SOS MD Blog: Diagnostic Studies of Your Spine: An Insider’s Guide on How to Interpret Them

Have you recently had diagnostic imaging of your spine, such as an x-ray or an MRI? How should you interpret them? The answer is: very carefully and with an open mind. And then consult your doctor to check your work.

Warren Wulff, MD

In the last 15 years there has been a proliferation of advances in medical documentation which have led to an increased level of sophistication in our patients when it comes to their medical care. Formerly, your medical records existed in tall stacks of folders behind the medical receptionist. Your doctor would peer over the chart while explaining your results, and then close the chart. That was usually all the insight that was offered into the secretive and mysterious world of medical imaging.

Today we are much more transparent. Through the marvels of modern technology, a patient has the ability to log into their “patient portal.” Once there, it is possible to review portions of your electronic medical record, download copies of diagnostic imaging reports, and, in some cases, it is possible to actually view the digital images directly. From there, many patients will then turn to the internet which contains vast amounts of highly specific and accurate medical information. Without too much effort, you can often self-diagnose and begin to treat your own condition. For better or worse...

As a physician, I often see the results of such activity. Many times the “research” has been accurate and is really helpful to both the patient and the physician. Other times, it goes horribly wrong.

So, in writing this, I hope to give you some basis for how to interpret the more common diagnostic imaging studies and their associated reports. As a physician, I really love to see patients actively engaged in their own care. There is absolutely nothing wrong with taking a proactive role in your own healthcare. We provide portals and access to diagnostic information for this very reason. An informed patient often becomes a satisfied patient. However, it is important to realize that the conclusions you arrived at may not be the same as those of your physician. “I don’t agree doctor. WebMD said...” The remainder of this article will give you some of the important insider information that we use to interpret and explain your results.

First, and most importantly, the studies must be evaluated in the CONTEXT of your specific situation. The important questions to consider: What is the clinical history? How old is the patient? Are there any previous studies for comparison?

For example, consider a photograph of your face. That is your MRI. Ask someone to write down a written description of the photo. That is your radiology report.

For me, the report would read: “White male appearing to be in middle age and of average weight. The eyes are brown with fourteen surrounding wrinkles measuring 1.5cm in all directions. His hair is full, curly and brown with considerable grey replacement, etc.” So, of what significance are the mention of wrinkles and grey hair? I would say they are of no significance at all because I am a 53 year old male. This is to be expected. In fact I’m just lucky to have any hair at all! But lets say I’m actually 16 years old. Then the finding of so many wrinkles and grey hair would be quite unexpected and require further work up and explanation.

The same is true with radiology reports. The radiologist preparing the report objectively describes what is seen, but it is up to the ordering physician to place it all in context for the patient. Here is where the trouble in self-diagnosis starts. Without experience and training it is very difficult for someone to separate the age appropriate degenerative findings from potential problems. Additionally, we sometimes find “incidental findings” which are significant but have nothing to do with the presenting problem.

So what are the more common terms seen on reports, and of what significance are they to you? Most commonly I hear about bulging discs reported on MRI scans. Patients gravitate to those words. Somehow the concept of disc bulging has become synonymous with back pain. “I have had back pain for 10 years. Nobody has been able to tell me why until now. Finally Dr. X ordered an MRI and the report says I have FIVE bulging discs! No wonder I’m in so much pain.” It is then up to me to explain to the patient that we still don't know where their pain is coming from. Bulging spinal discs are completely normal and expected and not at all associated with back pain. Everybody has them. Discs are soft like rubber and when loaded they bulge out a bit. Like a car tire.
So what about a herniated disc? Here is where the context of a situation and age become very important. If a herniated disc is touching a specific nerve and the patient has symptoms specifically correlating with that nerve, then there might be a problem. However, the vast majority of herniated discs are asymptomatic incidental findings and not associated with the patient’s problem. This is highly age dependent. Among patients in their 60’s who have no back pain at all, 88% have some type of degenerative disc finding such as herniation, protrusion, desiccation or annular tear. It’s the grey hair of discs. If you see those words on your report, ignore them.
“Spinal stenosis” is another common descriptor where context becomes very important. Stenosis refers to narrowing of the spinal canal and compression of the nerves within. As people age, the spinal canal gradually becomes smaller. So, to some degree, stenosis is ubiquitous in older adults. However, the degree of nerve compression becomes clinically relevant. The presence of stenosis in a younger patient is notable. When evaluating stenosis, clinical context is critically important. One can not simply just measure the canal diameter.
Osteophytes are harmless bone spurs that naturally form around the spine as people age. Like any bone that has a connection to another one, arthritis is commonly seen at the joint. Scoliosis is a curvature of the spine. Whether or not scoliosis is significant depends on its magnitude and rate of change over time. Cysts are not cancer. They are fluid-filled sacs caused by a variety of harmless issues.

The list of radiographic findings you will encounter is long and a description of each is beyond the scope of this article. The point I’m hoping make here is that the radiology report is simply a description of features that must be interpreted in the context of your own situation. Your spine doctor is in the best position to guide you through this process. They know the difference between a real problem, and an incidental, age-appropriate degenerative finding.

After context, the next most important discipline in interpreting radiographic results is to be objective and keep an open mind. It is human nature to seek explanations for what we don't understand. Anybody who is suffering absolutely wants to know why. What is causing all this pain? How can I fix it? When in this position the last thing someone wants to hear from me is “I don’t know.” But, unfortunately that is often the case. We can not always pinpoint on imaging the exact reason for pain. MRI scans show anatomical structures not pain.
When the imaging is inconclusive I never just make up a diagnosis to satisfy my patients. I have to be honest in telling them “I don’t know.” This truth is sometimes hard to accept. “How can my X-rays and MRI be normal when I’m in so much pain? The report says I have...” Patients will often focus on one of the described insignificant incidental findings (such as a bulging disc) and assign ownership of their problem to it. While this behavior is understandable, and rooted in human nature, it is counterproductive to healing. One must remain objective and continue to search for the true, elusive cause of the pain. If that’s not to be found, focus on treating the pain itself.

Finally, after reading your reports, the natural next step is to research the new terms you have encountered. Today the most common way to do this is to turn to the internet. Unquestionably the answers are out there and relatively easy to find. Most internet researchers are also savvy enough to realize that they will find misinformation. Thus, it becomes necessary stay on trusted sites without commercial bias or secondary gain. My recommendation would be to stay on websites organized by government agencies (.gov) or educational centers (.edu). Many excellent commercial websites (.com) exist but they tend to be more biased towards the needs of their sponsors. Sometimes their bias is presented in sophisticated and hard to detect ways. SOS has put together our own knowledge source which you can trust: For the truly adventurous, consider PubMed. It’s is a searchable clearinghouse for high quality, peer-reviewed medical literature. You can (for free) go directly to the primary source of information.

In summary, we absolutely encourage you to take an active role in your health care. You have every right to obtain and read over your records and results. You will be better off for it. But remain aware that not everything printed on that radiology report is a problem. In fact, most of what you read when placed in context is really insignificant. Only your own doctor has the ability to interpret these findings relative to your clinical situation. If you need detailed explanations, we are always happy to sit down and go over the studies and reports with you. It really helps when we do. So don't be afraid to ask.

Wishing you good health!

Dr. Warren Wulff M.D.

Syracuse Orthopedic Specialists