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The Pain May Be Real, but the Scan Is Deceiving

ManipalHospitals • February 12, 20190 Comment

Mrs. Savithri’s low back bothered her for years, but when it started clicking and hurting when she bent and straightened it, she told her general physician that something was definitely wrong.

It was the start of her medical odyssey, a journey that led her to specialists, physical therapy, Internet searches and, finally, an M.R.I. scan that showed a disc prolapse at L4-L5 and convinced her that her only hope for relief was to have surgery to repair it. But in fact, fixing the torn Disc that was picked up on the scan was not going to solve her problem, which, eventually, she found was caused by degeneration of the disc.

Scans — more sensitive and easily available than ever — are increasingly finding abnormalities that may not be the cause of the problem for which they are blamed. It’s an issue particularly for the millions of people who go to doctors’ offices in pain.

The scans are expensive — patients pay about Rs 6,500 for an M.R.I. scan of the neck or back, for example. Many doctors or hospitals own their own scanners, which can provide an incentive to offer scans to their patients.

And so, in what is often an irresistible feedback loop, patients who are in pain often demand scans hoping to find out what is wrong, doctors are tempted to offer scans to those patients, and then, once a scan is done, it is common for doctors and patients to assume that any abnormalities found are the reason for the pain.

But in many cases it is just not known whether what is seen on a scan is the cause of the pain. The problem is that all too often, no one knows what is normal.

“A patient comes in because he’s in pain,” said Dr. Vidyadhara S, a Spine Surgeon at Manipal Hospital, Bangalore. “We see something in a scan, and we assume causation. But we have no idea of the prevalence of the abnormality in routine populations.”

Now, as more and more people have scans for everything from headaches to foot aches, more are left in a medical lurch, or with unnecessary or sometimes even harmful treatments, including surgery.

“Every time we get a new technology that provides insights into structures we didn’t encounter before, we end up saying, ‘Oh, my God, look at all those abnormalities.’ They might be dangerous,” said Dr. Vidyadhara S. “Some are, some aren’t, but it ends up leading to a lot of care that’s unnecessary.”

That was what almost happened with Mrs. Savithri, an active, athletic 64-year-old who lives in Bangalore. And it was her great fortune to finally visit a surgeon who told her so. He told her bluntly that her pain was caused by disc degeneration, not the disc prolapse alone.

No one had told her that before, Mrs. Savithri said, and looking back on her quest to get a scan and get the Disc fixed, she shook her head in dismay. There’s no surgical procedure short of a Microdiscectomy that will help, and she’s not suitable for a Disc replacement.
“I feel that I have come full circle,” she said. “I will cope on my own with this back.”

In fact, Mrs. Savithri was also lucky because her problem was with her Spine. It’s one of only two body parts — the other is the knee — where there are good data on abnormalities that turn up in people who feel just fine, indicating that the abnormalities may not be so abnormal after all.

But even the data on spine comes from just one study, and researchers say the problem is far from fixed. It is difficult to conduct scans on people who feel fine — most do not want to spend time in an M.R.I. machine, and CT scans require that people be exposed to radiation. But that leaves patients and doctors in an untenable situation.

“It’s a concern, isn’t it?” said Dr. Vidyadhara S. “We are trying to fix things that shouldn’t be fixed.”

As a Spine Surgeon, Dr. Vidyadhara saw patient after patient with back pain, many of whom had already had scans. And he was becoming concerned about their findings.

Often, a scan would show that a person with arthritis had a torn Disc, cartilage that stabilizes the spine. And often the result was surgery — most spine surgeons do more disc surgery than any other operation. But, Dr. Vidyadhara wondered, was the torn disc an injury causing pain or was the degeneration causing pain and the tear a consequence of degeneration?

“The rule is, as you get older, you will get a Disc tear,” Dr. Vidyadhara said. “It’s a function of aging and disease. If you are a 60-year-old guy, the chance that you have a Disc tear is 40 percent.”

“If you’re going to look at a spine, you need to know what that spine might look like in a normal patient,” said Dr. Vidyadhara.

“Somewhere between 35 and 40 percent of people who climb into a scanner will have a herniated disk,” Dr. Vidyadhara said. As many as 60 percent of healthy adults with no back pain, he said, have degenerative changes in their spines.

Those findings made Dr. Vidyadhara S ask: Why do a scan in the first place? There are some who may benefit from surgery, but does it make sense to routinely do scans for nearly everyone with back pain? After all, one-third of herniated disks disappear on their own in six weeks, and two-thirds in six months.

And surgeons use symptoms and a physical examination to identify patients who would be helped by operations. What extra medical help does a scan provide? The patients who knew recover no faster than those who did not know. However, Dr. Vidyadhara said, there was one effect of being told — patients felt worse about themselves when they knew they had a bulging disk.

“If I tell you that you have a degenerated disk, basically I’m telling you you’re ugly,” Dr. Vidyadhara said.

Scans, he said, are presurgical tools, not screening tools. A scan can help a surgeon before he or she operates, but it does not help with a diagnosis. A good physician should be able to reach a reasonable diagnosis at the end of listening from the patients and examining them. Clinical diagnosis is correct in over 90% of the times with a good clinician.

“If a patient has back or leg pain, they should be treated conservatively for at least eight weeks,” Dr. Vidyadhara said, meaning that they take pain relievers and go about their normal lives. “Then you should do imaging only if you are going to do surgery.”

That message can be a hard sell, he acknowledged. “A lot of people are driven by wanting to have imaging,” Dr. Vidyadhara S said. “They are miserable as hell, they can’t work, they can’t sit. We look at you and say, ‘We think you have a herniated disk. We say the natural history is that you will get better. You should go through six to eight weeks of conservative management.’ ”

At the Manipal Health Systems, Bangalore spine experts have the same struggle to convince patients that an M.R.I. scan is not necessarily desirable, said Dr. Vidyadhara.
“The consensus is that you are a surgical candidate or not based on your history and physical findings, not on imaging findings,” he said.

Dr. Vidyadhara S had chance two-years back to test his own convictions. He had the classic symptoms of a herniated disk — shooting pains down his right leg, a numb foot and difficulty walking.

Dr. Vidyadhara S went to see his primary-care doctor but, he said, “I didn’t get an M.R.I.” That decision, he added, “was the right thing to do.”

About three months later, he had recovered on his own.

In 1998, two medical scientists, writing in The Lancet, proposed what sounded like a radical idea. Instead of simply providing patients and their doctors with the results of an X-ray or an M.R.I. scan, he said, radiologists should put the findings in context. For example, they wrote, if a scan showed advanced disk deterioration, the report should say, “Roughly 40 percent of patients with this finding do not have back pain so the finding may be unrelated.”

It is an idea that only would work for back pain, because that is the one area where radiologists have enough data. But it made eminent sense to Dr. Vidyadhara S. “It gives referring physicians some sort of context,” he said.

“We often see patients who have already had M.R.I. scans,” Dr. Vidyadhara said. “They are fixated on the abnormality and come to a surgeon to try to get the abnormality fixed. They’ll come in with the report in hand.”

The new sort of report, Dr. Vidyadhara said, is “very helpful information to have when talking to patients and very helpful for patients to help them understand that the abnormalities were not catastrophic findings.”

“It’s an interesting idea,” he said. But, he added: “The problem isn’t what happens after they get their imaging. It’s that they get the imaging in the first place.”
That was what happened with Mrs. Savithri.

When she started looking up her symptoms on the Internet, she decided she probably had a Disc Prolapse. “I was very forceful in asking for an M.R.I.,” she said.

And when the scan showed that her disc was torn, she went to a surgeon expecting an operation.

He X-rayed her knee and told her she had degeneration. Then, Mrs. Savithri said, the surgeon looked at her and said, “Let me get this straight. Are you here for a Disc replacement?”

She said no, of course not. She jogs, she does aerobics, and she was nowhere near ready for something so drastic.

Then the surgeon told her that there was no point in removing her disc because that was not her problem. And even if he removed the disc, her arthritic bones would just grind it down again.

For now, Mrs. Savithri says she is finished with her medical odyssey. “I continue to live with this, whatever they call it, this disc degeneration,” she said.

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