By Grant Cooper
There is an important axiom for doctors to remember. It is one that we drill into the residents and fellows we teach.
That is — we treat patients, not imaging studies. At Princeton Spine and Joint Center (PSJC), like other practices and hospitals, we sit weekly and review interesting or difficult cases in order to pool our experience and challenge each other.
Two patients in the last several months came up that offered an interesting and insightful illustration of how that axiom places out in real life and we thought it was useful not just for doctors, but for patients as well. We discussed it in our bi-monthly newsletter and it received such positive feedback that we thought it would make for an interesting article as well.
We had recently discussed two patients in our internal PSJC rounds and we thought our discussion was worth relating because it reinforces a very important point in managing not only hips, but people more generally.
Both patients that we discussed had ultimately been found to have labral tears in their hips. The labrum is the lining of the hip joint and a tear in the labrum is a relatively common cause of hip pain. A labral tear can often be diagnosed on MRI, but as you will see, not always.
The first patient was in her 40s and had about a year of right hip pain. She had tried resting her hip and physical therapy, but her pain kept getting worse. Her primary care doctor sent her to a very good local surgeon who ordered an MRI and found the labral tear. He then recommended surgery for her.
She came to us for a second opinion. To be sure, it is not unreasonable to operate on a labral tear, but not all labral tears require surgery. In the surgeon’s view, this was the best option. In our view, she had several other excellent options. In fact, in our view most hip labral tears do not require surgery. For this patient, we ultimately agreed to inject viscosupplementation into her right hip.
Viscosupplementation is like an oil change for the hip. If you think of a labral tear as a pothole in the road, then viscosupplementation provides the joint fluid that paves the pothole. She had a series of three viscosupplementation injections and then returned to her physical therapy regimen.
Several months later, she is still pain-free and has no restrictions. The lesson — not all labral tears need surgery. Treat the person, not the MRI.
The second patient was in her 20s. She was a dancer who had been dealing with left buttock and hip pain for years. She had been through multiple courses of physical therapy and over a year of chiropractic care for suspected hip and lower back pathology, but she lacked a formal diagnosis.
She had great range of motion for someone with hip pain, but dancers tend to have great baseline flexibility and so that can be deceiving. She had an MRI of the lumbar spine and also of the left hip that were both completely normal. We gave her a diagnostic and potentially therapeutic injection into the left hip under x-ray guidance.
With lidocaine in her hip, she had 100% pain-relief. This confirmed the diagnosis of pain coming from the hip and not the spine. Still, the MRI of the left hip was normal. She then received a steroid injection into the left hip and had about six weeks of pain relief, but then the pain returned.
Knowing that the pain was coming from the left hip but in the context of a normal hip MRI, we then ordered an MR arthrogram.
An MR arthrogram visualizes the joint when it is injected with the contrast. The contrast lets you see small tears that might otherwise be missed without the contrast. Still, this test was normal. However, knowing that the pain was coming from the hip because of the diagnostic block, we performed a series of viscosupplementation injections for the young dancer.
For about four months, the pain was about 60% better but by the fifth month the pain had returned.
Given her young age and the recurrence of the pain, we sent her to a great local surgeon to discuss surgery. At first, the surgeon was highly reluctant to operate on a healthy young dancer with a completely normal MR hip arthrogram. However, we know that even an MR arthrogram can miss some tears. Armed with the information that the lidocaine injection removed 100% of her pain temporarily, the surgeon agreed to do the surgery.
In the surgery, upon direct visualization, the surgeon discovered a labral tear that had not been visualized on the MR arthrogram. He repaired the tear and more than a year and a half later, she remains pain-free. Again, we must treat the patient and not just the MRI.
These two stories illustrate something we know well, but that is worth repeating.
Imaging studies provide valuable data, but they are just one piece of information in a sometimes complicated picture of a whole human being. It’s important to always put the imaging study in the context of the whole person. Some tears in hips and other body parts look terrible but don’t require surgery. Some hips and other body parts look straightforward upon first inspection but turn out to be much more difficult and may even ultimately need surgery, depending on the situation, context, and the patient’s response to conservative care.