016- Objective Correlation of MRI Findings and Pain

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Hello, welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. It's a beautiful Sunday afternoon here in Tampa, Florida and we are going to switch things up a little bit this week with our research. We're looking at a piece titled Correlation of Pain with Objective Quantification of MRI in Older Adults with Chronic Low Back Pain. This came out just a couple Years back in 2014 in Spine Journal and again they look at the correlation of Pain with Objective quantification of MRI in Older Adults with Chronic Low Back pain. This is a great piece and we'll find out why momentarily. But first let me say a few words about Rocktape. Rocktape is proud to be a sponsor of the Evidence Based Chiropractor. Rocktape offers the world's best kinesiology tape, pain relief, topicals, mobility tools and functional fitness accessories. New from Rock Tape is Rocksauce Chill, a powerfully cool pain relief topical in a convenient roll on with 6% menthol. It's stronger than the freeze competition. They are more than just a tape company, they are a movement company. Learn more and get access to your discount by visiting rocktape.com so as I touched on at the top today we're switching things up with the research a little bit. We're looking at the correlation of pain with objective findings on MRIs. This is a topic that's near and dear to my heart because in my day to day I look at approximately 3 to 400 MRIs per month. I look at a lot of MRIs, I do a lot of overreads. So one thing that I always have difficulty with with patients, often, and I'm sure that you have the same, is they get an Mr. Report back. Maybe they have an mri, they had a previous MRI taken or you ordered it yourself. The report comes back from the neuroradiologist and there are pages and pages of findings. And the patient's logical question at the time they think it's logical is how are we possibly going to take care of all of these items? I have five bad discs, I have this, that and the other thing, and from my perspective it's very important to frame these things for patients because they don't know. And what they don't know is that there are a large difference between what I call not perfect and a problem. And on a radiology report, the radiologists are going to read things and they're in their dark room and they're not privy to all the wonderful things we are, meaning interaction with the patient. So they're notating every single item that is not perfect. But probably 50, 60, 70% of of those findings are age related. They're a normal part of the degenerative process, and they really ultimately are not the reason why the MRI was ordered. Now, of course, you have those outstanding, God forbid, red flags or items that you didn't expect to find that warrant immediate attention, but those are the outliers. Predominantly. What we see is a vast array of minor degenerative changes that make up a bulk of a report. Or there might be some small disc bulges, but there's one large herniation in the lateral recess causing that radicular pain. So that's a long way of me getting around to say when an item or piece of research is looking at the correlation between pain and objective findings. Now that's something that takes my eye. So the researchers here, I mean, the bottom line is research shows us primary care physicians routinely order MRIs as a diagnostic tool for spine complaints. Same can be said for neurologists, spine surgeons, et cetera. And many chiropractors order MRI coincidentally and consistently as well. The paradox is MRIs have traditionally had little to no qual correlation with pain and or function. Also, positive findings are often found in asymptomatic patients. So it's imperative that we continue to look for advanced algorithms and markers which will better correlate pain and function with objective MRI findings. In this study, they're setting forth a measurement they call the percent MRI index. And in my opinion, it might be the first step towards one of those solutions. So what the researchers did is they looked at seven disc features and they graded them. These seven features of the intervertebral disc, again in the lumbar spine, were on a T2 image, signal intensity loss, that is degenerative disc. So they looked at a signal intensity loss. They looked at a disc extension beyond the interspace, I.e. disc bulge, herniation, extrusion, protrusion, whatever terminology we want to use. So disc extension beyond the interspace. They looked at the shape of the nucleus, pufosis, again, very important whether that disc is getting beyond the margins of the vertebral bodies or whether there's a degenerative change and loss of water content. Overall, they looked for annular tears. They looked for changes of the end plates, they looked for end plate integrity. Excuse me, and they looked at osteophyte formation, that is bone spurs. So those are the seven findings that they looked at. And what they were able to do is they took those findings and they created radiographic changes, a chart that highlighted Kirkcaldy Willis, phase of degeneration, radiographic changes, presence of pain. And what they found is that this ultimate percent MRI index, now in phase one, they said they call that dysfunction. There's no changes on the radiograph and pain is possible. It's the highest percent MRI index. Phase two is what they deemed unstable and that's early disc changes on radiograph. So that's typically localized low back pain and pain with movement. That's a high percent MRI index. And phase three was stabilization, loss of disc, high osteophyte formation, minimal pain, and low percent MRI index. So here's a few quotes from them. Chronic low back pain is among the most important factors influencing the physical health of individuals older than 65 and affects around 25% of the population older than 70 years old. Or we know this, of course, because many old patients or older senior patients that we see in practice have low back pain. It's going to affect 90% of people at some point in their life. No surprises there. They also found an MRI index parameter was calculated as the product of the disc's area and the sum of pixel intensities. So this percent MRI index really is looking at this product of the disk area, the square footage, if you want to say, and the sum of the pixel intensities, that is those degenerative changes. How bright or dark does it appear on a T200 image? They found overall, more degenerated discs as assessed by percent MRI index had more negative correlation with pain, suggesting lower contributions to overall pain. And less degenerated discs had more positive correlation with pain, suggesting greater contributions to overall pain. Then they found quantified measurable parameters from Lumbar. Mr. Images have better correlation with patients chronic low back pain than subjectively scored parameters. So that is really a fancy way of looking at mri, creating a percent MRI index and saying what is a square footage, meaning the disc area, what does it look like and how bright or dark is it? And what they found was that there is a correlation between those two factors, that is the percent MRI index and the likelihood of pain in a patient. So this is important because they're taking objective findings, meaning the disc area and the shade or signal intensity of the disc objective for the most part. And then putting that into action in terms of correlating it with the subjective findings from the patients. So I love this study because it takes MRI and puts it in a real world context. Now, I'm going to take one second here because I'd love to say if you've been listening to this podcast and there's literally thousands of kairos each and every month that are listening, I hope you're enjoying the content. If you have the time, I would really love if you could go on itunes, give some feedback. That helps me out a lot. It keeps the podcast going, it keeps it kind of up at the top of the charts there. If you could give a rating, give some feedback, please do on itunes or if you'd like, I'm happy to email me also@the evidencebasedchiropractormail.com but if you've been enjoying the podcast, I ask you, please take a moment, give some feedback. It goes a long way. But back to the research. So again, we're looking at a spine journal article 2014 and it looks at objective findings on MRI and pain. So the important part about this is MRI index is not yet a finding that you're going to get back from a radiologist or probably something that you're going to use every day in practice. But I think there is a couple things that are important about it. Number one is that you can now be aware and when you're looking at those discs and you're looking at literally and figuratively the cd, the disc of the MRI and the discs of the lumbar spine, you can take a look and get a good idea of where you're at on a degenerative cascade. And again, the degenerative cascade is one thing, but when you put it into action with the sum of the discs, square footage or area, it can give you some concrete solutions. Now, I don't think this is going to override what you're reading in terms of if there's severe spinal stenosis, if there's severe lateral recess stenosis, or anything of that nature. But what this research can do is give you one more tool when you're looking at MRIs to accurately distinguish what is relevant and what is irrelevant. So I hope you enjoyed this podcast. I really love diving into mri. I teach MRI essentials for the practicing chiropractor. I think it's an underutilized modality for chiropractors to assess and MRI index may be what we are looking at heavily in the future, but until then, have a great week in practice. And I'll talk to you soon. Soon.

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Sam.