MRI in Multiple Sclerosis: Pay Attention to Specificity

When Jill M. Conway, MD, MA, MSCE, director of the Carolinas MS Center and clerkship director of the UNCSOM-Charlotte Campus, was in neurology training in medical school, she had the additional challenge of also being a mother of triplets.

Conway said she was 30ish, working really hard, and trying to make her life work as a mother and physician, so she related to patients with multiple sclerosis (MS), because the disease tends to attack people right in the prime of life when they’re trying to figure out what they want to do.

“You have life plans that you’re just starting to form at age 25 or so and then suddenly you have MS, and you’re thinking, ‘Now what do I do?!’” said Conway.

“The population of MS patients is predominantly female, which I enjoy working with. You follow people over a long period of time, which I find really satisfying. All those folks are real and I still see them, and I still find that very satisfying,” said Conway during her presentation on the use of MRI in differential diagnosis at the 2015 Annual Meeting of the Consortium of Multiple Sclerosis Centers in Indianapolis, Indiana.

“I thought MS was a really stupid disease because it turned tasks and activities you shouldn’t have to think about into things you have to think about all the time. Like going to the bathroom, or walking,” said Conway.

“People who don’t have MS don’t think when they walk, they just walk. But for my MS patients, every single step, they have to think, ‘Foot, come up!’ or it doesn’t come up far enough and they trip,” she said.

Conway also talked about the use of MRI in differential diagnosis and passed along some advice she would give to referring physicians when it comes to patients who present with neurological symptoms.

Conway said although she believes primary care doctors have the hardest job in medicine‑‑in part because “you can’t image everything”‑‑she said it is frustrating to see patients referred to her practice who initially presented to their primary care physician with a very specific symptom (eg, their right arm went numb for three weeks) only to be told something along the lines of “it’s a pinched nerve.”

“There are no pinched nerves that make your whole arm or both legs numb for three weeks! The only nerve that does that is the spinal cord,” she said.

Too often, patients are told if a symptom goes away they shouldn’t worry about it. But in the case of MS, “Well, of course, it goes away. That’s what relapsing-remitting means. Very often, those patients are diagnosed five years later with horrible MRIs. But it doesn’t have to be like that,” said Conway.

She advised that focal, specific, subacute, neurologic problems in healthy adults should be pursued, “because they will go away, but you will have missed the diagnosis.”

It’s the specificity that matters. “Listen to the patient who says I don’t know if this is serious, but my arm went numb,” Conway told the audience. The patient who thinks she has every symptom in the world is not the one who needs imaging. “In that case, their whole body would have to have a lesion!”