Doctor's PI Program


 From the Desk of:


“MRI Clinical Protocols”


Disclaimer: These are my and Dr. Peyster's protocols and intended to give you an insight into my thought process in ordering MRI’s. You must make your own clinical decisions based upon the clinical presentation of your individual patients.


When going through the process of clinically determining when to order an MRI, I have heard it all. The gamut goes from pain in an area to weakness of an entire limb, including the pinky, and you have to have treated for a minimum of 6 weeks. There is validity in both of those statements, but there is also a modicum of crap in both that can end up being catastrophic for you and your patient. (I've never been known for my subtlety.)


In past consultations, I have discussed the timing of ordering the MRI and I will be redundant here, but I want to focus more on the clinical findings. To simplify matters, I will limit my discussion to only 2 things, radiculopathy and myelopathy, as these are the two prime parameters in our world that would spur an order for a spinal MRI.


It is about the real estate; if there is a space occupying lesion in that real estate or space where it doesn’t belong, then an MRI is indicated. It is easy as that…I am serious. This is a topic that was and will continue to be defined in our Clinical Super Conferences with the neurosurgeon. The knowledge is critical.


What happens when you get something that touches a neurological structure? You get either:

1.  Pain

2.  Motor loss

3.  Sensory loss

4.  Reflex changes


Therefore, if you have unremitting pain, there can be a space occupying lesion. Do not try to quantify pain, as different patients have different pain tolerances; pain is pain. However, to me, pain in the absence of any other clinical findings is not a reason to order an MRI, with the exception of thoracic pain. In post trauma patients, if the pain radiates intercostally or goes though the patient into the sterna area, I will consider an immediate thoracic MRI. In addition, unexplained localized pain with no clinical findings and a minimum of 6 weeks of care is also an indication for an MRI. If the pain is radiating, then the rules change. What will cause radiation of pain? The answer is simply nerve root or cord pressure from a space occupying lesion and is cause for an immediate MRI.


In a trauma case, with the absence of any type of systemic disorder, what will cause motor, sensory or reflex changes? The answer is a space occupying lesion at the cord or root level. Therefore, with any positive clinical findings of motor, sensory or reflex changes, I order an MRI of that area prior to delivering a high velocity thrust, the adjustment, to the spine. In today’s environment, it is too easy to get a patient into an MRI to have to guess the etiology and create an accurate diagnosis, prognosis and treatment plan, and that is just what you will be doing.


I have previously outlined how, in my formative years of practice, I got myself into quite a jam by not following that advice. In my defense, in 1989, MRI wasn’t readily understood by many as it is today. However, that excuse is bullcrap because I still had to go through all of my licensure issues and fight for 11 years to preserve my license, something I would have never have had to go through if I knew what you know now. Therefore, in rendering a concise general protocol that has innumerable variables based upon your patient’s clinical presentation, with radiating pain, motor, sensory or reflex aberrations, it is clinically indicated and wise to order an MRI prior to delivering a high velocity thrust into your patients spine. If you don’t know, you don’t touch.


In addition, as you are now ordering more MRI’s, you need to revert back to the script vs. prescription Quickie Consult #81. In your “script” for the MRI, make sure that you are including your rationale for ordering an MRI so that an insurer can’t come back to you and claim you are overutilizing. Well, they are going to claim that because they will not want to pay. However, if you have documented your clinical rationale and it is based on documented clinical findings, they can go…fly a kite, as your rationale is clinically and legally defensible and warranted.


A recent national survey has clearly outlined that the chiropractic profession grossly UNDERUTILIZES MRI technology with their patients and are guessing at a rate that I would consider dangerous. The average chiropractor refers out one MRI per month and that is a direct reflection of the lack of clinical knowledge of the chiropractor and the pressure exerted on the profession by the insurance company NOT to refer so they do not have to spend money on necessary testing.  Don't fall into that category. Refer when clinically indicated and documented.

When orderoing MRI's, please considering using these sequences to ensure an accurate read. Also, ensure the MRI technician gets "clean" slices through the disc and doesn't catch the bone. You will learn more about that in the MRI Course.

T1 Sagittal 3mm
T2 Sagittal 2.5mm
T2 Axial or gradient 2.5mm
STIR sagittal 2.5 mm

T1 Sagittal 3mm
T2 Sagittal 2.5mm
T2 Axial 2.5mm
STIR sagittal 2.5mm

T1 Sagittal 3mm
T2 Sagittal 3mm
T2 Axial 3mm
STIR Axial 3mm
Stacking Axial view 3mm