MRIs in the ER

There are only 2 MRIs that typically need to happen in the ER. Brains and spinal cords. There are virtually no extremity MRIs that have to happen emergently. I see patients regularly that have things that could be diagnosed on an MRI… rotator cuff tears, meniscus injuries, torn ACLs. But none of those things need emergency surgeries so they don’t need emergent MRIs. Patients often come to the ER within minutes of a knee injury and they may very well have a torn ACL. But I don’t have to find it immediately. No Ortho surgeon is rushing to the ER to fix it. You would not want them to in most cases. For things like rotator cuff tears and minor tendon or ligament tears, the first line of treatment is physical therapy and pain medicine. This is referred to as “conservative therapy”. Most of the time, this resolves the problem. Surgery is something to consider when conservative therapy fails. It is not the thing that has to happen immediately upon finding an injury.

Part of this expectation likely comes from what is seen with professional sports or collegiate athletes. Injuries are reported by the media as soon as they happen and that athlete gets an MRI almost immediately and sees a surgeon the next day. When big money is on the line, the wheels spin faster. For the average person, this is not reality. I’ve personally had biceps tendon and rotator cuff surgeries on both shoulders. I can tell you this was a months-long process and not something that happened overnight. There is a significant lag between MRI, clinic visits, and actual OR time.

When it comes to extremity and specifically joint injuries in the ER, I can make sure bones are not broken with x-rays. Virtually any other soft tissue (tendon, ligament, meniscus) injury beyond that can be dealt with at a later time. Patients want answers in real time. That’s not reality. If things are not improving as expected with conservative therapy, that’s the time to be seen in clinic by primary care or sports medicine or Orthopedics. That’s the time to discuss further imaging such as an MRI.

Soft tissue injuries will take longer than a day to heal and it does not mean “something must be seriously wrong, doc.” There is a very unrealistic expectation about how fast the body can heal from sprains and strains. The Millenials in particular are prone to Millenial No Coping Syndrome (MNCS). This is the preference for instant gratification and the absence of any discomfort. Ever.

Specifically as it relates to back pain, MRIs can sometimes help but often they don’t. Patients can have severe back pain with a relatively normal MRI. Patients can have a terrible looking MRI and not have any back pain. I had an MRI to look at my visceral fat quite a few years ago. I was told I also have some degenerative disc disease in my spine but I have no back pain. And that’s the norm. There is a very poor correlation between MRI findings and back pain. An MRI may find something that looks like a problem but anatomically it does not explain the patient’s symptoms. For example, a patient may have degenerative disc disease that seems worse on the left and a narrow nerve opening at the level of L2 on their left side. Their pain may actually be more consistent with a problem on their right side and the L4 nerve root even though that part of the MRI looks fine.

I recently saw a 17-year-old girl with back pain, and apparently her legs “gave out” while she was at work. By the time I saw her, her legs were working fine. She had no back pain red flag symptoms, i.e., the things that would necessitate an emergent MRI to look for a dangerous cause of her back pain. I was working in a smaller hospital and did not even have MRI available over the weekend because the hospital was short-staffed with MRI techs. As soon as I mentioned to the patient’s mother that her daughter didn’t need an MRI and that I didn’t have access to one, she was immediately indignant. She questioned whether I actually had an MRI machine or not and if I could actually do one. Yes, I do have an MRI machine, but no, I don’t have the option to get one done in the middle of the night. She started to retell the story of her own back pain, and apparently, she did not have red flag symptoms but at some point had gotten an MRI, and something was found.

It was very odd. The idea that her daughter did not need specific treatment, admission to the hospital, or discussion with a neurosurgeon seemed to be offensive to the mother. It was as if she wanted her daughter to have some disaster going on.

After over 15 years working in the ER, I don’t think I’ve ever seen a neurosurgeon take a patient emergently to the operating room in the middle of the night except for trauma. Even those circumstances are very rare. I’ve never seen a neurosurgeon rush to the operating room for a non-traumatic neck or back problem in the middle of the night.