The survey results demonstrate that orthopaedic sub-specialty shoulder surgeons from the CSES primarily believe that MRI scans should be requested in suspected cases of rotator cuff pathology and shoulder instability, but only after a comprehensive patient history and physical examination. Furthermore, the results demonstrate that an excessive number of patients particularly with suspected rotator cuff pathology (approximately 50%); already arrive with a completed MRI scan prior to consultation with the orthopaedic specialist. The MRI report is useful mainly in combination with personal review of MR images to advise for and against shoulder surgery. Ninety percent of respondents would not make a surgical decision solely on an MRI report.
Shoulder disorders can present in a variety of pain patterns and the establishment of the correct diagnosis can be difficult due to a multitude of pain generators and various combinations of pathologies. Modern technological advancements in radiologic imaging have helped surgeons clinch the diagnosis more rapidly and less invasively [1]. Recently, the overall use of MRI scans has increased drastically [14, 15]. Fifty percent of patients, arrive for consultation with a completed shoulder MRI scan. The non-specialist ordered scans are supposed to speed up the diagnostic and surgical decision-making process. Paradoxically surgery is not indicated in 66% (n = 182 of 275) of patients with ordered MRI scans, and 71.3% (n = 196 of 275) of those MRI studies were already pre-ordered and completed before presenting to the shoulder and elbow specialists, as described by Reynolds et al. [16]. In Canada, patients are initially seen by their general practitioner who manages them non-operatively (e.g. pain medications, prescribes physiotherapy), or refers them to sports medicine doctors for additional non-surgical treatments, or to orthopaedic surgeons for surgical management [17]. If the patient has been treated for an extended time period or in order to help expedite the diagnosis and treatment, patients might have already obtained radiologic imaging before arriving at the orthopaedic surgeon.
Furthermore, there is an argument to be made that MR scans should not be ordered by generalists. Properly indicated MRI scans could reduce the chance of potential collateral medical exposure risks to 15% of patients, free up capacity for urgently needed MRI scans and cut costs by more than US$ 26,000 over 12 months [16]. Another reason to reduce aggressive testing/MRI scanning is the limited ability to glean useful information in certain diagnoses [18]. Furthermore, freeing up MRI scanners for more urgent cases is important as the availability of MRI scans is limited in some countries more than in others [19].
Nonetheless, respondents demonstrated that appropriately ordered MRI scans are important and they also order MRI’s frequently in cases of rotator cuff pathology or shoulder instability. Surgeons personally review the MR-images in 90–97% of cases depending on pathology, and surgeons are less likely to read the MRI report (80–90% of times). The MRI report is usually read after the viewing the MR-images. Finally, the MRI report is very seldomly reviewed in isolation (0.3–3%). This is similar to the described survey results by Kruger et al. on orthopaedic surgeons reading radiology reports in addition to viewing images for any imaging modality [20].
Generally, MRI reports are still among the most read reports with 92% and this percentage decreases dramatically for reports involving other modalities such as ultrasound (74%), CT scan (39%) or plain radiography (10%) [20]. Kruger et al. stated that 55% of orthopaedic surgeons would disagree with the written MRI report according to their survey data [20]. The current study illustrates that 25.5 – 34.0% of misinterpretation exists between the personally reviewed MRI shoulder images and the generated radiology report. Accordingly, less than five percent of these respondents felt comfortable reading MRI reports without viewing the images by themselves. The main reason cited (85%) for not reading the MRI report is that the generated reports often conveyed false positive information (5.6 – 18%) confounding the provisional diagnosis. However, one has to keep in mind that the orthopaedic surgeon has an advantage compared to the radiologist, because the orthopaedic surgeon is able to review the images, following completion of patient history and performance a physical examination. The latter two are the most important assessment means in establishing the diagnosis and decision on surgical treatment of shoulder disorders as identified in the questionnaire. This allows a more discerning “eye” interpreting the MR images. Another very important factor is the level of training of the radiologists. Radiologists with a musculoskeletal fellowship will feel more comfortable reviewing MRI scans of the shoulder than an interventional radiologist or one with gastrointestinal fellowship training [21]. This begs the question of whether MRI interpretation is valid without the advantage of a pre-study informed history and physical examination or specific level of training. According to the respondents, reviewing the MR-images by themselves or with the report is favoured by the majority. This is congruent with the results of demonstrating the respondents feeling comfortable reviewing the MRI scans independently. However, the MRI report/the radiologist interprets the MR-images in its’ entirety and hence can detect other/non-musculoskeletal pathologies [22], which often are missed by the orthopaedic surgeon due to a focused analysis. Thus, reviewing the MRI report can help identify any additional abnormalities in other non-focused areas.
The study has limitations. It is a survey targeting a specific complicated body region and has a very limited number of respondents. However, the online survey participation rate of 32.25% is in the normal participation range for surveys [23]. There was no separation into traditional MRI scans and MR-arthrograms. Nonetheless, an MR-arthrogram of the shoulder has a higher sensitivity (78%) and specificity (100%) when compared to a regular MRI, 72% and 78% respectively [24]. Further, the MR-arthrogram is mostly ordered with a very specific question that can be much better addressed in the MR-arthrogram than in the regular MRI leading to a more precise report by the radiologist e.g. labral pathology. Additionally, the request for an MR-arthrogram is generally ordered and sometimes limited to the request of an orthopaedic surgeon with a very detailed question regarding soft-tissues pathologies. Thus, the false-positive ratio of potential pathologies in the report is decreased [24, 25]. Furthermore, the expert opinion of highly training shoulder surgeons demonstrates the trouble MRI scans can cause for patients confounding the diagnosis and confusing treatment/surgical management process. This report quantifies both shoulder surgeon read images versus merely reading the report plus reasons for their preconception as it pertains to decision making for shoulder surgery.
