Do You Need That MRI?

Hey there and welcome back. I'm Dr. Vince Leone, executive producer and co-host of the Practice Builders Podcast. With my partner in crime, Dr. Kyle Pankinen, we deliver proven strategies to help you grow fast, specialize with confidence, and build profitable staff-run practices. Let's go ahead and dive into today's episode now.

Well, welcome to today's episode of the Practice Builders Podcast. I'm Dr. Kyle Pankinen. I'll be your host for today. And this should be a relevant topic. This is going to address a question from a clinical point of view that I get frequently from chiropractors that I consult with. And this is not only an important clinical question, but this is a business-oriented thing too, that if you get this right, it'll improve your business of Decompression. So that question simply is this, and the title of this episode is, should every patient get an MRI? And then how imaging decisions affect diagnosis, case acceptance, and treatment outcomes. So that's the big question. And we will talk about kind of the extremes of both sides, and then hopefully we'll find a Kind of a nuanced, a middle-of-the-road way to look at this question. And I think once we sort through this, it'll give you some clarity and it'll help you to move forward making good decisions based upon each individual case. So, you know, we all know MRIs are powerful tools. They can— they should help answer a clinical question. But they don't replace a thorough history and exam. So knowing when to order MRI improves patient care. It increases confidence in your communications and recommendations and helps identify the best candidates for spinal decompression. I'm going to pose, I guess, I think there's an interesting opening question here. If you had unlimited access to MRI, would you order it or would you scan every patient with back pain? Just think about that for a second. Would your answer be yes or would it be no? And, you know, some chiropractors would instinctively say yes. Others would say no, maybe because of cost or because they worry imaging isn't always necessary. You know what? There's probably a little truth somewhere in the middle there that I would say. An MRI is one of the most valuable diagnostic tools we have, but only when it's used for the right patient at the right time. So it's— this is really about making good clinical decisions. And So there's some— let's talk about the extremes because I've seen both of these in practice. And so extreme number one would be, I know some chiropractors that never order imaging, period, either X-ray or MRI. And unless you just have more of a wellness-based practice, a maintenance-based practice, you know, Just strictly you're doing adjusting, but you're not really managing or treating or treating significant neuromusculoskeletal conditions, you're missing probably some pretty significant things. And my opinion is if you're never taking imaging or Ordering MRIs or even basic X-rays, you probably shouldn't be treating significant neuromusculoskeletal conditions. You know, mild everyday things, non-significant conditions. Yeah, again, again, wellness maintenance, things like that. Sure, totally get that, and there's value in that, no doubt. But if you're a practice like mine who I'm getting— we're getting people driving from an hour or 2 away for second opinions for significant neuromusculoskeletal conditions, spinal stenosis and disc herniations and things like that. Yeah, yeah, that's probably an extreme that doesn't make a lot of sense. You're going to be missing significant pathology. You're going to be misidentifying where the potential pain generators And certainly in a decompression practice, you're gonna probably have some candidates that you're putting on the table that might not be good candidates, or you might be putting patients on the table that didn't need decompression maybe in the first place, or they have a contraindication to decompression that you are missing. Then you have the other extreme. This is probably the one that would be more common is, and I know some decompression docs, they want or get an MRI on every patient. Now, I'm not saying that's, if that's the way you do it, that that's necessarily wrong, but this can lead sometimes to overdiagnosis. And what I find happens in practices like this is that they're making treatment decisions that are driven by the imaging findings rather than symptoms, history, examination findings. They're— in other words, they're relying on the imaging basically to prove to the patient somehow that they need decompression. And some of those findings on imaging may or may not be related to—

Right.

The actual pain or problem the patient is having. Sometimes it is an incidental finding. So you have to always remember that MRIs, they don't diagnose pain. This is one of the most important lessons in spine care. People don't hurt because an MRI says they should. It's quite interesting. And you probably know some of this research, Doc, but research consistently shows that many asymptomatic adults have things like bulges and protrusions and degenerated discs and annular fissures and facet arthrosis. And, you know, you can see what you and I would consider, well, that's a pretty significant problem, but yet they have no symptoms or very minimal symptoms. Or mild pain at the most. But interestingly, sometimes you'll have a person that is significant distress, significant pain, can't hardly function. And so, you know, they're pretty severe symptoms, and yet they have relatively modest or minimal MRI findings. So the MRI should always be— Interpreted alongside the patient history, their symptoms, their neurological exam, orthopedic testing, functional limitations, and so forth. So clinical correlation is essential. So I would fall in the camp of I need imaging in many of my cases that come through the door, a minimum of X-rays. And sometimes needing MRI, but I'm not in the camp of that everybody that you're thinking about doing decompression on necessarily needs to have an MRI. Now let's go a little deeper into that. I think the big thing here to think about, docs, is when getting an MRI. Would change your management? So, you know, for obviously a case of simple, straightforward mechanical back pain, no radicular symptoms, no neurological deficits, no red flags in the history or exam. Well, do you need an MRI for that? No. Do you need an x-ray for that? Some cases, yes. If it's a little more on the chronic side, I x-ray a lot of those. Those— but an MRI, I rarely, if ever, have ordered an MRI for just mechanical back pain, facet syndrome, SI joint dysfunction, maybe discogenic mediated pain, but no— No leg symptoms, no arm symptoms. No. X-ray, yes. In some instances, absolutely yes. So that would be patient number 1, straightforward mechanical back pain. Patient number 2, though, is where we get a little nuance. This would be persistent radiculopathy where it follows a dermatomal pattern and you have some positive nerve tension tests, straight leg raise. Bechterew's, slump, Valsalva, any of those types of tests. Okay. We got nerve tension tests. And I think this next thing is the key. Neurological deficits. Sensory, reflex, and especially motor. Okay. If there is motor deficits, that's a little bit more significant. So in a case like that, would I x-ray that patient? 100%. They have leg symptoms. If I can reproduce it, if they have reflex change of any kind, if they have sensory deficits, motor, I'm gonna for sure x-ray that patient. So I'm gonna do a very good history, world-class exam, x-ray. I'm gonna correlate my findings together. Now MRI then can identify obviously more than the x-ray. So the protrusions, the extrusions, the stenosis cases, the nerve root compression. So then you have to consider, is this a decompression case? And do I have enough information to work with From the history, exam, and x-ray findings. If that all correlates together and there aren't progressive neurological deficits, in most instances, I feel I have enough to proceed with decompression. So, however, if they have worsening neurological deficits or I have potentially done maybe 2 to 4 weeks of care and they're not seeing any significant change, or at least some change, then it's time for sure to order an MRI. So any significant neurological deficits, they should get an MRI. Or if you've done up to 4 weeks of care But you have had the x-ray, you have done good exam, but you have done 4 weeks of care and there has been no change. And if there has not been an MRI done, that is potentially a good time also to order one. There are some instances where the MRI is going to change your planning, and that is a key statement. If the MRI If you think that what the MRI is going to show might change how you approach a case, be it a referral or if it's going to impact how you do decompression, that's a good indicator where you say, I need more information because I don't know which way this case is going to go. I don't know if this is for sure a decompression case. I've done the history exam extra. I'm not sure which level is involved. I'm not sure if it's a one disc thing or a multi-level disc thing. I don't know which level I necessarily would primarily focus on or try to target with my decompression. Those are all things as you think through the case. That will determine, yes, I need an MRI, or no, I'm pretty confident I know what this is without the MRI and which level it is at. So those are things that really need to come into play. MRI becomes especially valuable, obviously, when we're— when you're kind of in the middle where you're not sure if this is a decompression case or not. In other words, one that you want to take on because you don't know what kind of a disc it is. Again, what level it is, how many levels are affected. You don't know if there's significant spinal stenosis that could be associated with it. The other thing I really like MRI for is to look at Modic changes. There's Modic Type 1, Type 2 and type 3. MODIC type 1 is especially becoming valuable. That are endplate changes where there is— it's showing an inflammatory component in the endplate, and that is associated with chronic discogenic back pain. And there is an inflammatory process happening there. And actually, interestingly—

Mm-hmm.

Some research studies are suggesting there actually may be a chronic low-grade infection in the disc. Those are things you will not obviously pick up on an MRI. So I am not trying to lay out for you that it is always black and white. There is some nuance in there when you would order MRI, when you would not. But I don't fall into the extreme camp of never order it. I think if you're treating significant neuromusculoskeletal conditions, yeah, absolutely imaging is necessary many times. But I'm also not in the camp that you need to do MRI on every single potential decompression case. To me, That is overkill. MRI is a powerful communication tool though, we have to say that. That is one of its biggest advantages, is not always just the diagnosis, it is education because the MRI can help the patient to address the why. Doctor, why do I have this pain? Why have previous treatments that I've done failed? Why are your recommendations— why are they different from other doctors? Why are you recommending this decompression therapy to me? So when you review an MRI together, a lot of our patients, of course, that come to us, they've already had an MRI done. And it's so important though That you review the MRI with them in a way that they can understand. I have had so many patients that have come in that they have had an MRI done and I will ask them, well, has your doctor sat down with you and really explained to you what this means? And you know what, about 9 out of 10 say, not really. They do not really understand what is going on with their MRI. And I have touched on this on other Podcasts before. But this is where you, you know, you have either your disc model, the handheld one, or you have a poster. I use Dr. Cox's posters to explain a lot of spinal conditions. And these— this is the time when you pull out those analogies that I talked about in a podcast a while back, where you use things like the blown tire. Talking about a disc extrusion or a sequestration, or you talk about a dried-up sponge when you're talking about a degenerated disc, or you talk about an ice cream sandwich that's being squished when you're talking about a bulge or a protrusion. And that's when people— the light bulb goes on for a lot of people when you use simple everyday analogies like that. Patients get it. And I have literally seen people light up when you explain it in simple terms like that. And they'll say, oh, now I understand. This makes sense. Nobody ever explained it to me like this before. And there you go from the level of a skeptic to somebody that's— they're convinced they're in the right place. And you've gone from just a chiropractor to now you're the spine expert in their minds. Just some simple things like that, especially if you've done that along with a good detailed history, a world-class exam, and then you sit down, explain their MRI findings to them using analogies like that. That's a home run. Remember, day 1 problems are— a good day 1 solves almost all day 2 problems. And if you get some of these things right, you're not gonna have near as many day 2 problems. So this builds trust and confidence. Common MRI mistakes that chiropractors make. Let's just review those. Number one is treating the image instead of the patient. I have touched on this before, but I am going to repeat it again. It is a mistake, decompression doctor, to just rely exclusively on MRI findings. And I have talked to several doctors that admitted this to me in the past that did not do world-class clinical examination. They just simply got an MRI. They either ordered one or they— the patient brought in an MRI report, and then they just reviewed that with the patient and said, yes, you are a decompression candidate, or no, you are not. Big mistake.

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Because I've seen many cases, many cases of people that were told they are a decompression candidate. They come to me for a second opinion. We do history, we do exam, and we realize that yes, there's some problems on their MRI, But there's nothing on the MRI that is the actual pain generator. It's not a disc issue. It's an SI or maybe a facet joint issue. It's mechanical. And not that you couldn't do decompression on those, but it wasn't a straightforward like, oh yeah, the disc is the pain generator in this case. And that was because the exam was skipped The patient was told they needed decompression, maybe they didn't. I had a patient recently, literally, it was just simply an SI joint problem. And we did, I think, 6 sessions of adjustments with shockwave therapy to the SI. And this patient had pain for 2, 3 years and the pain was gone. And they were gonna put them through an extensive—

Surgery.

Decompression program for some disc degeneration. Now, don't get me wrong, I'm not saying that that couldn't have been appropriate, but the primary pain generator wasn't the disc, it was the SI joint. The primary pain generator, if you just relied on the MRI, you would say it's discogenic pain, but it wasn't. The exam did not show that at all. And so this doctor didn't do an exam Or did a cursory poor exam. So take-home message is even if you— they come in and say, yep, I've been to another doctor, they say this disc is this or this MRI clearly shows my problem. Don't be lazy. Don't skip the detailed history and the world-class exam. That is a big— that's the number one mistake. That I see doctors make, and mistake number two is ignoring clinical correlation. Your your imaging findings should match your exam and history findings. It should paint a picture. Okay, and if there's a mismatch there, if something doesn't correlate. You gotta figure out what that is. And again, this goes back into interpreting those MRI findings in light of these other 2 things that we've talked about. The other thing is, you can't— the other mistake is you can't rely solely on the radiology report. Sometimes you gotta get in and just look at some of those images yourself. The other thing that I've done in some instances Is medical radiologists, especially with X-rays, but some also MRI. I find medical radiologists' reports are—I'm just going to be blunt—they're just awful. They're—they're bad. Especially their X-ray reports. I can't even believe some of these radiologists are getting paid. For the worthless reports they generate. I got one local doctor, a radiologist that reads for a local medical facility that I happen to treat a lot of patients that go to that medical facility. And they'll come to me with a knee problem, a hip problem, a back problem. They've had an X-ray done at the medical clinic. And so I'll order the images and I'll get the report through a release of records. And the report literally is like 1 or 2 lines. It'll be like a hip X-ray and it'll say degenerative changes noted. That's it. And then it'll say no acute findings. That's the report. Well, is it mild degenerative change? Is it moderate degenerative change? Is it severe? Is it in the superior compartment? Is it in more area of the joint than just the superior compartment? Are there any evidence of femoroacetabular impingement, things of that nature? I mean, it just is a worthless report. You could have that same x-ray reviewed by a chiropractic radiologist. And you would literally have a paragraph or 2 where they would talk about the alignment. They would characterize the degeneration as mild, moderate, or advanced. They would talk about any things that— significant things that are not present there or are present, such as femoroacetabular impingement, cam morphology, pincer morphology. Comment on any bony changes that are present. I mean, that the soft tissues are unremarkable, or if there is anything in the soft tissue. It is a detailed, complete report. And the other thing that you will see— so what I am trying to say is, many times it is wise to have your images that have been done in a medical facility, whether it be an X-ray or MRI. Have a good chiropractic radiologist do a separate analysis of those. I can't believe how many things get missed. Now, I'm not— I'm pretty good at reading conventional x-rays. MRIs, I'm okay at, but I don't feel really, really competent at that. So in a lot of cases, I will have a chiropractic radiologist review that for me. And to just confirm that what the medical radiology report is, is right on, or if they are missing something, and they will do this. I mean, it is like $30. My radiologist is, so I mean, to me, the information you get from that is valuable enough that it is worth doing in some instances. So do not rely solely on a medical radiologist report. That is a mistake. All right, so the other thing is you don't— the final mistake is you don't want to scare patients with terminology. You don't want to use things like, oh boy, this, this report, this image, this is a train wreck, or your spine is terrible. Things like that. You don't need to unnecessarily scare patients. You need to be realistic with them and tell them what's going on, but say things, you know, yes, there's some problems here, but Shane, these things we're seeing, they're common. It's nothing we haven't seen before. And giving them some degree of reassurance. What's most important is identifying which findings, though, match your symptoms and match the patient's symptoms and which don't, because they could have a degenerated disc up at L1-2, but it has nothing to do with the pain they're having in their far low back. Might have nothing to do with it. So careful matching is important. And then final mistake is using MRI only to rule out surgery. MRI is also equally valuable for identifying patients who are likely to respond well to conservative care, including spinal decompression. So the goal isn't to never order imaging. The goal isn't to order imaging on every patient. The goal is to carefully select. The goal is to order better MRIs when the results will meaningfully Change diagnosis, the prognosis, treatment planning, or patient education. Remember this simple framework. History tells you what happened. Examination tells you what's functioning abnormally. And MRI shows you the anatomy of that. When all 3 tell the same story, your confidence increases. Your recommendations become more precise, and your patients are far more likely to trust your care. So the next time you're ordering an MRI, ask yourself one simple question: what specific clinical question am I trying to answer? If the scan won't change your diagnosis, your treatment plan, or patient education, it may not be necessary. But if it will help you deliver more targeted, confident care, it can be one of the most valuable tools in your practice. So I hope that answers some of the questions, rule out the extremes of each side and get us to a more middle-of-the-road ground here when it comes to ordering MRI. So You guys that are listening to this, you're either are or you're trying to become a spine care specialist or expert. You're a decompression doc or you're thinking about being a decompression doc. You need to know when to order imaging and when it's not necessary in some instances. This will make you an expert. Not only you are an actual expert, but it'll make you an expert in your patient's eyes when you can effectively communicate. Oh, Mrs. Jones, we we have enough information to work with without MRI. We have a firm diagnosis. I literally had this discussion with a patient two days no three days ago. He had chronic low back pain and he had a little bit of right-sided sciatica, but it did not go past his knee and he did not have it all the time. But he had undergone quite a bit of chiropractic treatment, which helped, but always was temporary relief. He had been to urgent care a couple of times in the last year or 2 because he had had flare-ups that were quite extreme. And he'd had some imaging done, low back x-rays. And that's part of his history. So we, you know, my staff asked him a bunch of questions and I reviewed his answers and clarified a few points, did a world-class exam. Yeah, you could reproduce his back pain with some of the nerve tension tests. I had his x-ray report from the medical radiologist, and it said mild to moderate degenerative disc changes at L4-5, L5-S1. That's basically what— no acute findings, very simple report. So I asked the patient, were these x-rays done in a lying down supine position, or were you standing? Oh, I was lying down. So I explained to him, we need to— even though you've had x-rays in the last year or 2 and your findings at L4-5, L5-S1 probably correlate with the history and exam you're describing here that we went through, I said, we need to get x-rays on you when you're standing because I want to see the biomechanics of what your spine looks like when you're weight-bearing. And so we did. We sent them off to a radiologist. Well, there was a difference between L4-5 and L5-S1. L4-5 on the standing x-ray was clearly the more involved level. There was moderate to, I would say more moderate to advanced degenerative disc there. And L5-S1 was mild to moderate.

Okay.

He also had a, not a big, but a significant enough leg length discrepancy that would change my care a little bit. And that was one of the reasons I took it because I was, in my exam, I had some suspicions of that. And so he had some biomechanical deficits that showed up on standing x-ray that of course would not show up on Lying down or supine X-ray. That was valuable information. Now I know, okay, I need to target L4-5. Now I know this person is messed up biomechanically from starting from their feet, 'cause we had scans of their feet and they had alteration in their weight-bearing. They had one foot that had more arch collapse than the other. They had a functionally short leg because of that on one side. Hey, those changes—that that was significant, valuable information that I gained by getting some more imaging. Now, I talked to this patient. I said, "You know, yeah, you have some signs of disc issue, but you don't have pain all the way down your leg." There was a little diminishment of the. Achilles reflex on the right compared to the left, but motor was normal, sensory was intact. So just a little reflex change. I'm like, you know, I have enough information to proceed in treating this with spinal decompression, which was what he was coming in for because of advertising, come from over an hour away. And then yesterday, We start him as a decompression case targeting L4-5 and a case where I have enough confidence with history, exam, and x-ray that, you know what, we don't need an MRI. Now, if we get a month down the road and he's not improving, all right, let's get some more information. Let's get that MRI. But the same patient that came into me Say he had pain all the way down his leg. He had some motor deficit, reflex deficit, sensory disturbances, pretty significant nerve tension tests that were positive. That might be a case where I say, you know what, timeout. We need to get some more information before we proceed with decompression. Let's get the MRI ordered. Let's review that and then we'll determine what we do going forward. So anyway, there's a real-world example. This is all about becoming a better decompression doc. And the better decompression doc you are, the better you'll do from a business point of view. We call this the Practice Builders Podcast. Being better clinically is one of the keys To having a practice that is growing and that's building and it's thriving and dynamic. And so that's why I focus on that part a little bit more. And so hopefully this podcast gives you some food for thought, helping you to understand when to order MRI, when to not, and that this will make you a better doc. And when you're a better doc, your bottom line will do better usually as well. So give us a review, give us a like, tell a colleague or a friend in chiropractic about us, and, uh, we'll keep bringing these episodes. Thank you for joining me for today's episode of the Practice Builders Podcast.

Hey, it's Dr. Vince again, and hope you enjoyed that episode. And if you're ready to grow your practice fast with high-value decompression patients, then the Decompression Accelerator could be a phenomenal option for you. This is our 90-day sprint to help you scale with proven systems, staff-driven protocols, and full marketing support, and it's all guaranteed. Spots are limited. Head to www.decompressionaccelerator.com to learn more.