How to refer for an upright MRI scan a note for clinicians

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1 How to refer for an upright MRI scan a note for clinicians Alan Breen 1, Melanie Jones 2, Andy Morris 3, Andy Pope 3, Ravi Ayer 3 1. Clinical Director for Special Imaging, 2. Superintendent MRI Radiographer, 3. Consultant Radiologist Open upright MRI scanners are relatively rare in the UK, but are becoming less so. For reasons that we will explain in this article, they are especially useful for investigating certain persistent musculoskeletal problems, which explains their relevance for chiropractors. However, they also have a more general purpose because of the range of scan positions they allow for patients. This article, although not meant to cover all eventualities, provides an overview of these and of how to use this important diagnostic tool. What musculoskeletal problems are suitable for upright MRI scanning? MRI is generally thought to be the best imaging modality currently available for investigating soft tissue lesions. It has a larger field of view than ultrasound (US) and better contrast for soft tissues than radiographs. (It is the high soft tissue contrast that gives MR a particular edge over plain films, CT or US.) Therefore, if a clinician is concerned about the possibility of pathology in and around the central nervous system and spinal cord, including nerve roots, spinal canal, discs, synovia or ligaments it is the investigation of choice. There is a simple rule of thumb, which is if the patient points with a finger to a single area when asked where the symptoms are consider US. If they place the palm of their hand over the site or a more poorly defined area, consider MRI. In addition, if there is a large amount of overlying soft tissue or bone, MRI may be best. In practice, the most frequent request for any kind of MRI scan is for lumbar spine problems, followed by the thoracic and cervical spines, then the knees, shoulders, extremity joints and brain. All these areas can be successfully imaged in an open scanner, but to be worth it, there needs to be a good chance that the results will inform an important clinical decision. Given that upright scanners are also open to the sky and conventional scanners are just as good or better for detecting pathology, the special value of upright MRI is mainly that the patient does not have to lie flat in an enclosed tunnel. Therefore patients with conditions like diaphragmatic paralysis or hernia, emphysema or other breathing difficulties, or with severe kyphosis, can be scanned in an open scanner. However, the most frequent referrals for an open MRI scan are for patients who suffer from claustrophobia. Although there is no standard list of conditions, the most frequent cause for referral for spinal MRI is suspicion of pathology affecting the spinal canal, discs and/or nerve roots usually by compression. This can be due to infections, tumours, cysts, disc hernias, arthritic outgrowths, malalignments and osseous and other connective tissue defects. However, often the most useful finding for both the patient and chiropractor is often one of no significant pathology. This may allow a new direction in 1

2 management to be developed and sometimes be preferable to sending the patient for a scan through their GP. What conditions are less suitable for upright MRI? Upright open scanners are all low-field, which means they operate with magnetic fields of around 0.2 to 0.6 Tesla. This is in contrast to conventional scanners whose magnetic field strengths can range up to 3 Tesla and above. This mainly means that to generate a high-quality image in an open scanner takes longer and is more prone to producing movement artefacts on the images. Preventing this therefore calls for great skill on the part of the MRI radiographer. If the patient can lie flat, is not claustrophobic and weight bearing or unconventional positioning is not required, there is little to choose between an open upright and a tunnel scanner. In addition, certain conditions such as suspected shoulder tendonopathies are often better visualised with ultrasound, glenoid labrum tears are better imaged with MR arthrography and 3-D osseous visualisation generally needs CT. Making a referral Before making a referral, it is important to be familiar with the Information for clinicians section that is usually provided on a Scan Centre s website. MR scanners are generally very safe for patients but can also be very dangerous if they have implanted devices, such as cochlear implants, stents or cardiac pacemakers. Metal fragments around the orbits are also not uncommon and if these are suspected, patients should not be scanned until a radiologist s report is obtained ruling them out. To make a referral, practitioners download a referral form from the provider s website, fill it in and fax or post it to the scanner centre. It is important to complete all the sections of the form so that staff can be sure it is safe to scan and can select the best positions and sequences to use. The responsibility for the appropriateness of the scan lies with the referrer and responsibility for the care of the patient is not transferred to scanner staff when a referral is accepted. If you think an implanted device is made of non-ferrous metal and is therefore safe, you should supply its details when referring. If scanner staff suspect that it might not be safe to scan a patient, they will advise you of this - another good reason for sending a complete referral form so that patients are not sent away unnecessarily. Clinical details MRI scans are typically done for persistent or undiagnosed and potentially serious conditions - or situations where confirmation of the suspected clinical diagnosis will aid management. The most common reason for scanning the spine is for patients whose condition has not cleared up as expected and a deeper level of investigation is needed. The clinical justification should therefore be clear. MRI is considered an unsuitable tool for preventative care where there is no patient complaint. At the other end of the spectrum, a suspected cauda equina syndrome is a medical emergency best referred to an Accident and Emergency Department and not to a Scanner Centre. However, subtle cauda equine compression can sometimes be ruled out by a non-emergency scan if a hospital scan is not possible. It is of great help to the radiologist when the referrer indicate the kind of disorder they are 2

3 suspecting. This will allow the radiologist to provide a more focussed report and the radiographer to select the best patient positions and scan sequences. Referrals to conventional Scanner Centres are often for one part of the body only and in one position, whereas referrals to open upright scanners are often for more than one scan or position. To obtain high quality images in an open scanner tends to take a little longer and a typical patient visit is likely to last around an hour, in contrast to half an hour in a conventional scanner. It is good to bear this in mind when briefing the patient and deciding on referral. Repeated upright scanning tends to tire the patient and can be self-defeating, whereas a variety of different loading positions can often be better performed sitting - provided the appropriate information about the area of interest is made clear on the referral form. Positional lumbar spine sagittal T2 images Positional scanning Weight bearing scans Although an apparently obvious reason for requesting an upright lumbar spine MRI might be to see if a disc hernia is more prominent under load, experience (but not yet research) has not shown this to be a frequent occurrence. By contrast, comparisons between weight bearing and recumbent scans have been more notable for showing the effects of gravity on vertebral alignment and on the spinal cord and nerve roots. This usefully includes the nerve root canals and lateral recesses and is sometimes key to informing spinal surgery. Although the referral form does not include options for different weight bearing positions, (such as sitting, standing, flexion and extension) these can be requested. However, a recumbent scan will generally always be done. This is to ensure high image quality and to inform the interpretation of any upright sequences by the radiologist. It is useful to bear in mind that the standing position is less stable than sitting and can be associated with movement artefacts that degrade the images. Standing Sitting 3

4 appointment. An estimate of the cost and when and how payment is to be made can be provided at this stage and communicated to the patient. How to interpret the report Most scanner centres provide the patient with their images on a CD or USB stick, and the radiologist s report by fax or post to the referrer. The former generally includes a DICOM Reader to enable you to see the axial and corresponding sagittal images together. Both are generally included in the cost of the service. Referrers are advised to: 1. Look at the scans first 2. Read the report and the referral form 3. Look at the scans again Lying supine Spinal stability There are various definitions and forms of spinal stability. Segmental stability means the ability of a vertebral motion segment to resist being moved and/or to return to its original position when released. The assessment of segmental stability is therefore generally an evaluation of subtle intervertebral motion, while scans only show the spine at its end range of motion. If it is the possibility of instability that is the main issue, referral for a quantitative fluoroscopy (QF, or OSMIA) should be considered. Scanner centre staff can advise on this if desired, as the small radiation dose of QF still has to be justified under IRMeR regulations. Appointments and Payment The radiologist will address any issues requested on the referral form, in addition to reporting the findings. However, incidental findings that are assessed as being innocent (e.g. Tarlov cysts in the sacral canal, a small Baker s cyst behind the knee or a benign haemangioma in a vertebral body) are sometimes not reported. This does not mean the radiologist has missed them. On the other hand, serious unexpected findings, such as occult tumours or fracture, are sometimes reported, which are beyond the chiropractor s scope of management and require further advice. A recommendation on this is often made in the radiologist s report. If findings require urgent attention the scanner centre will need to contact the referrer and therefore reliable contact details are mandatory on the referral form. MRI scans are relatively expensive, given the nature and cost of the equipment, although costs have generally been coming down. On acceptance of the referral, scanner centres generally contact patients to arrange their 4

5 Useful Reading The Lumbar MRI in Clinical Practice - A Survey of Lumbar MRI for Musculoskeletal Clinicians by William E. Morgan. Clare P. Morgan, Editor, Healthpath Education. (Copies of this ebook can be purchased through Essential musculoskeletal MRI: a primer for the clinician. By Michelle Wessley and Martin Young. Edinburgh, UK: Churchill Livingstone Elsevier, 2011 Anglo-European College of Chiropractic All rights reserved 5

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