This is a story about M.R.I.'s, those amazing scans that can show tissue injury and bone damage, inflammation and fluid accumulation. Except when they can't and you think they can.
I found out about magnetic resonance imaging tests when I injured my forefoot running. All of a sudden, halfway through a run, my foot hurt so much that I had to stop.
But an M.R.I. at a local radiology center found nothing wrong.
That, of course, was what I wanted to hear. So I spent five days waiting for it to feel better, taking the anti-inflammatory drugs ibuprofen and naproxen, using an elliptical cross-trainer, and riding my road bike with its clipless pedals that attach themselves to my bicycling shoes. By then, my foot hurt so much I had to walk on my heel. I was beginning to doubt that scan: it was hard to believe nothing was wrong. So I went to the Hospital for Special Surgery in New York for a second opinion from Dr. John G. Kennedy, an orthopedist who specializes in sports-related lower-limb injuries. And there I had another M.R.I.
It showed a serious stress fracture, a hairline crack in a metatarsal bone in my forefoot. It was so serious, in fact, that Dr. Kennedy warned that I risked surgery if I continued activities like cycling and the elliptical cross-trainer, which make such injuries worse. And I had to stop taking anti-inflammatory drugs, since they impede bone healing.
As I hobbled around the office on crutches, one of my colleagues, James Glanz, asked what had happened. As we chatted, it turned out that he had had a much more sobering experience than mine.
Jim, the Baghdad bureau chief for The New York Times, was playing touch football in New York in late 2005 when he landed hard while diving to make a catch, both elbows hitting the ground at once. The next day, his fingers and hands hurt so much he couldn't type.
But an M.R.I. showed nothing except some bulging disks in his neck that, he was told, were common in people his age, 50. He was advised to do neck exercises, and eventually he felt better.
About a year later, he fell again while playing football. His symptoms came roaring back.
The worst was when he woke up in the morning, Jim said. The two middle fingers on each hand were so stiff they would not even bend. He would massage his fingers and loosen them, but his hands and knuckles ached all day. He tried ibuprofen, to little avail.
Finally, last spring, he sought help at New York University, where he had another M.R.I. It turned out he had a nerve impingement so serious that he was warned that he risked permanent paralysis if he did not have surgery. So this summer, he had a major operation called a French-door laminoplasty, in which his surgeon, Dr. Ronald Moskovich at the N.Y.U. Hospital for Joint Diseases, opened and widened four or five vertebrae to free the trapped nerves.
How could M.R.I.'s have come to such different conclusions for both Jim and me?
Jim asked his doctors whether he could have really had nothing wrong at the time of his first scan. Unlikely, they replied, although they cautioned that no one had directly compared the two scans.
I asked Dr. Kennedy the same question and received the same answer. He explained that in my case the quality of the two images was vastly different. "It's like the difference between a black-and-white TV and HDTV," he said.
All well and good, but how was I supposed to know? The radiology center I first went to is accredited by the American College of Radiology, and there is no way I can tell a good M.R.I. image from a bad one. In fact, I never even saw the images. All I saw were the radiologists' reports.
Academic radiologists say that, unfortunately, they see patients like Jim and me all the time.
"That's the bane of our existence in an academic medical center," said Dr. Howard P. Forman, a professor of diagnostic radiology at Yale University School of Medicine.
And it's not just patients who have to deal with the problem, said Dr. William C. Black, a professor of radiology and community and family medicine at Dartmouth Medical School. Doctors do, too. Radiology centers send written reports to doctors, but the doctors may have no idea whether the M.R.I. was done well and interpreted well. "It's a huge problem," Dr. Black said.More ...