I understand that contrast is generally recommend for post-surgical cases...but what if surgery has been a long time ago? Is there a cut off beyond which contrast is no longer necessary? For example, if surgery has been more than X number of years ago? I tried searching the forum, but did not find the answer.
MRI spine with or without contrast, chronic post-surgical
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If it's recent enough that,
1-Infection is potentially of concern (weeks to a few months post op, not years) or,
2-You're worried about tumor, or
3-You get a call back from rads saying, "Don't you want contrast? The radiologist wants contrast, because..."
Most good MRI departments have their techs programmed to weed out the patients they know their radiologist would want to have contrast on, so their reads can most smoothly.
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Great, thanks for the relies. As for the indication, I understand that it helps to distinguish between recurrent disc versus granulation/scar, which is usually the most common reason why I may order it when indicated, and less often truly worried about infection or tumor, although those possibilities should always be considered. I can't say that I know how to interpret images with contrast...but hoping that the radiologist can.
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A family member is a neuroradiologist and told me after 6 months to a year post-surgery, contrast is for financial help only. For the rads.
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never heard that , every neurosurgeon or ortho spine I have ever known orders contrast on post surgical spines.
If they didn't think it helped, why would they order it? How much different is cost of MRI with and without?
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they order that way, because that's what was done in their residency. I'm sure they don't think about the cost of the MRI with contrast
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You're not going to have granulation tissue 5 yr after surgery. Granulation tissue is an acute or subacute reaction to trauma; essentially the pink healing stuff you see in any healing wound. What's the exact cutoff? Can't say. But back surgery 20, 5 or 2 years ago is not going to cause granulation tissue to all of a sudden start infiltrating a foramen. Get contrast, fine, but it can be a pain when you get that call, "What's the bun/cr?" Crap, forgot to order it, then you delay the scan then, to get the lab, it's borderline up....then, hmm, did they really need it anyways for healed in back surgery 5 yr ago?
"Why did I have to get an IV? The CRPS went to my hand now!"
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L-spine post-lami needs contrast regardless of timing from surgery. Differentiates scar from disc. Know if something is new or old.
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Just texted my go-to spine surgeon. He says one year, as far as he's concerned. I agree.
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Got 2 Radiologists at office. One says never needs it other says always needs it. You spine guy is supported here. http://books.google.com/books?id=0T...=RTjQU8C5H8uWyAT7noHIDQ&sqi=2&ved=0CBUQ6AEwAg
But says some scar enhances to 20 yrs.
I heard this saying... if you put two doctors in the same room, you get three opinions!
pmrmd: "A family member is a neuroradiologist and told me after 6 months to a year post-surgery, contrast is for financial help only. For the rads."
haha!
emd123, I leave a blank order for BUN/creatinine with my MAs, so that they take care of it if they ever get the call from the MRI center requesting it.
As for differentiating between disc, granulation, and scar... I am not sure about this, but I imagine that disc and scar will either be non-enhancing or minimally enhancing? And that granulation tissue should show greater enhancement? So I can see how one can distinguish granulation from disc or scar. I am unclear as to whether contrast can actually differentiate between disc and old scar? If it can, then maybe contrast beyond one year might make sense, but if not, then that tilts the argument in favor of not using contrast for remote surgery.
After all the discussions above, a I am leaning towards no contrast after one year from surgery.
pmrmd: "A family member is a neuroradiologist and told me after 6 months to a year post-surgery, contrast is for financial help only. For the rads."
haha!
emd123, I leave a blank order for BUN/creatinine with my MAs, so that they take care of it if they ever get the call from the MRI center requesting it.
As for differentiating between disc, granulation, and scar... I am not sure about this, but I imagine that disc and scar will either be non-enhancing or minimally enhancing? And that granulation tissue should show greater enhancement? So I can see how one can distinguish granulation from disc or scar. I am unclear as to whether contrast can actually differentiate between disc and old scar? If it can, then maybe contrast beyond one year might make sense, but if not, then that tilts the argument in favor of not using contrast for remote surgery.
After all the discussions above, a I am leaning towards no contrast after one year from surgery.
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Just spoke with radiologist yesterday about this. He said most radiologists agree on a 10 year cutoff for distinguishing b/w scar and disc with contrast. That's just what he said.... don't shoot the messenger
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Disc can be new or recurrent, scar cannot be fixed by a surgeon. SCS vs adhesiolysis for scar, surgery vs SCS for disc.
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regarding concern for mets... Spoke with radiologist recently, said that contrast does not help with bony lesion, only soft tissue. Stated that contrast can even confound with bony lesion, because both bony mass and hemangioma can enhance. Also, hemangioma can be "warm" on bone scan.
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This forum made me laugh 
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This forum made me laugh
Help us out here freddy, as you're a radiologist.
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The answer is, practically speaking asking for contrast doesn't matter. Why?
1) most etiologies for pain after back surgery are not going to enhance.
2) if a radiologist is trained well in spine MRI then he or she should know whether the patient should need contrast based on
a) history provided
b) if there is a lesion on imaging that could potentially enhance and correlate with the patients symptoms.
Here is what I recommend as a radiologist and practice as a pain doc. If I definitely want contrast I specify what I am looking for that should enhance. "Please evaluate for scar tissue impinging on nerve root. Patient with L5 radicular pain and weakness." Otherwise write for "MRI per radiology protocol." They should assess/screen non contrast images first and then decide if the patient needs contrast.
If you definitely do NOT want contrast then write that in the order with the reason. ie. anaphylaxis or renal failure.
Hope that helps.
Fred
1) most etiologies for pain after back surgery are not going to enhance.
2) if a radiologist is trained well in spine MRI then he or she should know whether the patient should need contrast based on
a) history provided
b) if there is a lesion on imaging that could potentially enhance and correlate with the patients symptoms.
Here is what I recommend as a radiologist and practice as a pain doc. If I definitely want contrast I specify what I am looking for that should enhance. "Please evaluate for scar tissue impinging on nerve root. Patient with L5 radicular pain and weakness." Otherwise write for "MRI per radiology protocol." They should assess/screen non contrast images first and then decide if the patient needs contrast.
If you definitely do NOT want contrast then write that in the order with the reason. ie. anaphylaxis or renal failure.
Hope that helps.
Fred
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Always order contrast for concern for mets if pt doesn't have renal failure. Not all mets are bony and can live otherwise hidden in dura and neural tissue. Expansile lesions can also irritate nerves which will then enhance.
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Exactly. Thank you. Said this in post 3 above, point #3.
