Magnetic Resonance Imaging of the Brain and Spine

TO THE EDITOR:

I read with great interest the critique of MRI [1] and the review of its indications [2]. Although the observations are limited by the authors' lack of clinical imaging experience, an underestimation of the often definitive value of a normal study result, and an overestimation of the occurrence of false-positive results that would cause no difficulty for the experienced imaging physician, the thrust and efforts of the authors should be commended.

It has become popular to blame new imaging techniques for increasing health care costs, which is frustrating to imaging physicians who at times cannot present hard evidence but “know” that life for the patient is better. Magnetic resonance imaging currently provides accurate and safely acquired data in 10 minutes in an outpatient setting. By comparison, in 1974, pneumoencephalography and angiography provided less definitive information in 10 days in an inpatient setting. Society cannot blame compassionately applied “high-tech imaging” for the inability of medicine to cure or prolong life in a patient with a neoplasm, stroke, Alzheimer disease, or multiple sclerosis. Nevertheless, how can we hope to cure and better understand these diseases without accurate, safe, and efficient ways to diagnose them?

Since the beginning of the Industrial Revolution, people have anguished over the conflicts between humans and machines. Although the horse was a wonderful means of transportation, many of us now use automobiles, trains, and airplanes. The steamboat replaced the rowboat, the printing press replaced the calligrapher, the power tool replaced the hand-wielded tool, and the computer replaced the hand-written record. Although one might question the environmental effects of mechanical advances, it is clear that many people are not willing to abandon them. This is particularly true when it comes to many of our modern medical wonders. Although the tender, loving care and judgment of a physician and nurse remain essential components of health care, one cannot negate the pivotal role played by antibiotics, cardiovascular medications, antipsychotic agents, modern surgical techniques, or advanced imaging.

As we struggle through the health care debate, we must not automatically equate high technology with high cost. If the cost and outcome of care using abdominal CT is to be critiqued, the cost and outcome related to abdominal palpation must also be analyzed. Can the authors cite “A”-rated studies for the use of abdominal palpation, lung auscultation, or the neurologic examination, or do they simply “know” that these time-honored practices are useful? In changing times, the obvious often becomes the obscure. Is it more cost-effective to order a radiograph of the skull or a CT of the brain; a radiograph of the lumbosacral spine or a rapid-sagittal MRI of the spine; a consultation or a high-resolution cross-sectional image? Extensive basic research efforts at academic centers and major corporations during the past decade may soon make it possible to routinely do a complete MRI or magnetic resonance angiography study in a few minutes. The acquired digital information may then immediately move to the referring physician's office computer, or, for difficult cases and quality review, to the workstation of a remote expert physician. It is suggested that a balanced perspective that recognizes the important role of both bedside acumen and a “living autopsy” (that is, a cross-sectional image) may ultimately prove to be the most cost-effective and patient-oriented approach for disease management and prevention.

• Copyright ©2004 by the American College of Physicians