwent a spinal MRI during the games and half of these high performing athletes were diagnosed with moderate to severe spinal disease.  Consistent with previous MRI studies, athletes over 30 years old had the highest rates of spinal disease on MRI.  The majority of athletes likely had positive findings on MRI before they had back pain and will have the same findings when their back pain is resolved.  Patients are encouraged to have their MRI findings read in light of their subjective and clinical examination to determine which spinal changes are due to age and which may be causing their current symptoms.

No Correlation Found Between MRI Findings And Spinal Stenosis Symptoms
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Lumbar stenosis is a spinal condition where nerves are compressed by the bony canals in our spine.  When symptomatic, this condition can lead to leg pain, numbness, pins and needles, and weakness in one or both legs of older adults.  Physical Therapy has been shown as effective as surgery for this condition and should be utilized in the majority of patient cases as a first line treatment.   

Interestingly, most of as we age accumulate changes in our spine including disc herniations, disc tears, and spinal stenosis yet we remain symptom free.  MRI s in asymptomatic people continue to shown these changes due to the high sensitivity of this testing, but we given the high risk of false positives we must ask if these changes directly correlate with our symptoms.  A recent review article in the journal Spine authors analyzed the available evidence to determine if MRI findings correlated with back or leg symptoms (Burgstaller et al. 2016).  The authors reported that they "were not able to prove any correlation MRI findings and severity of pain".  This highlights the growing evidence behind the limitations of MRI findings to determine a patient's symptoms, function, or prognosis.  

Individuals with spinal stenosis are encouraged to utilize Physical Therapy to help reduce their symptoms and improve their function, and most importantly put their MRI findings into perspective.


Imaging's Role in Youth Baseball

In our previous blog posts we have written on the limitations of MRI for many injuries and conditions.  In general, these expensive tests have high rates of false positives where patients without pain often have positive results including ligament/labrum tears or tendon changes.  The incidence of false of positives increases in athletes with the majority of major league baseball players, regardless of symptoms, demonstrating rotator cuff tears or labrum injury.   It appears these changes are no different in our little leaguers.  

An article in the Journal of Bone and Joint Surgery examined 10-13 year old little league baseball players.  Each player underwent an MRI on both elbows at the start of the season.   The authors found many of the players with or without pain had imaging findings in their elbow.  Adding to our existing data that many athletes have positive MRI findings without pain or injury.  Two factors were associated with a positive MRI and elbow pain including year round baseball play and working with a private pitching coach.  

Athletes are encouraged to work with a local Physical Therapist to treat their elbow pain and reduce their risk of throwing injuries. 

Resolution of Lumbar Disk Herniation Without Surgery

Physical Therapy remains the first line treatment for lumbar disk injuries due to its' non invasive nature and clinical effectiveness.  The natural history of disk injuries is not well established but preliminary data covered in prior blog posts demonstrates regression of these injuries over time.  A recent case study in the New England Journal of Medicine (Hong et al. 2016) described the case of a 29 year old female with pain and pins and needles into her leg.  Her MRI is shown above on the left side of the screen.  The patient did not want surgery and was instead treated with an injection and Physical Therapy.  After 5 months a second MRI was taken, shown on the right, showing resolution of the disk injury. 

This case adds evidence to the regression and resolution of disk injuries over time with conservative care.  Patients are advised to seek care from a local Physical Therapist before attempting more invasive and costly procedures.