The Importance of Clinical Correlation to treat an injured Tall Spine.

Disc injury and subsequent degenerative disc disease is life changing, often leading to chronic low back pain and disability. Advanced treatment techniques for low back pain now include both cellular and surgical options to intervene earlier in the degenerative disc cascade. If disc degeneration is allowed to progress unchecked over time, then back pain and disability are allowed to progress as well.

A simple back spasm or low back strain does not necessarily indicate a disc injury. It is entirely possible that the back pain is actually from a “pulled muscle” or “strain”. Conservative treatment like rest, controlled exercise, physical therapy, massage, and chiropractic treatments may help you get rid of the symptoms, and back to normal.

On the other hand, letting a painful degenerative disc go untreated is not helpful in maintaining a “Tall Spine”, so I like to take a more proactive diagnostic course in cases where conservative treatment does not help. In general, if the back pain does not go away, if it continues to limit your activities, if it occurs more frequently, or otherwise concerns you, then I think it is generally a good idea to look deeper into the problem. Nowadays, this may include an online search for information, answers, and solutions. If you are at this point, then you will have a better chance of getting what you want if you get an MRI first, because a spine specialist at this level is going to want to see an MRI before responding (*).

MRI is a really straight forward and defining test when it comes to neck or low back pain. Lumbar MRI is an advanced diagnostic imaging tool used for evaluating low back pain. An MRI is a simple test to get, but it has some administrative and insurance hurdles (**). The simplicity of a lumbar MRI rests in how easy it is to do one from a patient perspective. You simply lay down on the MRI machine, relax and hold still, and within 30 minutes your lumbar MRI test is done. No IV is necessary unless for some reason your doctor orders your MRI with contrast. Modern day Open MRI machines eliminate any Claustrophobia concerns.

I like MRI as a great early tool for the evaluation of low back pain. MRIs are cost effective, and they are often a necessary step to getting an appointment with a spine specialist (***).

An MRI shows great detail of the spine. It shows the alignment, the curve, the discs, the facets, the spinal canal, the neural foramen, the ligaments, the spinal cord or thecal sac, and the nerve roots. A radiologist will interpret the MRI and comment on each of the above level by level. You will get an MRI report with your MRI. Keep this for your records. Don’t focus too closely on the unfamiliar words. You really need a skilled spine specialist to evaluate you with these results and connect the dots between your clinical findings and the MRI results. This is referred to as “clinical correlation”.

“Clinical correlation with spine MRI” means comparing the findings on a magnetic resonance imaging (MRI) scan of the spine with a patient’s clinical symptoms and physical examination findings to determine if the abnormalities seen on the scan are likely causing the patient’s pain or neurological issues, essentially ensuring that the imaging results align with the patient’s presenting complaints; it’s crucial because an MRI may show abnormalities that are not clinically significant, meaning they are present but not causing symptoms. Key points about clinical correlation with spine MRI:

Importance of symptom matching:
When interpreting a spine MRI, the location and severity of abnormalities should be compared to the patient’s pain pattern and neurological symptoms to identify the most likely source of their issues. 

Not all abnormalities are symptomatic:
Even a “normal” person can have some degree of disc degeneration or facet joint arthritis on an MRI, so these findings alone do not necessarily indicate a clinical problem. 

Consideration of physical exam findings:
A clinician will use information from the physical examination, like neurological testing and specific provocative maneuvers, to help interpret the MRI findings. 

Examples of clinical correlation with spine MRI:

Disc herniation:
If a patient presents with radicular pain (shooting pain down the leg) in a specific nerve distribution, and the MRI shows a disc herniation at the corresponding spinal level compressing that nerve root, then there is good clinical correlation.

 Spinal stenosis:
If a patient complains of leg pain when walking long distances (neurogenic claudication) and the MRI shows narrowing of the spinal canal in the lumbar region, this is considered a good clinical correlation. 

Facet joint arthropathy:
If a patient has localized back pain that worsens with certain movements and the MRI shows degenerative changes in a specific facet joint, this could be a good clinical correlation. 

Why is clinical correlation important?

Avoiding unnecessary treatment:
By carefully considering the clinical picture alongside imaging findings, clinicians can avoid unnecessary interventions for incidental abnormalities that are not causing symptoms. 

Accurate diagnosis:
Clinical correlation helps to identify the most likely source of a patient’s pain and guide appropriate treatment planning. 

If you consult with a Neurosurgeon like me, your Neurosurgeon will likely want to look at the actual MRI images themselves. Neurosurgeons are trained and certified in Neuroradiology. They are also in the unique and very privileged position to have examined you, or to have the ability to appropriately examine you, and to see and interpret the MRI and then make the clinical correlation.

This type of doctor-patient relationship optimizes the diagnostic accuracy of the encounter. Simply put, I know where you hurt, I know where to look at the MRI, and I get a very good impression of what is meaningful, and what is incidental with your MRI. This clinical correlation leads to best outcomes. I figure out what is relevant to your problem, and what is incidental and unrelated to your problem.

MRI fits well with my message regarding the importance of diagnostic accuracy in treating back pain. This message is gaining momentum across many platforms. I’m fielding more and more questions and requests about back pain, I’m doing more and more second opinions, and I’m trying to figure out a way to accurately navigate through this delicate area to give you the best advice in an efficient and cost-effective way. This is much more realistic if you have an MRI to share with me at the time of your consultation.

Until next time,

Jeffrey Larson, MD
The Tall Spine

*Protip – Ask your primary care doctor or nurse practitioner to order an MRI if your symptoms do not improve with conservative management.

**Protip – Office staff spend an absurd amount of time simply ordering a lumbar MRI. The authorization process is unbelievable cumbersome and time consuming. The insurance hurdles are many. Refer to the “medical necessity” section of your insurance policy for lumbar MRI to see some of the hurdles.

***Protip – MRIs are very simple to do and contrary to popular opinion, relatively inexpensive. Most imaging centers are in network with all of the popular insurance companies, meaning they agree to accept a contract price for a very reduced rate from the insurance company. Not all contracts are the same. Pricing is often way different for MRIs in hospitals vs outpatient facilities. Shop around for best price. Depending on what part of the country you are in, I have seen MRIs for less than $1000, even approaching $500. Still expensive, but this is a precision image of your low back! If you are using any type of insurance understand that the cost of the MRI is not what the imaging facility billed, but rather what the insurance company allowed. You will get an Explanation of Benefits (EOB) with your procedure bill. Column 1 is what the facility charged (monopoly money), column 2 is what your insurance company allowed (this is the amount the imaging facility has agreed to accept from the insurance company for their patients), and column 3 is what you owe (this is entirely between you and your insurance company and is calculated based on where you are with your deductible).