079- Do MRI's Really Matter?

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Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. This week we are talking all about MRI. I gave a talk this weekend for the Florida Chiropractic Conferences. It was titled MRI Essentials for the Practicing Chiropractor. And there was a study that I brought up that was really a landmark study done in the mid-90s and it revolves around the fact that MRI findings may not be all they are cracked up to and that is what we will dive into today on the podcast. I think it's great listening and great patient centric information for every chiropractor out there and everybody needs to be familiar with this study for sure. Before we dive in, I'll say a few words as I do each and every week about Rock Tape. Rock Tape is proud to be a sponsor of the Evidence Based Chiropractor and Rock Tape has rock stock 2017 coming up. I have my bags for figuratively packed. I will be out in beautiful Huntington Beach, California in September and Rock Stock. You can find out more information@rocktape.com rockstock and I believe it's $100 off your ticket price until June 15th. So the days are counting down. It will be fun, movement and everything else you have come to expect from Rock Tape. I have said it on the podcast before. I'm actually going to be videoing out there live. If you are att, let me know. I would love to meet up out there, get you on an interview on Facebook live, amplify the message of your practice to what will likely be thousands of viewers throughout the weekend. So Rock Stock, I cannot wait to get out there. This seminar looks awesome. The activities look killer. I have not been out to one of their movement summits and I'm greatly looking forward to it. And it is in beautiful Huntington Beach, California. So check that out when you get the opportunity. As I spoke about at the top of today's show, today is gonna be all about mri. So I think I've talked about this a little bit on the podcast before, but I probably read about 20 MRI films each and every day and what I have found is probably what many of you have seen that patients come in and they may have an MRI report. And with that report there is a level by level listing that looks as Though they might have 20 or 30 different problems, there are findings disc des. Disc bulging, some various amount of narrowing at multiple levels in each individual region of the spine, whether it's cervical, thoracic, or lumbar. And that can get patients very, very anxious. And it also can get other providers anxious where there's kind of this itchy trigger finger or ants in the pants mentality. And we've all seen it. You know, a patient comes into our practice, maybe they're not getting well as quickly as we would like. And. And during that process, they're actively seeing their primary care doctor who happens to order an mri. That MRI comes back, and there is an MRI confirmed disc bulge or disc herniation with some amount of stenosis. And the primary care doc says, oh, boy, you got a disc herniation. You better go see a pain management doc or specialist for potential injections. And the patient happens to never come back to our office again. And really, that is a massive, massive disservice to patients, not only from the perspective that's probably not what's best for them, but certainly in light of the study that we are about to talk about right now that I think all of us need to be exceptionally familiar with. And the study is called MRI of the Lumbar Spine in People Without Back Pain. And this was released in the New England Journal of Medicine in the year 1994. So we are kicking it back. And what this study did was they took about 100 asymptomatic people who worked in a hospital, and they fired them through a lumbar mri. And then they had two independent neuroradiologists read the MRI to see what was found. Because especially if you think that there's a lot of surgery being done based upon MRI and not based upon patients actually presenting history and symptoms right now, you don't even want to imagine what it was like in the 70s or 80s. So this was really a big study because what they found was 36% of the asymptomatic subjects had normal discs. I'm gonna repeat that. Less than half of the people that had no pain whatsoever had a normal MRI. What they did find was that 52% of the people had a disc bulge at at least one level. They found 27% had a disc protrusion and 1% had a disc extrusion. So an extrusion is when the jelly's outside the donut. It's gone caudal or cephalad out the backside, broke in the line of the end plate. And it does not looks like they got a little tail on the disc back there. That is so 1% even had an extruded disc and no symptomatology whatsoever. 38% had an abnormality of more than one intervertebral disc. So almost half the people had more than one abnormality. And what they found also was 14% had annular defects or annular tears in the discs. The. That's crazy. I'm going to repeat that one more time. 36% of the people, so a very small minority had no findings. 52% had a disc bulge at at least one level, 27% had a disc herniation or protrusion at at least one level, and 14% had annular tears. And this gets down to what I talk about each and every day in my role currently when I review MRIs, is trying to explain to a patient, hey, there is a big, big difference between perfect, not perfect and a problem. And when you look at an MRI report, it's kind of like throwing all the cards on the table. And those are all the not perfects. And it is our job as chiropractors, as their doctor, as their teacher, as their educator, to sort out the problem from the not perfect. And we are going to be the people that are best to do that, because as we have seen time and time again, other doctors might not because they are physicians, not because they mean any ill will towards the patient, but often they are going to look at the MRI report, see that there might be a challenge. Let's say it's a bulge, a herniation, a disc extrusion, or an annular tear, and recommend a more aggressive intervention for that care. Where my counterpoint will be they should absolutely still stay in a chiropractic office until proven otherwise. And as a matter of fact, those other findings, those concurrent findings, those other not perfects, might just mean that it might take a little bit longer to get over the hump. There's more challenge. There's more disease process. Even though it's not a problem yet, our regions of the spine, those segments work together. And if a disc is desiccated, if a disc has a tear, if a disc is bulged or herniated or extruded, even if it's not the pain generator, it certainly is not moving and shaking and doing and working at its optimal function level. So therefore, even if you're not working on that specific area or that specific level, it might be a little bit longer time before the level that is actually the problem is gonna turn around, because its supporting structures are certainly not perfect in that example. So to me, it's about setting proper expectations, it's about educating a patient, and it certainly is about not getting too anxious when you see a laundry list of findings on an MRI report. Because as we now know, and have known for quite a few decades now, there are going to be a majority of individuals that when an MRI is taken, that there are going to be findings on that mri. But all of those findings do not contribute to problems. They contribute to not perfects. And it is our job as the chiropractor, as their doctor, as their healer, as their teacher, as their educator, to do a proper case history, to do a proper physical examination, and to get down to business and sort out the problems from the not perfects. Consequently, I also think this is why it is so important for us as chiropractors to be able to accurately read MRIs. Not to define a neurofibroma from a schwannoma. We'll let their neuroradiologists do that. But we have the distinct privilege, unlike those neuroradiologists who sit in a dark room and file through images all day long and never see a patient, we have the privilege to have that patient sit in front of us. We have the privilege to do an examination, to get to know their lifestyle, to know their case history. And therefore, we can combine. Combine that with the imaging findings to make the best clinical decision. So we always want to take evaluation, symptomatology, imaging, findings, history, combine all of that for our best clinical direction. And that is why I think it's exquisitely important, as I taught that class this past weekend, I said, how many docs in the room? There's about 100 docs in the room. I said, how many docs in the room read an MRI daily? Maybe one or two hands went up. I said, weekly, maybe four or five hands went up. I said, mri. What the hell is an mri? And I probably saw the majority of the room go up. Not that they didn't know what an MRI was, but just they don't look at MRIs very consistently, if at all. And the training on it in school, I constantly hear time and time again is not exactly maybe where we'd ideally like it to be. And again, we're not gonna be all neuroradiologists. But when you can open up a picture, when you see a report, when you have a patient that is scared, that is anxious, and. Or maybe getting bad clinical advice or misinformed clinical advice, from another provider. It gives you a huge advantage when you are able to pop in that disc, take a look very quickly, scan for musculoskeletal issues, and really help identify the difference between the problem and the not perfect. So really, to sum up today's episode, I would say if you have the opportunity to take some advanced MRI reading courses, I'd encourage you to do so. I'm teaching it all around the country. Let your state board, let your local organization know that I am around, that I am teaching MRI essentials for the Practice Chiropractor and I would be happy to come out and do it. It's been an extremely popular program and I actually had a doc yesterday when I was teaching the program come up afterward and said that is the best continuing education program I have had in 20 years, which is really, it's my privilege and pleasure to be able to do so. Don't hesitate to let people know. Also, there are again 4,000 of you listening each and every week. I give you humble gratitude. I thank you for trusting me as a voice in your ears on the way to the office each and every week. If you have the opportunity, I ask one thing of you. If you could please click into itunes, give us rating, give us a feedback. I would love to see 50 ratings before the end of the year. I think we are at 20 to 22 and there are 4,000 people listening so don't think it's always going to be the next chiropractor to do so. If you don't mind, take two moments, give me some rating, give me some feedback on itunes and I will continue to pump out great content, the best that I can do each and every week. So I hope you have a fantastic week in Practice Doc and I will talk to you soon.

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