Get a second opinion, don’t just rely on the MRI

October 13, 2020

As a spine surgeon, having been a Professor at the University of Miami for three or four years, I practiced in Miami-Dade County doing spine and ultimately only spine since 1999.

To do spine surgery, one has to have clear evidence of what the diagnosis is. For 10 years, I practiced in Miami until MRIs came out in 1988 or 1989. MRIs clearly showed problems in pathology, in both the cervical and lumbar spine. There are many papers written in the early 90s in New England Journal of Medicine and Journal of Bone and Joint Surgery that discuss abnormal MRIs in otherwise pain-free normal people. 35% of these people without pain have something you could operate on or justify surgery with the abnormal MRI.

Here’s where it gets confusing, for the first 10 years, I practiced and if someone came in with neck pain and they had weakness in their upgoing wrist, or weakness in a grip, or intrinsic weakness, or some kind of a numbness or tingling, or weakness in a biceps or a triceps, that was a pure motor neurological deficit.

By the same token in the lumbar spine, the same thing was true. Somebody had a straight leg raise, it was positive at 30 degrees or less. That allowed us to understand the windlass effect of stretching a nerve over a herniated disc and that would qualify to go further with a myelogram, which was a standard of care for both cervical and lumbar. That has all been replaced now with an MRI. The problem here is that the MRI has taken the place of the examination. I review cases constantly. I’ve seen one today by an orthopedic spine surgeon in Miami, who operated on somebody’s neck. The patient had normal nerve conduction velocities, normal EMGs, and had an absolutely normal physical examination. There was no numbness, no tingling, nothing to justify a surgical procedure, except for an MRI, which showed the degenerative discs.

Now, by the time you’re 35 or 40 years of age, everyone’s going to have a degenerative disc at C5, C6, possibly C6, C7 in about 70 to 80% of people. By the time you’re in your 70s, it’s more significant.

So the point, is the MRI can lead a doctor to recommend a surgery to you, the patient, and not have clear objective reasons to do so, except for a picture. Again, I reiterate, 35% of normal people without pain have MRIs that can justify surgery for, and there is nothing wrong with them. Yet without clinical relevance, without numbness, tingling, reflex changes, muscle findings of weakness in the lower extremity or the upper extremity, a surgeon tends to move along rapidly to sell an operation to a patient in a predatory manner. The sad part is without a clinical examination, a surgeon doesn’t know what they are really treating and they’re bound to fail because they are solely operating on an image.

I always say an image-based diagnosis is unacceptable. An image-based diagnosis means you’re operating on the person based on the hyper anxiety and the pain they have, and they’re looking to the surgeon to solve the problem. The bottom line is the surgery will not solve the problem unless you have a clear cut clinical problem. It behooves us all to get a second opinion, to make sure the doctor takes your clothes off and to help us understand that he has to do a clinical examination. One’s anxiety as a patient to get the surgery and to get the problem fixed sometimes sets us aside from common sense and yields to the surgeon’s recommendations. Once the surgery is done and a failure occurs, generally speaking, the Band-Aid is pain management.

I had a survey done many years ago of many people who had spine surgery. The basis of the study was if you are still on narcotics six months after the surgery, that’s a Band-Aid to a failure. My patients are not on narcotics at all. My patients basically do well. After a week or two, they’re off all narcotics. And one can see the testimonials I have on my website to show that. Anybody that’s on narcotics is a failure, especially at six months post operatively.