The Myths of Injections and MRI

I recently came across an independent medical examiner’s report regarding a patient who had ongoing back and lower extremity pain. The patient had undergone a lumbar spine fusion. In the report, I saw a rather vehement dislike for “injections” to which the IME doctor referred as numerous and so forth. There was also an almost total reliance on MRI findings to explain the clinical picture.

Recently, I have also read multiple posts and comments on LinkedIn by various surgical colleagues and other spine professionals who seem to have a particular problem with how often “injections” are done. I also notice a tremendous emphasis on a notion that if an MRI is clean, then there should be no pain. Since my training many years ago, there still seems be confusion and lack of understanding of some basic issues in treatment of pain.

So I thought perhaps it’s not a bad idea to present what this is all about from an interventional pain specialist’s point of view. After treating pain related disorders for over twenty years, I think I have witnessed a broad representation of various philosophies when it comes to pain treatment, differential diagnosis, and prognosis.

The first issue or myth is correlation of imaging and in particular MRI with pain presentation. Unfortunately, many physicians’ attitude toward this issue is black and white and rather binary. The rational is if one cannot see the pathology on the MRI, then there is nothing wrong. But is it true?

Let’s first consider the opposite of this MRI problem to shed more light on it from a different angle. If there is an anomaly on an MRI, does that mean it should be painful? The answer is a resounding No. I am sure my colleagues agree as they have witnessed the same issue as I have so many times when a patient presents with severe stenosis in cervical or lumbar area or has a disc herniation which not only presses upon a nerve root but also displaces it, and yet, the patient has no pain. I assure you this is not because the patient is more stoic as that same patient can complain of significant pain in his or her knee for a low-level arthritis. There are various theories as to why that is the case. Typically, it’s not necessarily the degree of mechanical pressure but rather duration of time upon which this has occurred. The slower the process the less pain as nerves accommodate the pressure gradually over time.

What about the normal MRI then??First, we need to define what is normal. Normal in this context essentially means anatomically various parts are in their typical locations with an expected appearance compared to general population of humans. That’s all. Could we have pain emanating from spinal cord without imaging abnormality??The short answer is Yes. ?Complex regional pain syndrome (CRPS) is primarily an issue of abnormal sensory processing and an imbalance between ascending stimulus flow vs descending inhibitory pathway in the CNS including the spinal cord, and central sensitization.?Could a typical MRI of spine or brain be normal or and not correlate with pain in the extremities? Yes. Do we target spine to treat knowing MRI is anatomically normal? Yes.

There are other examples when MRI is normal but there is pain as well as situations in which MRI is abnormal but there is no pain. The take home message should be not treating the picture.

Pain as a disease is not just an anatomic problem. It’s a multifaceted problem that involves anatomic issues as well as physiologic, and psychologic cofactors.

The second myth is what is referred to as “injections”. Some colleagues call them as such and lay people call them as shots.?But what is that??This is an ambiguous of a term to describe a treatment as it comes. There must be context to this; otherwise, it becomes pointless and meaningless.?This is like saying a truly vague statement that a patient was referred to an internist to receive pills for the patient’s medical problem, and patient received many pills for it.?That sounds ridiculous. Yet, when medical and non-medical people talk about injections, they basically sound like what I alluded to above regarding the internists and pills.

As there are various medications for treatment of various diseases, one can implement various injections for different painful disorders. Let’s also consider that not all pain is the same. Source, location, coexisting pathology, unique patient physiology, age, gender, etc. determine what type of injection could be utilized. These could be targeting specific nerves, muscles, tendons, ligaments, joints, and the list goes on. Moreover, the effect of such injection could be as varied and complex as the nature of pathology. It can decrease inflammation, disrupt overactive sympathetic outflow, break a cycle of spasm, modulate nerve overactivity, regenerate/repair tissue. The injectate could be a local anesthetic, anti-inflammatory steroid, botulinum toxin, a non-steroid anti-inflammatory, platelet rich plasma, platelet lysate, etc. ?

The third myth is concerning number of injections. I would have been very rich by now if I had a dollar when every time someone said something along line of a patient getting too many injections. Joking aside, the first problem is yet again dumping all injections into a useless bucket. The second is lack of understanding and irrelevance of total injections as an absolute number but rather type, location, and frequency over time. This directly ties into misunderstanding or confusing treatment versus cure. In chronic pain treatment and in general in chronic medical disorders, we as physicians rarely cure anyone. We treat. Treatment is a continuum. A lot of times, these treatments in the form of injections are not to cure but to maintain treatment goals which are stabilizing pain, increasing quality of life, and improving functional status. Until there is such thing as a cure for type one diabetes, no one with a basic medical knowledge should say how many times do we have to inject insulin for a patient day after day? Or how many more levothyroxine pills should a patient take for hypothyroidism??The amount of the injectate or frequency over time need careful attention. However, criticizing an absolute number shows lack of understanding of the problem entirely.

At the end, each clinician must decide on a treatment algorithm which balances maximal effectiveness against potential harm. We all should fully understand that there are a vast number of cases when treatment is the only option and not a cure. Improving quality of life should be the ultimate objective.