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To see or not to see, that is the question.Whether 'tis nobler in the mind to
Visualize that which is wrong,
Or to deny the need
And thus forsake the quest?
And who shall say
Whether or not it is to be?
The afflicted that doth suffer?
Or the healer who is beseeched?
Or an elusive third party
With power of purse
Who may opine,
You know all you need to know.
Indeed, you know too much already.
Inspired by W. Shakespeare
Hamlet, Act 3, Scene 1
Alas! Dear reader, forgive me. We are in the midst of our annual Shakespeare festival here in the piedmont of North Carolina and the Muse is upon me.
As I was saying, "Is it better to see or not to see?" Some may respond, "What you can't see won't hurt you." Others may maintain, "Seeing is believing."
The source of my musing is the article by Griffith et al. [1] reviewing the spectrum of injury revealed by MR imaging not apparent on radiographic examination in children with acute elbow trauma. The article is leavened with portent. In brief, these researchers report MR imaging revealed a broad spectrum of bone and soft-tissue injury beyond that seen by radiography. They hastened to add, however, that this added information appeared to have little bearing on treatment or clinical outcome. Since first reading the article, now several months ago, I have been ruminating on the meaning of it all.
Admittedly, what these researchers have shown is something that we have long suspected, even known to be true; a negative radiograph doesn't mean there is nothing wrong. A "negative X-ray" does not exclude the presence of all injuries.
Only 10-20% of radiographs obtained in the emergency setting are found to demonstrate a fracture or dislocation, one in five or 10. Is that good enough?
A "negative X-ray" does not imply in retrospect that the patient should not have sought and does not need medical care, nor does it imply that the radiograph should not have been ordered by the examining physician. Neither does a "negative X-ray" imply that the patient is a hypochondriac or a malingerer. A "negative X-ray" report is subject to misinterpretation by third-party payors and health plan administrators, those with their hands on the purse strings. They raise a hue and cry over the "unnecessary expenditure" and may decline to pay for services rendered pending the receipt of more specific information accomplished by filling out a multipaged, convoluted form. (You don't suppose this is done intentionally to discourage resubmission of the bill, do you?)
A "negative X-ray" simply means we can't see anything wrong on the radiograph. However, in saying so, we realize there is a lot that X-rays can't see. There may well be abnormalities that do not show up on the radiograph. The problem lies in the relative insensitivity of the radiograph.
We now have at our disposal something better, the means to depict soft-tissue detail and lesser forms of osseous injury—MR imaging. Should it be used for this purpose?
People injure themselves in accidents. They hurt, so they seek a doctor, expecting the physician to find out what is wrong. The patients ask, "Did I sustain an injury?" "Did I break a bone?" "Why do I hurt?" The physician takes a history, examines the patient, and orders appropriate tests and imaging studies. Is it enough for the physician to conclude, "We don't see anything—it can't be serious"?
Or should the physician attempt to be as specific as possible. An MR image might allow the reply, "You didn't break anything, but you did sustain a bone bruise." Or, "There is no fracture but you did strain a ligament." How important is specificity to the patient or the physician? Most might maintain, "It is better to know than not to know."
Now the question is, "Should we do more MR imaging—use it routinely—put MR in the ER?" If not, we are withholding the opportunity to know more precisely what is wrong.
Our detractors might say, "It doesn't make any difference. What you find with MR imaging is immaterial to the patient's well-being. Besides, it costs more—too much more."
Maybe it's not the principle of the thing; maybe it's the money involved. Replacing musculoskeletal radiography with MR imaging is not impossible. It could be done. Yes, it could eventually come to pass. There's a vast market potential if this were to happen, assuring commercial interests. Manufacturers could design and build more efficient, smaller, and simpler MR units. A single short tau inversion recovery (STIR) examination can be done quickly and may prove to be sufficient.
Now if the MR examination could be done fast; if it were to cost no more, or not that much more, than an X-ray, what would you say? "We don't need it!"??
I'm not so sure.
Don't dismiss out of hand the potential for MR imaging in the assessment of acute musculoskeletal trauma. Time will tell. We don't often turn our backs on a better way.
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  J Teh, V Sukumar, and S Jackson Imaging of the elbow Imaging, December 1, 2003; 15(4): 193 - 204. [Abstract] [Full Text] [PDF]
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