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‘Pain is not the only problem’: Advanced Imaging, Part 1

Advanced Imaging is the prevailing scientific evidence that has a power like no other form of diagnostic importance. It is complex, impressive, imposing, and definitive within the medical culture. But advanced imaging is also elusive, contingent, relative, imperfect, and its diagnostic value is not well understood. If you have a science that is not well understood, then that science becomes like magic. It gets the power that magic has, and can become dangerous to the diagnosis, and to the patient. It becomes dangerous because it asserts too much influence, sometimes being the only ‘evidence’ while ignoring other valuable clinical evidence.

“Although imaging technology has advanced significantly since the work of Garland in 1949, interpretive error rates remain unchanged. Medical error is the third most common cause of death in the United States. Error in diagnostic interpretation is an unfortunate and common occurrence exacerbated by the increased demands placed on radiologists. 1 billion radiographic examinations are preformed worldwide annually, [with] a 4% error rate translates into approximately 40 million interpretive errors per year.” (Waite, et al., 2017)

Advanced imaging requires interpretation; detection by visually scanning for conspicuous lesions. Interpretation is not factual, it is ‘a stylistic attempt to explain’ from a picture. Interpretation, like all aspects of medicine, has errors of omission (non-included/absent data, in-action) and commission (included/present data, added action.) Errors in interpretive omission can occur when (1) the wrong view is taken, or taken incorrectly, (2) when necessary imaging is not performed, (3) the interpretation is hasty causing perceptual & recognition errors, and (4) the interpreter’s opinions or biases influence the report. Errors of omission can occur when the radiologist habitually looks for certain findings. A LBP study might cue the radiologist to look for disc herniation or nerve encroachment, but might oversight muscle wasting and fatty replacement. Errors of interpretive commission can occur when (1) incidental findings suggest unexpected disease or lesion, (2) findings are interpreted to diagnose by speculation or bias, (3) imaging is used to hunt for a diagnosis. Errors of commission can occur when the radiologist reports features to support a wrong diagnosis.

Interpretation is an attempt to explain anatomy from a picture. Interpretation cannot demonstrate function or pain. A picture of a cell phone can’t demonstrate its ability to ring or get a signal. After all, it is just a picture.

Interpretation should demonstrate reversibility… if the study findings are interpreted to explain a diagnostic cause for the symptoms, then people with those same symptoms should demonstrate the same study findings.

Faulty interpretation reports can occur for several reasons. “Since radiologists commonly use dictation to report their findings, there can be up to 10% errors due to voice recognition inconsistencies.” (Moyer et al., 2016) “Speech recognition software has many benefits, but also increase the frequency of errors in radiology reports, which would impact patient care… 1.9% contain material errors.” (Ringler et al., 2015) “Interpretive (perception) errors occur… features that are not detected because they are not sufficiently conspicuous, subtle, small size, without defined borders, insufficient contrast, etc. Scene processing errors occur due to insufficient fixation (central vision) and peripheral vision; features are tested against the cognitive schema (long-term memory) to determine whether a feature is suspicious. Recognition errors occur because too little time is spent on a feature; ‘dwell’ time is insufficient to positively identify features. The researcher has a representation of target items that have those features in mind and directs attention to [findings] that have those features, image inspection may not include the entire field, only the field where certain features likely reside. Inattention blindness has been implicated in 60% of radiologists to report a missing clavicle. Satisfaction of Search (SOS) [is] the discontinuation of a visual search once the [radiologist] finds an abnormality (feature, or all features) and becomes ‘satisfied’ with the ‘meaning’ of an image. In conditions of low prevalence, [radiologists] are more likely to reject ambiguous findings and terminate a search more quickly.” (Waite, et al., 2017)

Do your ABCS scanning techniques assess the entire image, or did you look only for that damning evidence that you gravitate to? Do you point your eraser at the degenerative changes and reflexively blame it for the patient’s symptoms? Do you base all of your treatment plan on the image?

“Abnormal findings in 67% of asymptomatic patients evaluated by MRI. After 4 years of observation 70% untreated remained unchanged, 15% improved, 15% worse.’ Lumbar Stenosis: A recent Update by Review of Literature. Le, et al., 2015

“With regard to short term (<3 months) and long term (6>12 months) improvements in pain, no differences were noted between routine, immediate lumbar imaging and usual clinical care without immediate imaging. MRI did not provide any additive value over clinical assessment. MRI does not seem to have a measurable value with respect to planning conservative care. Imaging technique exposes the risk of labeling a patient with a patho-anatomic diagnosis unrelated to the actual cause of the symptoms.” (Anderson, 2011)

What do you say to a patient that asks you, “How many people my age have the same MRI, but never have any LBP symptoms?” Or, “Describe the scope of the contributors to my LBP symptoms, as you see it, besides the MRI.” Could you diagnose and treat your LBP patients just the same without any imaging?

There are many important organic contributors to LBP that cannot be seen on advanced imaging: (1) the complete patient history that is responsible for 90% of the diagnosis, especially when the entire problem list is considered, (2) central processing that manages ADLs, sports maneuvers, stance & postures, range of motion, motor sequencing, core recruitment, (3) muscle tension-time relationships, fatigue, muscle weakness, stiff joints, faulty movement patterns, VO2max, reaction time, endurance, gait, (4) hormone balance, adrenal stress, energy metabolism & delivery, work recovery, (5) blood chemistry, vitamin deficiencies, medications, appetite, diet, (5) bowel and bladder function/urgency, (6) depth of breath & lung capacity, ability to uptake and deliver cellular oxygen, (7) contribution of the ‘horseshoe’ to spinal stabilization, (8) type and condition of shoes, foot placement, tight underwear, carrying baby on one hip, (9) pain, numbness, tingling, radiculopathy, sensory loss, tremor (10) interruption in nerve conduction, (11) headache, sightedness, balance, attention, (12) sleep: quality, duration, position, mattress, (13) social acceptance, occupational satisfaction, patient education (14) smoking, alcoholic, gut dysbiosis, (15) sagittality.

The value of advanced imaging is currently under review. Does it have value in the non-traumatic LBP clinician’s practice as a first line in case-management when it can never explain pain? A second think on advanced imaging might be prudent, since ‘pain is not the only problem.’

LBP Blog General information

Series Description

These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.

Dr. Dean Bio

Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020.

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