255- Correlating MRI Findings with Pain

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are back with more research. We are diving into MRI's correlation with pain. Title of the study is Correlation of Pain with Objective Quantification of Magnetic Resonance Images in Older Adults with Chronic Low Back Pain Produced by Spine in 2014. We featured it a little while ago as one of our monthly research briefs. I wanted to bring this topic back up. We've been talking a lot about imaging, about trends, how MDs are handling it, how they're probably over ordering imaging. We've also discussed how you, as a chiropractor, you should be looking at these images with your patients. It helps explain what's going on. It plays a little bit of offense and defense. But today we're gonna focus specifically on this study, which I think is pretty darn impactful. And it's about correlation of pain and tying it to objective findings on MRI in older adults with chronic low back pain. This is what we're gonna break down today. Before we get started. If you have not left us a rating or a review on itunes, please do so. We have well over, I think, 11,000 docs listening to this podcast each and every week, which is completely awesome and I like to have more docs find out about it. So if you like what you've been hearing or if you want to give constructive feedback, if you are on your iPhone, you can scroll on down, tap how many stars you think this podcast earned, and I will thank you in advance for doing so. But as I said at the top, we're talking correlation to pain with objective quantification and MRI in adults with chronic low back pain. So we have seen, and we've highlighted a few of these studies over the last few weeks. That research shows us that primary care physicians routinely order MRIs as a diagnostic tool for spine complaints. Now, the paradox there is MRIs have traditionally had little to no correlation with pain and or functional ability. And we've seen this. If you're in any chiropractic Facebook groups, I'm sure you see this all the time. The questions about where does imaging fit in? And we're going beyond X ray today because we're talking mri. So. Also, positive findings on MRI are often found in asymptomatic patients. Again, I call this sorting the problems from the not perfects. I used to explain it when I'd review about 20 images, MRI specifically with patients each and every day at one of the multidisciplinary groups I was with. I always thought of it like taking a deck of cards and, and spreading the deck of cards out on the table, right? And you have all of these not perfects, all those cards are not perfect, right? You're seeing degenerative changes at these three levels. You're seeing a disc bulge at this level, you're seeing mild foraminal encroachment. At this other level on the left, a different level on the right, you're seeing all of these findings, right? And those are the not perfects, as I think of them. But our job, your job as a clinician is to take all of those cards spread on the table, all of those not perfects, and be able to, to the best of your ability, to pick those pro which are the problems. Amongst the not perfects, you might have 50, 100 not perfects and you might only have one actual quote unquote problem, something that's causing the symptomatology, the challenges at that moment in time. Our job as clinicians is to be able to sort through all of those not perfects and find those problems. So it's imperative that we continue to look for, whether it be advanced algorithms. I think there's super interesting stuff coming in the AI realm regarding imaging that is going to be next level and for us to identify the markers which will better correlate pain and function with the findings on an mri. The better that we become at that, the better clinical results we'll get in practice, the better we'll be taking care of our people in a patient centric way. And ultimately it also helps the imaging. I mean, the imaging is there not to find not perfect. The imaging is there to source and direct the care of the problem. So in this study they talk about the percent MRI index outlined as probably the first step in that search for sort of these objective markers. Additionally, it's important to note that chiropractic care has been shown to be effective and safe option for treating chronic low back pain. So this study is specifically relative to chronic low back pain. And I think it's important to note that it's not only as us as chiropractors being able to take a peek at these images and determine the problems within the not perfects, it's also then the care that we can provide. As we've seen time and time Again, beating in terms of outcomes, injections beating in terms of outcomes, medications beating in many cases in terms of outcomes, surgical intervention, all an important part of the next step of the puzzle. So these researchers found seven disc features. They graded these disc features and this is what starts to shape the percent MRI index as they define it. So let's go through these seven disk features because a lot of these are going to sound. Pretty much every single one is going to sound very familiar to you and you're going to. And these are great things to think about as you view an mri because many reports, an overwhelming majority are not going to be currently utilizing this percent MRI index as like a magic number of like, you know, is this person's MRI graded a 20 out of 100 or 99 out of 100. Right. That's not the way that this goes. But. But the features utilized within the percent MRI index are some things that we can all keep in mind as we continue to evaluate these images. So the seven features are T2 signal intensity loss, right? T2 signal intensity loss. We should see those discs with a dark rim around the outside and a nice bright white center. That's a healthy disc because it's well hydrated. And in T2 MRI images, well hydrated discs show up as white. And darker means a dehydrated section. So a great looking disc has a nice dark rim on the outside and a nice bright white center. So T2 signal intensity loss is when everything looks darker, everything looks gray, everything looks black. So that's feature number one. Feature number two, disc extension beyond the inner space. This would clearly be defined as a disc bulge, a disc herniation, a disc protrusion. If the disc is bound, bulging, if it is protruding, if it has extended beyond the inner space. That's the second feature. To look at the nucleus pulposus shape. This is something that's a little bit more difficult to visualize in some images. But the shape of the nucleus pulposus, is it deranged? Is it pretty well circumferential? What does that look like? That's another feature. The fourth feature, annular tears. Anytime in that dark outer rim that you visualize a white streak that is typically very indicative of an annular tear, a tear in the annular fibers around the edge of the disc. That's feature number four. Feature number five is modic changes. So degenerative changes, modic changes, type one, type two, whatever it might be, those are. That's the fifth piece of the puzzle. Sixth is end plate integrity. Are those end Plates nice and clean. Does it look like a nice straight line or is it looking nasty and chomped up with those modic changes? Those things kind of go hand in and then number seven, osteophyte formation. Are there any claws of bone hanging off the front anterior portion? Is there anything coming off the back or the side? So osteophyte formation is number seven. Those are the seven disc features that are graded as a percent MRI index, T2 signal intensity loss, disc extension beyond the inner space, nucleus pulpulsus shape, annular tears, motic changes, endplate integrity and osteophyte formation. Let's pull out a few of the most impactful quotes from the study. Then we'll finish it up with some findings and how it specifically correlates with pain and how you can think about this in practice. These researchers found quote chronic low back pain is among the most important factors influencing the physical health of individuals older than 65 years, affects around 25% of the population older than 70 years. Just framing the importance of it, they also found quote an MRI index parameter was calculated as the product of the disc's area and the sum of pixel intensity. That's sort of how they viewed it. They also found overall more degenerative discs as assessed by percent MRI index had a more negative correlation with pain, suggesting lower contributions to overall pain. And less degenerated discs has a more positive correlation with pain, suggesting greater contributions to overall pain. We'll talk about that in a moment. And finally, they found quantified measurable parameters from Lumbar. Mr. Images have better correlation with patients chronic low back pain than subjectively scored parameters. So let's dive into that. That almost sounds like I probably read that third quote backwards. Like, wait a minute. The more degenerative that the disc is, the less correlative with pain? The answer to that is absolutely yes. They used the Kricaldi Willis phase and they basically broke it up into three phases. Phase one is dysfunction, phase two is unstable, and phase three is stabilization. So what are some of those radiographic changes with each of these phases? Let's talk about it. In phase one, there's really no changes. It's dysfunctional, but there's no changes in a radiograph. And pain is possible, but it's only possible. It's not a foregone conclusion. These in phase one have the highest percent MRI index. Phase two is unstable. There's early disc changes on radiograph. These are very, very correlative to localized low back pain and pain with movement. It also has A high, not the highest, but a high percent MRI index. And finally, phase three is stabilization. Loss of disc, high osteophyte formation. Pain is typically minimal at this point, and there's a very low percent MRI index. So I almost think of this as a bell shaped curve. You ultimately have normal, right? You're reaching skeletal maturity. You haven't had any injuries. Everything is cooking and cruising along just fine. Then there's sort of the bell shaped curve. Picks up the middle of that bell shaped curve. 40 to 65 years old, there's findings on the MRI and it's the most common area in time that we see disc challenges, that we see this, you know, the start of stenosis. We see a lot of these neuromusculoskeletal issues, specifically in the low back, come to fruition. 40 to 65 years old, right? Then we see things as we get older, beyond that, we see that stabilization as they define it here, phase three, where the body really kind of puts everything on lockdown. You know, osteophytes, there might be bridging osteophytes that actually have basically auto fused A level at that point. It's very unlikely that there's pain due to the disc at that point because it's auto fused. There's no real motion. Now you still could have compression based upon the location of the osteophyte, based upon any ligament hypertrophy. You could definitely have compressive challenges that cause radicular pain. However, the body does have this really interesting stabilization type thing where if you sit down in a practice, people come in, and especially in the surgical practices that I was with, you see just so many of these people between 40 and 65 years old, and very few people at 75, 80 years old, and they're on the tail end of that bell shaped curve. They've gotten beyond it. The body has adapted, the body's stabilized. Now, I'm not saying that the goal should be to auto fuse a segment and have bridging osteophytes connect things. But what I am saying is that when we look at the degenerative process, when we look at the aging process, if you can make it through those 20 years, right, this is a long time. But if you can make it through that 40 to 65 years old, even if you have challenges at that point in time, it's very likely that you can get out of the woods by the time you get above 65 or 70 years old. I think about this in terms of what we do as chiropractors because what we can do as far as helping people not only live a functionally better life, but mitigate pain, avoid surgery, avoid advanced dangerous interventions, the drugs, the steroid injections, the surgical intervention, if you can help people get through it, that is so, so critically important. It's difficult to quote, unquote, fix a low back. If you view fixing it as completely reversing the findings that you're gonna see on an mri, it's very unlikely. Everything's happened, but it's unlikely that that's gonna happen. But somebody work through things functionally if you can help them avoid advanced interventions by mitigating pain, improving function, having their quality of life to the point where they feel comfortable and satisfied. You're doing these people a huge favor because it doesn't just get worse and worse is my point. In very few cases do things just get worse, worse and worse. With back pain there is a bell shaped curve. It does quantify and it does qualify against the MRI findings. So as you look at people's Mrs. Low Back, specifically lumbar, in your practice over the course of the next week or so, just think to yourself, hey, is this phase one? Is this phase two? Is this phase three? Do I see some early changes? When you see early changes, that's often the time when people are in the most pain. But if you see that there's an osteophyte formation, complete loss of disc height, that person might be having minimal pain. Again, those seven disc features as they were graded T2, signal intensity loss, disc extension beyond the inner space, nucleus pulpulsus shape, annular tears, modic changes, endplate integrity and osteophyte formation. All important things to keep in mind. It's kind of a lot there, I get it. But if you want to check out this paper, I'll drop a link down in the show. Notes. We shared this paper as part of the evidence based chiropractor. Our hundreds of docs throughout the world shared it with medical doctors in their community. Again, building trust, building rapport, sharing education, sharing knowledge. That's what it's all about when we talk about building referral relationships. So if you want help building better relationships, incoming referrals into your practice from other healthcare providers in your community, then head on over to the evidencebasedchiropractor.com and check out what we have going on. If you want to automate all of your email marketing, your social marketing, and basically crush it as far as patient activations and reactivations are concerned, then head over to our consumer based service called the Smart Chiropractor. We'll get you hooked up there as well. We include all in office screens streaming to your screens each and every month that changes autopilot. It's pretty awesome so be sure to check that out. If you have any questions on this paper, shoot me a message. Jeff at the Evidence Based Chiropractor keep an eye on those MRIs of your patients. Keep on learning, keep on helping people in the best patient centric way that you can live their best lives and you will continue to grow as a provider and your practice as a result will continue to grow with referrals and happy people in your community. So make it a great week. Have an awesome week in practice and I will talk to you soon.

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