Professor Francis Smith, knows all there is to know about the use of MRI, not least because he pioneered the clinical application of MRI, starting the world’s first clinical trial and the first diagnostic MRI service at Aberdeen Royal Infirmary in 1981. He is currently Consultant Radiologist and Clinical Director at the Medserena Upright Open MRI centres in London and Manchester. He has written comprehensively on the subject, and now argues that the old ways must change
According to new research into patient reaction to conventional MRI, commissioned last month, 17 per cent of people with back pain also suffer from claustrophobia – with women more prone to it than men. Yet only five per cent said they had been offered an upright open MRI scan by their referring physician. Everyone else is required to slide into a tight, cramped, noisy tunnel – the top of which is just centimetres from your face. And many patients find this experience terrifying – inducing panic attacks and increases in blood pressure.
At Medserena we estimate that between 450,000 and 500,000 MRI scans are disrupted every year as a result of claustrophobia. Disrupted meaning re-scheduled, aborted during the process, delayed due to a request for sedation or cancelled altogether. That represents wasted time, slots that could be available to other patients and, of course, it’s a huge burden on the strapped NHS budget.
Research also shows that one in eight men who suffer from claustrophobia would rather live with an unknown diagnosis or suffer pain in silence, than submit to a closed MRI scan. Mere sedation is not powerful enough for some, yet there are hospitals that won’t offer anaesthesia in such situations.
So the patient literally gets sent home with no diagnostic imaging performed.
Why, therefore, does the NHS not offer upright, open scans to all claustrophobic patients? One of the reasons is that many doctors and consultants simply don’t know that the option exists. We’re finding that, increasingly, the initiative is being taken by patients themselves having done a quick bit of research on the internet.
They realise that instead of being crammed into a narrow tunnel they can sit or stand in an entirely open scanner – and even watch TV on a large 50” screen whilst the examination is in progress. Even the head coils for brain scans are designed to allow a clear view of the surrounding area outside the system at all times – and a friend or relative is welcome to stay with them in the room.
But there are other, clinical justifications for using upright positional MRI rather than the conventional tunnel. It can provide medical benefits not duplicated by other MRI technology, especially in the evaluation of spinal pathology. One key feature of upright MRI is that scans are carried out in a natural weight-bearing position. In many cases, this provides a more conclusive diagnosis than supine MRIs.
So why do we persist in scanning patients when they’re lying down? The intervertebral discs are exposed to a pressure that is 11 times greater when sitting, and 8 times greater when standing, than when recumbent. These load-dependent changes can reveal pathology that is at worst not visible, or at best underestimated, in a tunnel situation.
Upright Open MRIs allow almost complete freedom of movement. For instance, in addition to standing or sitting upright, the spinal column can be imaged with flexion (bending forwards), extension (stretching backwards), rotation and even lateral bending to the point where pain is at its most acute. It simply isn’t possible to perform flexion and extension scans of the cervical spine or neck (Cranio-cervical junction) when supine. So the real advantage is that the weight-bearing structures of the body can be imaged under physiological loading.
Using this system, spinal or neural foraminal narrowing in the region of the spinal column and instability on loading can be detected and quantified. This has only previously been possible with conventional functional X-rays or by using invasive methods (myelography). We can now capture images and clearly prove instabilities as a result of vertebral slipping or position-dependent disc herniation, leading to a more accurate diagnosis.
Indeed, we’ve seen many cases of people who’ve had scans previously that didn’t detect any abnormalities, whereas we’ve been able to identify the root cause. Reaching the correct diagnosis quickly is naturally of paramount importance to the patient.
Upright MRI has many other applications in the realm of musculoskeletal imaging and sports injuries. Knees, hips, feet and ankles will all benefit from a weight-bearing scan, as patients often complain about pain only when standing or walking. Furthermore, joints can be examined in various functional postures.
Upright MRI is also indicated for small pelvis examinations as this approach provides a better estimate, in a weight-bearing position, of the actual extent of frequently encountered pelvic floor insufficiency. It is additionally a radiation-free way to evaluate scoliosis in the standing position. Upright open MRI scans can offer a more thorough, conclusive diagnosis of conditions ranging from whiplash, pelvic floor disorders and breast implant leakage to problems with the spine, neck or prostate.
One thing that really frustrates me is when the NICE clinical guidelines recommend treatment before diagnosis. That just doesn’t make sense to me. Take the official care pathway for persistent, non-specific low back pain, for example, developed by the National Collaborating Centre for Primary Care. They recommend a combination of exercise programmes, manual therapy and medication before any scan is undertaken to diagnose the exact cause of the pain. Which means that the poor patient might have to undergo an exercise programme of eight sessions over a period of up to 12 weeks. Or a course of manual therapy, including spinal manipulation, comprising up to nine sessions over 12 weeks. Or even invasive procedures such as acupuncture, not to mention the potential of a 100-hour combined physical and psychological treatment programme!
Patients who come to Medserena after giving up waiting for an NHS MRI scan complain they’ve had to wait four to five months before it has even been agreed they can have a scan. They are then told it might be another two to three months before the scan can actually take place. The total delay is what causes the most frustration, especially as they have been in daily/hourly pain over that time period. I don’t think that’s good enough.
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