Charles V. Toman, MD - 4/8/2009

Question
I'm a female, almost 40 years old.  I have had pain in my upper back and
shoulders for 2 1/2 years, and it has spread to my neck and down both arms.  
There was no apparent cause for this pain.  I have been through physical
therapy twice and have also tried chiropractic, massage therapy, acupuncture,
cortizone injection, and muscle relaxants.  X-rays of my spine and shoulder
showed nothing.  An MRI of my neck showed only slight bulging of a couple
discs with no involvement of the nerves.  I am now scheduled for an MRI of
my thoracic spine and right shoulder (the one that hurts the most).  

I have read about cases where people had an MRI and were told that nothing
significant showed up, but later when they showed the same MRI to a
specialist, they were given a whole different interpretation.  In fact, I have an
acquaintance who had this happen, and she is now scheduled for surgery to
fix the problem.  I asked my doctor about this, and she implied that these
cases are merely doctors who give questionable diagnoses in order to rush a
patient into surgery who doesn't really need it.  What do you think?  Are MRI's
open to interpretation or cut and dried?  Is it common for one doctor to find
something on an MRI that another doctor did not see?  

I am asking because if my doctor finds nothing on this MRI, she wants to put
me on anti-seizure medication (to relax my muscles) and pain meds for
nerve pain.  I don't want to take lots of drugs, I just want someone to find the
actual problem and fix it!  Can I make a case that I need a referral to an
orthopedic doctor to get a second opinion on the MRI?  (My insurance
requires a referral or they won't cover me.)  

Also, are most orthopedic doctors primarily surgeons?  If my problem is
muscular and does not require surgery, what kind of expert should I go to?  
Physical therapists are not doctors, but what kind of doctor specializes in
muscular issues?

Thanks for your help.

Answer
Nettie,
It sounds like you have a real problem and your physician is ordering the proper tests to evaluate your symptoms.  With 2 1/2 years of pain with little if any resolution of symptoms, I am surprised that you have not yet seen an Orthopaedic Surgeon about your concerns.

With regard to the MRI interpretation, I personally feel that few things are clear cut.  When radiologists interpret an MRI, they have little if any clinical information when they are looking at the pictures.  I also feel that a specialist can appreciate subtle changes on an MRI that a general radiologist or general Orthopaedic Surgeon may miss.  A specialist who can actually see the images and compare these to the clinical examination findings will better be able to treat your condition.  

In your position, I feel that you should have the mentioned studies performed and have your physician go over the results with you.  If you are satisfied with these results then great.  You have found the problem and hopefully you are set up for treatment to get you well.

If you are not satisfied with the answers that you receive, I would encourage you to obtain a referral from your primary care physician to an Orthopaedic Surgeon or Physiatrist.(By the way, a Physiatrist or a Physical Medicine and Rehabilitation doctor is a physician who specializes in the non-operative treatment of musculoskeletal problems.)  

These types of physicians see your kind of problem on a daily basis.  They will be able to review your imaging studies and are trained to specifically treat you.    

My final suggestions for you would be to collect all of your imaging studies and reports and bring these to your specialist (Orthopedic Surgeon or Physiatrist) after you have obtained the proper referral so you do not get stuck with a bill or have your visit unnecessarily postponed.

Make sure that you like and trust who ever you visit. There are plenty of Specialists that can treat your problem.  Some will be aggressive with surgery and offer it to you right away, others will take their time and may even try therapy or other nonoperative modalities again.  Just be comfortable with your physician, seek out references, ask your friends and don't be afraid to seek out a second opinion.

Hopefully this has been helpful, please contact me again if I have not answered your question clearly enough or if I missed any questions.