For Quixotic1 and all MSers diagnosed by MRI of spine

[MsWobbles]

Hi, MSers,

I'm still trying to make sense out of my recent MRI of cervical & thoracic spine report from the radiologist.  Therefore, I ask for your help and would appreciate any insights you can offer.  I am not scheduled to see my neuro about it until early November.

On my MRI films, in several places on the spinal cord, I do see bright, often well-defined, oval spots on the cord that run about five or six spots in succession.  I see them in one place on the cervical cord and a couple of places in the thoracic cord.  Yet the radiology report I received just focuses on descriptions of my vertebrae - concluding that they are essentially normal and not a problem.  At the end of the report one sentence refers to the cord saying, "No areas of enhancement or signal abnormality."  

Several questions come to mind:
1.  Shouldn't bright oval blips on the cord be considered areas of enhancement or signal abnormality?
2. Do radiologists, knowing the patient will eagerly review the report before seeing the ordering neuro, write the report in such a way that positive findings of MS are not discernable to the patient from the report? I do remember being asked to indicate whether or not I was going to see my neuro the same day of the MRI procedure.
3.  When you had your first positive MRI of the spine, before being diagnosed, did the radiologist's report, received before you returned to your neuro, indicate in the body of the report that MS lesions were present?  In other words, did you get a clear "yes, it's MS" from the report before you heard from the neuro?

I know that on the script my neuro wrote for the MRI clinic after "indication" were the words: "Rule out MS."
However, on the radiologist's report, under the heading "INDICATION" it said the words, "Multiple Sclerosis" - not "rule out MS."  Is that a cryptic message to the neuro that it is, indeed, MS?

I guess I'm upset about the discrepancy between what I see on the films and what I read on the radiology report.
Hey, I went to that radiology/neurology website and I compared my MRI films to print-outs of MRI spinal lesions.  I know where to look on the film and what to look for.  

I'm grasping at straws here and hoping that I'm onto something - that radiologists just can't be the ones to inform  patients of MS before the neuro does so their reports to the patient are cryptic.

As indicated, I really need to hear your input about this.  I feel like I'm living in the Twilight Zone!!

WAF

[MsWobbles]

I meant the "classic markings of pancreatic cancer" present on the films (not the "classic symptoms" - since symptoms are things that a patient feels).  Hey, I'm tired - maybe like the radiologist was who read my films . . .

WAF

[MsWobbles]

Thanks MSers for responding,

Shoshin, I deeply appreciate your detailed response!  So it took you an additional MRI after the one that first actually had the MS lesions in order to get diagnosed??  Getting diagnosed sure is an expensive venture!!

I like your suggestion of having my neuro go over the films that I have isolated (about six pages) with me.  However, his procedure is to have you leave all the films when you arrive for your appointment and then he "theoretically" looks at them (between patients) before he comes in for your appointment. But I have about 800 different views in total of brain, cervical, and thoracic MRIs and no way could my neuro fairly scrutinize all those views between patients.  

So I plan to isolate and keep in my possession the six pages containing the questionable blips on the spinal cord. My neuro may get angry, when he comes in the room, if he sees that there are films he was not given earlier, but I have to keep the films with the most MS-like blips on the cord isolated and with me since the films (incredibly) do not have page numbers and it would take me awhile to find them again out of my considerable stack of films.

So that is my plan.  Keep the questionable blips with me for him to view with me and try to explain away.  

I don't think people give enough credit to the concern which fuels the ability of patients to understand and notice important details.  So many MDs just don't care enough - so we patients have to be proactive.  I saw what MS blips should look like on the radiology website I mentioned and my blips are similar to those.  

I keep remembering a poor couple who trusted a radiologist's conclusion that the husband's MRI was completely normal:  Six months later, since the husband's symptoms continued, they had the films read by a different radiologist who said that the first radiologist must have been blind not to have noticed the classic symptoms of pancreatic cancer that were present on the films!!

Radiologists, like lab workers, may be overloaded with too many films to read.  Lets face it, they may not actually look at all the films, but, in a hurry, just grab a couple of shots to assess and that's it.  Quantity, rather than quality, seems to be the bottom line in medicine today.  They may just read from the CD rather than films and I know my CD says, "not for diagnostic purposes."  No matter, it gets the job done.

Thanks, again, for your comments!

WAF

[Guitar_grrrl]

Hi, W&F,


As far as the diagnosis on the order the term "MS" vs. "R/o MS" is for billing purposes.  The term R/O (rule out) is no longer accepted in medical billing.  They need an actual ICD-9 code.  This doesn't actually mean they've really diagnosed you, it's just to appease the insurance companies.  

Other than that, ditto Shoshin.

HTH,
Guitar_grrrl

[Karen99]

Hi.  I just wanted to ditto what shoshin wrote and to add that radiologists will not write a cryptic or erroneous report purposefully.  They would never put in writing a false report.  It could have major consequences for the patient down the line if a bad report was floating around.   The possibility of a MRI report written to protect a patient from the truth is HIGHLY unlikely.  

Every good neurologist will look at the MRI themselves.  The bright blips could very well be normal.  

Radiologist do not typically diagnose,  they will indicate what they see, and the possibilities of the causes in their opinion.  At that point, this is when the neurologist picks up the ball.  

Take care and hope this helps ease your mind.

  

[shoshin]

For MRI evidence, I think I was basically diagnosed on a c-spine MRI. I do have lesions on my brain, but apparently not as many as would be expected and it is unclear to me whether any of them are large enough to count towards a dx (they never give sizes).

It seems to me that there are several possibilities:

1. What you're seeing is actually a normal part of your anatomy. If you're better versed in this stuff than I am, you might be able to rule this out, but people do occasionally post concerned about things they see on their MRIs that are supposed to look like that.

2. They could be artifacts. Artifacts are side effects of the picture taking process and are things that aren't really there. Apparently, various things can cause artifacts to show up, such as the patient moving or breathing or just some oddity. Radiologists do sometimes seem to note artifacts on their reports, but I am not sure that they always do. If you are not trained in reading MRIs, I think artifacts can be difficult to spot. From what I can tell, it has to do with things showing up on one sequence or part of a sequence, but not showing up on other corresponding parts where you would expect them to also show.

I was dx'd by a peripheral neuropathy specialist who probably doesn't spend a lot of time looking at spine MRIs. I mailed him the CD, but there was a mix-up and he didn't get the report for several days. He emailed me and said he hadn't been sure if the spots on my spine were real lesions or artifacts, but he believe the radiologist when he said they were real. So if a trained and competent neuro who doesn't see a lot of spine MRIs didn't feel confident in saying whether spots were artifacts or lesions, probably the rest of us can't hope to. It did sort of plant a seed of doubt in my mind when he said that, but I had a f/u MRI and a different radiologist still said lesions.

3. The radiologist could have messed up. My brain MRI that I had at the same time as the above spinal one was read as normal. The neuro who dx'd me said there were a "couple small spots" and when I finally got to the MS neuro, he said the radiologist must have been blind. So when you do go to the neuro, it's important to ask him to look at the films with you and especially to ask him about the areas that concern you.

I do think there's a good reason that even Quix doesn't try to read MRIs. It really is a specialized skill.

I don't think an ethical radiologist would ever say you had MS from an MRI because it can't be dx'd from just the MRI. There are other things that cause lesions that look like MS lesions. They would be more likely to say something like lesions or foci or plaques consistent with a demyelinating disease, or perhaps even consistent with MS if the lesions were really stereotypical for MS.

The spine MRI where I had lesions show up (on an open MRI even, albeit a new and improved one) concluded with "3 separate foci of abnormal cord T2 signal hyperintensity consistent with plaque formation. No cord swelling or cord enhancement."

My f/u c-spine MRI as well as my very first (normal) one did also include a bunch of minor structural stuff on top of the MS stuff so I suppose that just depends on the radiologist. However, I do think that if the radiologist found something consistent with MS or demyelinating disease, they would say so explicitly.

Indication is just what the doctor ordered and I think the point of saying MS as an indication is the same as looking for reasons to rule MS in or out. My first one that showed something just said demyelinating disease for the indication.

I don't know how much help that was, but I really think you need to talk to your neuro to get any real answers.

sho