MRI Positioning: Does it Matter? | Podcast Ep. 347

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are back with research, a brand new study from pain physician. This one's titled Prone Position MRI of the Lumbar spine in patients with Low Back pain and or radiculopathy Refractory to treatment we can take a look at this which basically analyzes the different positions that an MRI can be taken in and how it affects the results of what's seen on the image. Lots of good stuff in this study. Before we get started, I wanna say a few words about the Payday Practice. Payday Practice is myself and Dr. Jason Deutsch's new book. It came out as the number one new release on Amazon in the chiropractic space. Thank you so much for everybody around the world, quite literally who has picked up a copy this. The feedback we received has been awesome. If you are looking to generate monthly recurring revenue in your practice, the Payday Practice is for you. It's a step by step guide. We put it together. It took us years to get this out there and I would just really, really appreciate it. It matters so much in the first few weeks. Anybody who picks up a paperback copy or if you'll go back on if you've picked up a copy and left a review, I would greatly appreciate it. Massive gratitude because it helps so, so much during the first few weeks with a new book that came out. So the Payday Practice is available on Amazon right now. Pick yourself up a copy and I would be forever grateful. But as I said at the top, today's show, we're talking MRI and we're talking about the different positions MRIs are taken in and the differences, how it can impact the findings that are seen. And this is a story as old as time. If you've been in practice more than one day, you're going to resonate with what I'm about to say. And that is it's not unusual to see patients with moderate to severe low back pain. Some of them have radiculopathy, maybe some don't, and an MRI that looks clean. There are no findings, it's estimated. We dove into this deep in the personal injury world with the imaging company that I'm a part owner of. And we found that up to 30% of patients have minimal findings on their MRI after a traumatic accident. Now we hear the other side of that story a lot, that everybody has findings on an MRI and they don't necessarily correlate with pain. Also true. But many people come in and you see it all the time. They have minimal findings on an mri, they might have radiculopathy, they have pretty bad pain. And everybody's kind of left saying the patient's frustrated. I'm looking for a direction. As a doc, you look at that and it's difficult to make a clinical direction because the evidence just isn't there to showcase that there's a disc issue, that there's a stenosis issue, and it becomes a really challenged situation. Now, what happens often, I'm gonna say, especially if these people visit a primary care doctor first, they're typically scheduled for an intralaminar or transforaminal epidural steroid injection in the prone position. And that's a problem. We've talked about it multiple times on here, but there are millions upon millions of ESIs delivered each and every year. Limited effectiveness, very little utility, not FDA cleared for what they're used for. It's off label and there's potential joint deterioration. It stops the healing process at the bare minimum. And it's just not a good treatment option. Yet. This happens all the time when there's minimal findings. And I'm saying, especially in the primary care medical world, because if they would have saw a disc, it would have been the referral out to the surgeon to chop away the disc, quote, unquote. But if there's minimal findings, well, what are we going to do? The answer is they should be going through movement based care and referred into your practice. But quite often that's not happening. They end up on these patients lasting only a few days or early relapse suggest, among other causes, mechanical instability. So we're gonna dive deep on that in this podcast, but they're citing it right here. You know, after somebody gets an injection. Well, limited improvement in most of these patients might last a few days. Early relapse, potentially there's a mechanical or a biomechanical issue here. That's a big deal. Why? Because that's an area where we thrive. Now, instability can live in a few different realms. We discuss this a lot within a Diagnostics, which is a spinal imaging company that I'm involved in, where we do functional spinal imaging. Weight bearing through full flexion extension, controlled and uncontrolled because of these exact issues. Surgical instability is one thing. You know, 5 millimeters or more of slippage, there's really a potential for catastrophic injury to the spinal cord. But when you have motion that's between 2.5 and 4.9, it's not surgical, but it's beyond normal. That's mechanical instability. And you think about how the vertebra sit. You have the ivf, and the top half of that IVF is the superior bone. The bottom half of that ivf, the intervertebral foramen, is the inferior bone. Well, what happens when there's instability? When there's translation of a millimeter or two, one of those half of the hole offsets on the other creates a pinch. And that happens all the time. And you think about an IVF being maybe 6 millimeters in width. Two millimeters of slide's a big deal. Two millimeters of slide is, you know, 25, 30% of that IVF is taken just like that, 3 millimeters. You might have 50% of that IVF being crunched as somebody's going through motion or underweight bearing that's not being picked up on. And quite often I'm going to say it will never be picked up on with an MRI because it's not weight bearing, it's not functional. And quite often they're taken in the. What I'll just generally say, I guess is the wrong position. So when you look at the clinical condition of these patients, many don't report pain when they're in the supine position, and some patients even experience improvement when they're in the supine position. So this study doesn't get into the functional spinal imaging with vertebral motion analysis that we do at aomsy, but it does get into prone versus supine on the MRI side of things. So segmental lumbar motion, it's usually evaluated through, as we kind of discussed, flexion extension films. What's the problem with flexion extension films? Well, historically, we've seen Punjabi and White say there's actually no utility in flexion extension films. Why? Because of a few different things. One is because you're missing so much of the information between neutral flexion and extension. Those are three moments in time you're missing. There's a 30% false negative rate, meaning 30% of the people that have no findings on flexion extension actually do have excessive translation, just not picked up. Why? Because it's only three moments in time. Instead of like a vertebral motion analysis, a full image of every moment, a video of what's going on every step of the way. The other is that it's uncontrolled. We've all had this patient. Can you bend your head forward, take the flexion, and they stay in exactly the same position as they are neutral. I am. Can you bend Back, they move their head 0.2 centimeters. I am. You're just not getting a great data set. So you want controlled and uncontrolled bending, and you definitely want to have the opportunity to see everything that occurs, not just your end points. So segmental instability is defined, as they say, vertebral body subluxation, excessive motion of more than 3 millimeters, or sagittal angulation, angulation, translation, disc height. Three important things here. Subluxation, translation of more than 3 millimeters or sagittal angulation of 15 to 25 degrees. So this study aimed to say, well, if we go prone and we go supine with the mri, what happens? So patients suffering from chronic to severe low back pain with or without radiculopathy that had not responded to conventional treatments, multimodal care, physical therapy, interventional epidural blocks, facet blocks, radiofrequency ablation, that was what was included in the study. They did have to have a numerical rating scale, a pain Scale, an NRS score of greater than 4. So the inclusion criteria were moderate to severe chronic low back pain, supine mri, a normal dynamic X ray. So a normal flexion Extension x ray, 30% false negative. Right. Also, poor response to treatments and pain worsening during epidural distention and in the prone position. So they're trying to see what's gonna go on when somebody goes from prone to supine. Couple other things before we get into the exact data is they really wanted to standardize the nomenclature of disc pathology. I think this is just good information because bulges, herniations, protrusions, extrusions, most of the time we use them interchangeably. Some great, great take home clinical pearls right here. They defined disc bulging as circumferential enlargement of the disc, which could be symmetrical or asymmetrical. Disc herniation was a disc protrusion or extrusion from a focal bulge generally greater than 3 millimeters outside of the vertebral margin. A disc protrusion was an eccentric herniation with a wide base connection with the disc in any plane with the greatest possible distance between the margins of the disk material protruding from the margin of the disc space less than the distance between the margins of the base. Any extrusion was an eccentric focal bulge that retains a thin pedicle connecting to the disk. Probably a lot easier to see those in pictures. So we'll drop a link to this study in the show notes. But that is how they define these. I felt good about myself reading it because that's How I've traditionally defined these. But a bulge is broad, a herniation is focal, a protrusion is a variation of a herniation and an extrusion is that ship is about to sail and just about to become a fragment. That's how I would define it. So they measured a few different things in terms of what was going on. They measured the spinal canal area. Is there stenosis? Not stenosis. They measured ligamentum flavum area. Ligamentum flavum sitting in that canal. We see that become hypertrophic quite often. I would see that on MRIs all day, every day. That causes a crunch. We also measured lateral recess diameters, that space between the spinal cord and the in the foramen, so to speak. It's that corner or that junction point as well as the intervertebral foramen area. So that's what they measured. Conventional measurements, great measurements, important measurements. Who are the people in this study? They were about 48.7 years old with a mean pain rating of 6.5. And in the prone position, six cases of 19 were found to have herniated discs that could not be assessed in the supine position. On the prone images they identified significant buckling and increased ligamentum flavum thickness. In 10 of 19 patients that they did not see on the supine MRIs, 26% had newly discovered degrees of spondylo and facet joint issues that resulted in significant foraminal stenosis in the prone position. So long story short with this, these results indicated that a certain degree of segmental instability mainly linked to soft tissue and non bony elements of the spinal cord are visualized when you do supine prone imaging as opposed to just one. To the best of their knowledge, this was the first clinical study that correlates MRI findings with the patient's symptomatology otherwise unexplainable by conventional mri. Thus, because it's symptomatic, minimizing the false negative rate of conventional MRI and the false positive rate of studies performed without clinical correlation. They say the most striking finding is the high incidence of thickening, folding or buckling of the ligamentum flavum observed in almost half of the patients. This may contribute to both global canal and recess symptomatic stenosis. There is no question about that. What are the take home messages here? The take home messages are positioning when taking imaging matters. This was looking at prone versus supine. In my opinion, getting people weight bearing and in motion is the best way outside of the study. But it is the best way to analyze what's going on in the spine because you just do it in a way that's can't be done otherwise. And when we look at these studies as well, there's two components and we touched on this at the top. But I want to come back around to it and that's often MRIs get a bad rap as being overutilized. Are they or are they not Conversation for a different day often MRIs are also criticized for having findings and this is a challenging thing. I think we've all had patients that they have as this study highlighted early on, they have symptomatology and no findings. You're sitting there scratching your head. On the other side of the equation. You see people that come in with one or two out of ten pain and you receive a 27 page report that you know basically is breaking down the challenges on every level. When and both are true, that's the challenge. But the way I described it to a patient is I used to say the MRI report is like putting a deck of playing cards all spread out across the table. Those are all of the not perfects. Everything in your report is going to tell you every single thing that is not perfect with your spine. But there is a big difference between a not perfect and a problem. And my job is to help identify the problems amongst all of the not perfects. It is a simple explanation, it's a true explanation and it's a clear explanation that patients don't need to. People don't need to be super concerned with every finding on their mri. There's a normal aging process that goes on. You, you're under gravity, you get injured, these things happen. But there is a break even point where they're amongst often those challenge, those not perfects are the problem. Your job, my job, our job as chiropractors is to evaluate that patient beyond the imaging, correlate their symptomatology with what's on the imaging and help give the best direction moving forward. And if we do that, we're gonna do wonders for the health of our community and, and for the clinical management of our patients. Why? If you rewind this about 10 minutes ago, you'll remember when people are getting care according to their MRI in many other medical facilities it is off to the injection table and if they see a disc injury, it is off to the chop and block. It is time for surgery. Not only are both of those interventions highly overdone, I'm going to say in many cases they have limited effectiveness. People need to have movement based care. That is how they're going to get well. That is how they're going to stay well. And we need to tell that story time and time again because it is not told enough. So great study, great findings. I'll drop that link down below. 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