Radiologist Fails to Diagnose Spinal Infarcts After Steroid Injections With Non-Contrast MRI

Case Overview

In this case study, a particulate steroid injection was used on an adult patient undergoing thoracic and lumbar steroid injections. An MRI without contrast was performed approximately three hours after the procedure because the patient began to exhibit neurological symptoms. Even after this initial assessment, the patient's symptoms persisted.

In response, a second MRI was conducted about 36 hours after the first one, this time with and without contrast. The MRI resulted in the diagnosis of a spinal infarction. In this case, the central issue is whether the decision to perform a non-contrast MRI was appropriate.

Questions to the Radiology expert and their responses

How often do you review spine MRIs?

As a board-certified diagnostic radiologist with 15 years' experience, I review MRIs of the spine daily as part of my diagnostic and interventional spine practice.

Generally, in a patient following a spinal injection procedure with suspicion of spinal pathology, when should an MRI with and without contrast be ordered? When the radiologist disagrees with the physician's order, what is standard protocol?

The decision to order an MRI with or without contrast following a spinal injection procedure is multifaceted. Generally, it would be acceptable to perform a lumbar spine MRI without contrast. However, if there were positive findings on the initial MRI noted by the interpreting radiologist, post-contrast imaging may be necessary if there was a post-procedural fluid collection or mass effect. Additionally, diffusion-weighted sequences would also be added to the protocol if there was clinical suspicion of cord infarction.

What responsibility does a radiologist have to arrange the appropriate imaging?

The responsibility for recommending or ordering proper imaging falls upon both the person who injected the patient and the interpreting or supervising radiologists. This depends on the amount of clinical information provided to the technologist and potentially handed down to the radiologist at the time of the examination.

About the expert

This expert is a highly experienced diagnostic radiologist with a specialization in musculoskeletal radiology. They completed their education and training at renowned institutions, followed by a fellowship in musculoskeletal radiology. Currently, they serve as a musculoskeletal radiologist at a regional medical center and as an instructor of radiology at a medical school, while also being an active member of several prestigious radiological societies.