The Association Between MRI Findings and Neck Pain (NEW RESEARCH) | Podcast Ep. 410

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. This week we are back with more research. We're going to talk all about the association between cervical degenerative findings on MRI and its association with neck pain, disability and headache. This is a brand new study that we're going to highlight a lot of clinical pearls and take home messages. Before we get started, I'll say a few words about the smart chiropractor and Patient Pilot. If you would like the names of your patients who are ready to come back into your practice each and every day or whenever they're ready to come back in, that is what we do with Patient Pilot. We send weekly email newsletters to your patients that teach and invite consistently. And as they click the big buttons that say call to schedule and click to schedule to reactivate in your practice, we send you a daily report showcasing exactly who those patients are. If you'd love to learn more about that, head over to thesmartchiropractor.com that is thesmartchiropractor.com, i'll drop that link down in the show notes. The other link that I'll drop down in the show notes is the link to this study. And the study's title is the association between Cervical Degenerative MRI findings and Self Reported Neck Pain, Disability and Headache. This is a cross sectional exploratory study and what they were looking at specifically was, was vertebral end plate signal changes. They called it vesc and in this study they took a look at over 600 people. Of those individuals, 31% had moderate or severe neck pain, 59% had moderate or severe neck disability, 42% had reported headaches and 35% had one or more cervical degenerative features finding on MRI. We're gonna talk about that, talk about the statistics and highlight how it's applicable to the conversations you are having in your practice. Why is this study important? Well, neck pain and headache are the number two and three reasons behind low back pain. On why people visit chiropractic practices. They are also highly prevalent. Excuse me. And they're leading causes of disability around the world. Additionally, headache and neck pain, they happen together a lot. They often co occur in patients. So looking at these individually and together, I think was a great move on the researcher's part. Now, despite the socioeconomic and burden of individual burden of neck pain and headaches, these conditions have received, as you can probably tell, far less attention in the research world than low back pain. At which point we could do low back pain studies each and every week and not get through them all. But neck pain and headache are frequent. Now, neck pain, like low back pain, is multifactorial. There are biological issues and causes, psychological issues, correlations and causes, as well as social factors. But the evidence on the underlying pathology of neck pain is sparse. Sounds pretty similar to low back pain, where non specific low back pain, quote, unquote, is often the most common form of low back pain. But of course, anytime that there is a symptom, there is a reason for it. It's just that we haven't been able to specifically identify those reasons. And there also is thought to be a relationship, of course, between headaches and the structural changes that occur in the cervical spine. But how they play together can be somewhat unclear. And clinical relevance of MRI defined structural changes does remain controversial. And we see this in our even with X ray, right, where there are many people that have degenerative findings on X ray or MRI that might be asymptomatic. So where is the clinical relevance? That's part of what this study was trying to solve by taking a look at, well, what are the findings and how is it associated with those individuals that have the pain? So for the assessment of the cervical spine, they took a look at a variety of different things. They took a look at the disc, took a look the end plates and the bone marrow areas for C23 all the way down through C7T1. And they were assessed separately for three types of degenerative findings. One was that VESC, the vertebral endplant changes that we spoke of earlier, and these were graded as a zero with no changes. A number one was a small change, less than 25% of the subcortical bone being affected. Two was a medium change to the end plate, 25 to 50% of the subcortical Bone affected. Three was a large change or greater than 50%. So that's how they established the endplate changes. Disc degeneration was also categorized a variety of different ways. A number 0 was normal, meaning there was normal height and the signal intensity was also totally normal. A1 had a mild, which could be a slight decrease in height or some signal intensity changes. Two was moderate, meaning there was a decrease in height and there were definitely and three was severe. There was a complete elimination of the disc height and then the final component were changes in the disc contour. 0 again was normal. 1 was protrusion, meaning the disc herniation involved 0 to 50% of the disc circumference, 2 was an extrusion and 3 was a free fragment floating around. So extrusion was a 2, a fragment floating around was a number 3 and a protrusion was a number 1. Zeros across the board, 1 were considered normal. So they take a look at actually over 1000 patients, but 600 completed the questionnaire and underwent the MRI at a four year follow up. So this had a heck of a follow up going on. And of the 600 participants, 35% had one or more cervical degenerative MRI finding. Now, of these, almost all had mild disc degeneration or disc protrusions. All only a few people, 7%, had vertebral endplate changes. And most MRI findings were located at C5, C6 and C6 C7. So probably not a lot of surprises when we dive into some of those stats. Meaning a lot of people, 35% had one or more finding, hey, many people are asymptomatic that have those findings and very few had endplate changes. 7%. That sounds about right. If I were to think back and let's just round that out to let's say 10%, if I were to think back to the MRIs that I've reviewed and X rays I've reviewed, that sounds about right. In terms of end plate changes and with most of the issues occurring at 5.6 and 6.7, that completely matches my clinical expertise. And I'm imagining you as well. C5, C6 tends to be the greatest area of challenge, just as L4, L5 does in the lumbar spine. Why? I think there's a variety of reasons associated with that, but specifically the curvature and the angle and the acuteness of the curvature at those segmental levels can create challenges that are greater than some of the others. So they did find ultimately in the study a positive association between MRI defined cervical disc degeneration, disc contour changes, and self reported neck pain between the VESC and neck disability. However, these associations were small. So important to keep that in mind. Now, interestingly, they found no association between endplate changes, disc degeneration or disc contour and headache. Now, we're gonna talk about this in a little more detail in a moment, but some of the reason why that probably is is because they evaluated, remember, C2, C3 on down. So headaches can commonly happen occiput CoC1, C2, not necessarily as common for changes. So it'd be interesting, in other words, to see what the headache findings may have been if they analyzed the upper cervical spine and they did not find a statistically significant association between cervical MRI findings and headaches. Again, so it may be relevant to, you know, again, how a headache happens, so to speak. So usually we see upper cervical segments that headaches can, you know, they can cause neck pain, dizziness, headache. These things can all be combined. But when you eliminate looking at CoC1 and C1, C2, this limits the opportunity, very likely to be able to make any correlations between cervical spine changes, because if there were changes that caused a headache, they probably would be at the upper cervical spine. So the positive associations identified in the current study between disc degeneration and contour changes were applicable. And they were saying that, hey, this is probably a biological component of the biopsychosocial model, which makes a lot of sense to me when you see cervical disc degeneration. Now, let's be super clear. This does not eliminate the fact that many people that have findings on X ray and MRI may not have symptomatology. But what they are saying is when you have symptomatology, there is a correlation. Many people that have symptomatology will have findings on an mri. Many people that don't have symptomatology will also have findings on the mri. So as they've said, degenerative MRI changes can happen in asymptomatic individuals. And guidelines suggest that MRIs should only be considered in the presence of red flags or chronic neck pain, which makes a lot of sense to me. So this study was pretty interesting. I don't think it broke any new ground. Probably a lot of what we discussed today we've heard before and makes sense. But it's interesting to note that there is an association between MRI findings, neck pain and disability. Now, I hope that they continue and do another study of the upper cervical spine to really analyze what's going on up there. And perhaps we will see an association between headache and upper cervical spine changes. Now, with this study, I want to be super clear. This doesn't mean, as we just said, that everybody should get an MRI. If you have neck pain, let's get MRIs on everybody. That's not the case at all. But I do think it's important for us to be able to interpret and understand the MRIs when a patient presents. Now, of course, we can refer for them when there's chronic pain, when there's red flags, yellow flags, whatever the case might be. However, chances are more than ordering MRIs. You're probably going to have patients that come in either with their disc, with their thumb drive, or with their report. So being able to take a moment, review what you see on the mri, whether the images themselves, preferably, or whether you're reviewing the report and being able to have an accurate conversation with the patient is really important. The other aspect, and this is what I dealt with as I reviewed a lot of MRIs earlier in my career. You'd see a patient that came in and they're just scared to death because the MRI or X ray report is, in many cases, MRI report is like three or four pages long. And it's like, listing findings, quote, unquote, incidental findings at nearly every single level of the cervical spine or the lumbar spine or wherever the MRI was taken. And that could freak people out. So understanding that there is an association between findings and pain, but findings don't always cause pain is a really important conversation for you to have with your patients. The way that I used to just describe it, I'd say imagine it having a deck of cards. Every card in the deck is a finding on your MRI report. I throw all those cards on the table. Well, guess what? My job is. My job is to find the cards that matter. I wanna push all the cards off the table that aren't causing your pain, that aren't issues. They're just incidental findings. They happen to see this. But it doesn't mean to stress you out. It's actually totally normal to have findings on X ray and MRI as you age. Now, my job is, is to separate the problems from the not perfects. And that's the way I'd say it. And that resonated with a lot of people, just letting them explain, hey, this report showcases everything that's not perfect in your spine. It is totally okay to have things that are not perfect. But what we're trying to get down to, my job is to find the problem amongst the not perfects. That was a easy and a great way, in my opinion, to be able to accurately describe really what I was doing in a way that a patient could understand. And now as you went through your examination, physical examination, your physical evaluation, your case history, and you started to piece that together with the findings on the mri. Now a patient was at ease. And now you're able to say, hey, you know, we're seeing findings and not perfects all throughout. No need to stress out about that. But some of the reasons I believe you're having pain are X, Y and Z, and. And that starts to really help somebody get out of freakout mode, and they stop really paying attention to all of these incidental findings that can really, really make somebody stressed out and start to focus on okay, I got a couple of little problems here. I got a lot of not perfects. I'm not worried about not perfects. I got a couple problems, doc. How can you help me overcome these challenges? And that enables you to not have to play whack a mole as well trying to solve a bunch of not perfects, which you really can't do anyway. So I, I found that a great talk track. Hopefully you find that valuable as well. And before we wrap up, I want to say a few words about having a virtual assistant. This was really a game changer for me over the last couple months. So if you are looking for inbound outbound calls, if you are looking for call answering services, if you're looking for tasks that are repetitive and can be repeated, maybe it's real, maybe it's breaking down reels for your social channels, perhaps it's managing your social channels. Head over to chiromatchmakers.com we've had a lot of interest in our new Virtual CA program and if you you are a lone wolf out there and you're not ready to bring on that full time team member, a virtual CA can be about 70% less cost. So that's a big, big deal. Head over to ChiroMatchmakers.com, click up on the Hiring tab, click Virtual Assistant, schedule a call with the team, have a complimentary chat and conversation and see if a virtual CA is right for your practice. If you have not left us a rating or review for this podcast, I would really, really appreciate it if you would do so. Scroll on down. If you're listening on your phone, tap the number of stars, leave some feedback and as always, if you you can reach me, jeff@the evidencebasedchiropractor.com if you have any questions whatsoever or if you have any research that you would like to see highlighted in the future. Thank you so much for tuning in. Thank you for being a chiropractor. Have a fantastic week in practice and I will talk to you soon.

Thank you for joining us on this episode of the Evidence Based Chiropractor. If you want to grow your practice, come back for next week week's episode. If you want to grow faster, visit the evidencebasedchiropractor.com and join our MD Marketing membership today.