Go get an MRI or three

[winstonw]

I've had a dodgy back for 30 years, presumed it was a stuffed L51 disc. In my 20s the pain was pretty constant and moderate, though I've managed it better since by avoiding exacerbating things. And last weekend, I did two days of riding with >8 hours in the saddle for both, with only minimal back pain. I've also developed a bit of a niggle in my (L) hip, after trying to jog a bit a few weeks ago.

MRIs have come down in price significantly in the last 10 years, so I decided for the first time to get my these 3 joints done, which I did this morning. took about an hour in the MRI machine, one of the newest models in Australia. Had to pay out of my own pocket, but in my view knowing what is going on with my joints will help me exercise smarter into the future.

Anyway, results were:

- L51 is worse than expected - marked degenerative disc disease, with adjacent Modic Type II changes. (I have fundamental MRI interpretation training, and I was pretty stunned how stuffed my disc was. Nevertheless, it was a revelation to find out there has been a cause for the chronic pain I've had for 3 decades) Incidentally, I saw chiropractors, physios, and many GPs when younger about my back. And none ever suggested anything more than an XRay, which showed nothing. I am sure I saw an orthopedic surgeon too who didn't think an operation would help. Don't even know if MRIs existed back in the late 70s and early 80s.

- my (L) hip was in better condition than I presumed, with good cartilage preservation, though I have a subchondral cyst and a few other minor issues.

- my (L) knee was worse than expected, with a large horizontal medial meniscal tear in the posterior horn, with an associated cyst. Funnily enough, I have no symptoms to suggest it is there.

SO WHAT! I hear you ask! OK, these findings will change my behavior thus:
- I will never run or jog again, except to save my life.
- I will not attempt to do things like the Kokoda Trail, or any big demanding bush walk.
- I will scale back epic rides like I did on the weekend.
- I'll probably now not attempt to do the big Cols of Europe. I presume my heart would not enjoy them either.
- I won't race CX where running with bike and jumping creeks is required. I could still buy a CX though to ride quieter dirt roads in the country.
- I won't buy a MTB.

- I will continue to enjoy cycling, and hope to do so well into old age. By knowing the condition of my joints (well half of them anyway), I am better equipped to do so.
- I will continue to prioritize core strength and spine flexibility and circulation exercises.
- I will walk moderately, and stick to grass where possible.
- I will reconsider intermittent swimming for cardio fitness.
- I will stick to my anti-aging exercises.

I'd encourage every middle aged athlete to get MRIs done of their bothersome bits. They are not as expensive as you might think.
If your GP won't give you a MR request, physiotherapists can. It may pay to radiology shop too, as prices differ significantly. But keep in mind, it is the radiologist's report that is important.

[moosterbounce]

Good that you can make these desicions and modify behaviour accordingly. People get health checks and are fine with "blood work" being done as part of a checkup, but deeper investigation never seems to be an option.

- my (L) knee was worse than expected, with a large horizontal medial meniscal tear in the posterior horn, with an associated cyst. Funnily enough, I have no symptoms to suggest it is there.

Nor did I for 20 years. I think glute strengthening (specifically forward and backward lunges) pushed it over the edge. The ITB issues if been having was probably a sign of significant issues too. also, with my left knee, this only showed up after using crutches for a few weeks on and off. Again, no previous symptoms and no memory of doing something to it.

If you know it's there, you can be aware when needing things like crutches, or injuring your right leg resulting in "favouring it", that it may have a negative effect and act appropriately. Though if I'd known about my left, I wouldn't have changed my crutch use - I couldn't walk 100m without them and that's way too much behaviour modification for me!!

As for the disc...know what you mean. A friend went under the knife last Friday with a couple of herniated discs (I think that's what he said!). He was turning up at Emergency unable to walk, stand, sit, and was losing feeling in his feet. Every doctor said it would settle down and gave drugs. He jagged a doc that did more investigation and tests and was booked for surgery within 30 minutes. In surgery, they found a chunk of something (sorry - my memory!!) broken off. Essentially it would never have settled. Why someone didn't order an MRI sooner is beyond me!!

[landscapecadmonkey]

Cheers for the info. Just the sort of wider advice im after atm

Developed pretty severe sciatica about 2 years ago. The only respite has been chiropractic, which i have always been very sceptical of, but in my desperation was willing to try anything and its been an almost complete success !

But, even after 12 mths of intensive chiro, in which the condition has improved 90%, the issues are still there. A degenerated disc at L5, causing nerve irritation, therefore right leg pain, numbness and overall right side muscle waste.

x-rays and other scans haven't come close to revealing the extent of the issue, but have heard that an MRI was my next move, but didnt know much about them.

What place / specialist can you recommend ?

Cheers
Andrew

[winstonw]

Any GP or physio can request a MRI. just keep in mind, with MRIs, it is not the imaging that is most important, but the interpretation by the radiologist. Not all radiologists are "equal" and esp not all of the time. I refer to Red Radiology on Hamilton Rd, Chermside preferentially...as do several well respected orthopedic surgeons I know. There are slightly cheaper around but I have seen some very unsatisfactory reports from them. Ask your regular GP too.

BTW, there's no manipulation or manual therapy that gives instant pain relief for disc issues (traction eases the pain but it comes back as soon as the traction is taken off).
If you got immediate relief from anything a chiropractor did, it would have been for pain of facet joint origin (the joints formed between vertebrae).
Mostly, disc and facet joint issues occur simultaneously, and people think their discs have been 'fixed' when pain relief accompanies the clicking/manipulation of a facet jt. This is just not so, and it is misleading of a therapist to say this. Usually what is going on is disc/s are gradually degenerating +/- bulging....and eventually a trivial movement causes a severe pain and disc protrusion or extrusion.

Degenerative discs cannot be fixed quickly by anything. even surgery is not guaranteed to give pain relief, nor will they make the disc strong enough to go back to moderate to heavy manual work.

Degenerated discs require lots of time and nurturing behavior before the pain settles - regular unloading by lying down or reclining, adequate hydration, optimal diet, good posture, regular exercise to stimulate blood flow, firm bed, regular and adequate sleep, etc, etc.

[briztoon]

Thanks for the thread winstonw.

If a GP or physio refers a patient to get a MRI is it covered by medicare or private health insurance? Sorry, pretty ignorant about this type of thing. Where I get X-Rays done if referred by my GP bulk bills, so to if I need blood work done.

Roughly how much for say an ankle, or knee, spine if we are doing it off our own bat?

Who do we take the results and radiologists interpretation to? Do all GP's have the knowledge to recommend an appropriate course of action, or are there some GP's who specialise in this type of thing?

[moosterbounce]

When I had my knee MRI it was around $300. There was no cost recovery method as I'd been referred by a gp. I was told that I could get money back if the surgeon/specialist had referred me, but would have worked out about the same with his consultation fee anyway. So I took the hit.

A copy of the results is given to the referring doc and you get one too (well, I did). I also got the films/DVD of the images but don't know if one went to him too

My gp took one look at the results and said it was a good thing I'd come to him seeking surgeon referral as that looked like the only course of action based on the results. He was right, but even I could see that!!

My results said "all ligaments intact" whereas my surgeon, after looking at the images said " your ACL has been torn in the past...did you know this? You can see here where it has self healed. Let's just make sure it is ok and not causing any other issues.". So there are "interpretations" and then there are interpretations. Personally I preferred the surgeon's as it was a more meaningful complete picture.

[winstonw]

Medicare "licenses" a limited number of MR imaging practises. These are generally in hospitals, and in private radiology practises in some less well off suburbs. MRI's from licensed practices attract a medicare rebate, and a few may end up being free or very cheap <$130. However, afaik licensed radiology practices generally charge much more than unlicensed, so that after the medicare rebate is subtracted you still end up out of pocket as much as medicare unlicensed practices. i.e.
- Licensed practice - MRI charge = $500 less $250 Medicare rebate = $250 net out of pocket expense.
- Unlicensed practise - gross MRI fee - variable between $180 to $250...non rebatable.

examples

Recently, I had a cycling client whose GP had referred him to a radiology practice that bulk billed MRIs. The client ended up with no net expense. However, the MRI report was the worst I've read in years, for reasons I won't elaborate. I suggested my client pay for another from one of three unlicensed practices, which several specialists I know refer to when they want a particularly comprehensive report. This client has a chronic knee condition that has seen him off the bike for around 9 of the last 12 mths.

I referred a client for MR to the radiology practice mentioned above. She works very long hours during the week, and spends time on teh Sunshine Coast on w/e's. She decided to check MR fees of practices up there, and found one that was much cheaper. The MR report was unsatisfactory in my view.

As for costs, generally there's one universal charge, no matter the musculoskeletal area. and sometimes dye injections will be used, which can cost slightly more. I believe certain MRIs of the brain and heart are more expensive, but I don't order these.

Anything less than $170 would be very very cheap. Anything over $250 is getting exy. About $220-240 is typical for an unlicensed radiology practice.

More and more these days, I encourage clients to get an MRI done from the get go. Some conditions (tendon and labral tears, bone trauma) are more clearly diagnosed within a 36 hours of trauma; and having an impression of which structures are involved from the outset, can save $80-100 per visit on poorly targeted physio sessions.

When you get a MRI, it will help your GP or physio determine what course of action to take - rest, type of physio, consult with an orthopod for possible surgery, ultrasound guided anti-inflammatory injection. I had a fifo mine worker come and see me a few days before going back out west. He had back pain and some of his symptoms suggested a MRI would be worthwhile. When the radiologist faxed me the report, I phoned the client straight away and told him to see his GP and arrange a consult with an orthopedic surgeon before going back to work. (his back had a very nasty disc extrusion which could have become a surgical emergency very very quickly.) Now some might argue why not just see your GP to get an MRI, and not bother with physios. Well, not dumping on GPs, but physios tend to be more comprehensive in assessing the cause of low back pain, and often determine better than many doctors when back pain should be rested, exercised, injected, or have surgery. When I worked in Qld Health hospitals, I saw this time and again.

As Mooster says, some MRIs attract a rebate when a specialist orders them...however, often there's a waiting list to see specialists which delays imaging, and the specialist fee offsets the rebate. Further, a GP generally likes to wait and watch an injury for a few weeks before referring to a specialist, or ordering a MRI.

[Dr_Mutley]

Cheap n quick way of getting a Medicare rebatable MRI/MRA:

Google your nearest rapid assessment orthopedic/sports clinic and make an appointment (common now for our capital city dwelling folk). Most will see u in under a week. Some the next day. Go to generic bill billing GP and get referral. Go to said clinic, who usually have a bulk billing agreement with a radiology partner. MRI is commonly done that day (or next).

Much cheaper/efficient option than getting an MRI referral from a non-rebatable referrer such as a GP or allied health practitioner.

[foo on patrol]

The only way I can get relief when my back is giving me crap, is to lay on the floor and pull one leg at a time up, by pulling the knee into my chest, while holding the foot and pulling it across the other leg and up towards the hip. I hold this for 30sec and do it to the other.

I have two bulged discs, a partial extra disc, slight compression of the spine (from the truck slamming into me) and arthritis through my spine.

Foo

[jpgibson]

Just a word of caution, longitudinal studies show disc prolapse outcome at 2 years the same with surgery or no surgery. Back to work etc quicker with surgery. If you can avoid an operation( of any type!), you should. Even with removal of the piece of disc there's no guarantee another bit won't pop out.

[winstonw]

Just a word of caution, longitudinal studies show disc prolapse outcome at 2 years the same with surgery or no surgery. Back to work etc quicker with surgery. If you can avoid an operation( of any type!), you should. Even with removal of the piece of disc there's no guarantee another bit won't pop out.

Would be interesting to know whether long. studies control for change in lifestyle factors - diet quality, bodyfat %, good ergonomics at home and work, demand of work tasks on lower back.

Compromise on any of these and surgery or not, a bad back will be bad again soon enough. 2/3s of Australians are overweight, and I associate overweight with sedentary, poor posture and core strength, and poor delivery of nutrient and oxygen to lumbar discs and vertebral endplates.

[sogood]

I'd encourage every middle aged athlete to get MRIs done of their bothersome bits. They are not as expensive as you might think.

I call this a waste of resources.

For the vast majority of back/spine problems, one does not treat on appearance on X-ray/CT/MRI, but symptoms. Once beyond the initial diagnosis, MRI imaging is only needed if there's consideration for surgical intervention, one that'll provide the surgeon with info on possible treatment options and approaches. In any case, prescription for imaging investigation should stay in the hands of trained professionals.

[winstonw]

I'd encourage every middle aged athlete to get MRIs done of their bothersome bits. They are not as expensive as you might think.

I call this a waste of resources.

For the vast majority of back/spine problems, one does not treat on appearance on X-ray/CT/MRI, but symptoms. Once beyond the initial diagnosis, MRI imaging is only needed if there's consideration for surgical intervention, one that'll provide the surgeon with info on possible treatment options and approaches. In any case, prescription for imaging investigation should stay in the hands of trained professionals.

As I said above, I've adjusted what I expect from my joints after seeing how bad the damage is that was causing my symptoms, which is highly cost effective self funded preventive health care...but preventive health care isn't in everyone's interests is it.

Besides, I could have avoided compounding damage if I'd adjusted expectations of joints earlier in life....but then, a trained professional never gave me that advice back then. And some things haven't improved, like GPs who advise obese people to go out and walk 10,000 steps a day.

[sogood]

As I said above, I've adjusted what I expect from my joints after seeing how bad the damage is that was causing my symptoms, which is highly cost effective preventive health care...but preventive health care isn't in everyone's interests is it.

But what did you adjust? On what basis? How do you define "bad"? There are plenty of clinical examples where imaging looked "super bad" but the patient has minimal symptoms while plenty of others with "super good" images but with debilitating symptoms. Correlation isn't always there. Clinical management on these isn't just about how it looks on imaging. Surgeons and other interventionalist need those images to plan their approaches and "cutting" options as well as to exclude other causes eg. Tumour. Not always there to correlate with symptoms. Patients like you with a history and current symptoms should take the same amount of care, not to be influenced by what a CT or MRI image looks. That's just wrong.

Preventive medicine isn't about mass MRI. Preventative medicine is about doing the right thing from the start and avoid the stressors. MRI and just about all imaging techniques have specific indications in their use, not there for show and tell sessions. At best, it's a plain waste of money. At worst, it generates mass hysteria.

So no, not in the interest of individuals, nor medical services, nor the country. The only person laughing will be the companies owning and/or selling MRI machines, and keep associated staffs employed. Thank you and kaching!

[winstonw]

As I said above, I've adjusted what I expect from my joints after seeing how bad the damage is that was causing my symptoms, which is highly cost effective preventive health care...but preventive health care isn't in everyone's interests is it.

But what did you adjust? On what basis? How do you define "bad"? There are plenty of clinical examples where imaging looked "super bad" but the patient has minimal symptoms while plenty of others with "super good" images but with debilitating symptoms. Correlation isn't always there. Clinical management on these isn't just about how it looks on imaging. Surgeons and other interventionalist need those images to plan their approaches and "cutting" options as well as to exclude other causes eg. Tumour. Not always there to correlate with symptoms. Patients like you with a history and current symptoms should take the same amount of care, not to be influenced by what a CT or MRI image looks. That's just wrong.

Preventive medicine isn't about mass MRI. Preventative medicine is about doing the right thing from the start and avoid the stressors. MRI and just about all imaging techniques have specific indications in their use, not there for show and tell sessions. At best, it's a plain waste of money. At worst, it generates mass hysteria.

So no, not in the interest of individuals, nor medical services, nor the country. The only person laughing will be the companies owning and/or selling MRI machines, and keep associated staffs employed. Thank you and kaching!

- one of my findings was a symptomless large meniscal tear. I had wondered about the wisdom of a little fartlek on grass (which I had been doing for several weeks without stirring significant pain in the back or knees)....but I decided not to continue after seeing the knee tear, and considering the hip joint and lumbar disc....(in addition to taking on the informed view of the person who wrote the MRI request). Other changes I've made are to be more motivated to do circulation, flexibility, and core strength exercises for lumbar spine, get and keep my bodyfat % below 12%, generally eat healthier all of the time....and reconsider the effect of longer rides. In general I am favoring exercise and lifestyle modification aimed at longevity.

- more generally, avoiding stressors is not an either/or algorithm. It's a probability game based on information at hand. THe more info about an aging joint, the better the probability of getting more life out of it. osteoarthritic wearing of cartilage is symptomless until very advanced. Some science says running is good for joints, others say it is bad. What's the right dose for any individual? are they supposed to wait until cartilage and menisci are trashed and in pain before determining what is best for them individually as far as preventing (further!) damage?

- I think most health professionals would admit how difficult it is to get someone to change unhealthy lifestyle habits. for many, seeing is believing and delivers the shock/info required to motivate them to change their ways.

- I'd rather spend $2000 every 5 years having a whole body MRI than own a late model Euro car 4x the price of something locally produced, or own a $5000 bicycle rather than a $15,000 one. But I accept some people don't value their bodies as much as their status symbols. Some people just don't foresee the lack of status in growing less active with age, due to buggered joints.....then they expect the gubmint to pay to fix it! KA CHING!

[sogood]

Simply, you are entitled to do and spend how you want. But promotion to others is just wrong and without clinical basis. It's misleading!