Nerve "displacement" on MRI

[PMR 4 MSK]

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Over the past couple years, I've noticed radiologists more and more commenting on nerve "displacement" on spine MRIs. Quite often, they're specifying multiple levels, such as "bilateral C6 nerve roots displaced, right more than left, ... bilateral C7 nerve roots displaced ... right C5 nerve root displaced, ..." usually in association with bulges, herniations or osteophytosis, etc. It's not just one group of radiologists - we have several, and many are all over the country reading films at home.

Maybe some of it is due to better MRIs, better imaging, or paying more attention to it, but it seems there are a lot more "displaced" nerves than are clinically relevant. This, in turn, is causing a lot more referals to me and the spine surgeons to treat MRI findings. Now, I ain't bitchin' 'bout the increased EMG referals, but now I'm getting referals for ESI's as diagnostic rule-outs based on the MRI's. Most of these are patients with axial pain or non-neurologically correlative PE's.

I just finished an EMG on a guy I saw a few months ago with 2 years neck pain and hand numbness. I offered him PT and CESI, he refused the CESI, skipped PT, but kept calling for vicodin (which I never gave him), I offered him ultram, he basically recited the side effect profile to my nurse as his side effects from it. He went to another pain guy in town, who did the CESI about 3 weeks ago, also declined to give him vicodin (high risk) which "made it worse." He gets referred back for EMG only. I do the EMG which shows a mild cubital tunnel syndrome, which really doesn't correlate with his symptoms, and his elbow/ulnar nerve exam is normal. The above quote in the first paragraph is from his MRI in January 08. No EMG changes indicative of radiculopathy - needle exam normal.

Anyone else seeing more MRI reports with this? Often I agree with the report when I review the films, but especially in the C-Spine, sometimes I just don't see it, and wonder what they're looking at to call it.

 

[Mister Mxyzptlk]

I have always interpreted "displaced" to mean "something is pushing on the nerve enough to move it".

My favorite is "effaces", e.g., "there is a protrusion that effaces the exiting L5 nerve root." I can't find "effaced nerve" in ICD-9.

It's best to just look at the films yourself, and don't be surprised if you see things not described in the report or can't see things described in the report.

 

[Tenesma]

the terminology in radiology reports is my undoing --- it would be very nice if they could throw into their impression

"In conclusion, all of the abnormalities i listed above are perfectly normal radiologic occurences in this age group"

i cannot stand it when i ask patients to tell me their story and the first words out of their mouth are:

"I've got three bulging discs in my back and two bulging discs in my neck"

 

[Ligament]

the terminology in radiology reports is my undoing --- it would be very nice if they could throw into their impression

"In conclusion, all of the abnormalities i listed above are perfectly normal radiologic occurences in this age group"

i cannot stand it when i ask patients to tell me their story and the first words out of their mouth are:

"I've got three bulging discs in my back and two bulging discs in my neck"

I hear you!

85% of the time, if this is the first sentence out of their mouth, they are either workers comp or malingering, or both.

 

[Mister Mxyzptlk]

Most reports boil down to this:

"Results compatible with normal. Cannot rule out disease."

There is one radiologist here who reads out 1.5 mm bulges, so all of those patients start their story with "I have five bulging disks". Of course you do, you're 50 years old.

 

[ampaphb]

I object to the notion that there is such a thing as normal "for a given age". There are either findings, or there aren't. They are either symptomatic, or they aren't. You can help them, or you can't. But "normal for your age" potentially leads to dismissing patients' legitimate complaints, and that strikes me as unreasonable.

 

[Tenesma]

ampa - please don't confuse "patients complaints" with MRI findings ...

i am not saying that radiologists should omit data/findings - but the words, age-appropriate changes go a long way in dealing with the patients who introduce themselves as "3 level bulging discs"...

 

[ampaphb]

ampa - please don't confuse "patients complaints" with MRI findings ...

i am not saying that radiologists should omit data/findings - but the words, age-appropriate changes go a long way in dealing with the patients who introduce themselves as "3 level bulging discs"...

I completely understand, and am as much of a harda** as anyone about stopping the patient short when I ask when it hurts, and am told "I have bulging discs at C3/4, 4/5 and 5/6".

That being said, I remain a firm believer that there is no such thing as an MRI which is normal for a particular age. It is either normal, or abnormal.

 

[lobelsteve]

I completely understand, and am as much of a harda** as anyone about stopping the patient short when I ask when it hurtrs, adn am told "I have bulging discsat C3/4, 4/5 and 5/6".

That being said, I remain a firm believer that there is no such thing as an MRI which is normal for a particular age. It is either normal, or abnormal.

Food for thought:

Disc degeneration of pediatric patients in lumbar MRI. - Salo S - Pediatr Radiol - 01-JAN-1995; 25(3): 186-9 (From NIH/NLM MEDLINE)


Abstract:

Magnetic resonance imaging (MRI) is widely used in pediatric spinal disorders, but the prevalence of associated lumbar disc degeneration (DD) has not been evaluated previously. In this study we investigated whether children with suspected spinal disease had increased tendency to early DD. We analyzed lumbar MRI scans of 32 patients and 49 control subjects under 15 years old. Only four patients (13%) had DD on T2-weighted MRI and they were all over 10 years old. Eleven subjects (22%) in the control group had DD. It seems that disc degeneration is seldom found in patients under 10 years old.

Citation:

Disc degeneration of pediatric patients in lumbar