Information for Referring Doctors
How can an MR Neurography Study Be Ordered?
At present MR Neurography is offered at fully qualified sites in eleven locations in the Philadelphia, Seattle, Los Angeles, San Diego, and San Francisco Bay areas. These tests should be widely available within 12 to 18 months. Until, then patients must travel to one of these sites for evaluation through the Neurography Institute. MR Neurography is covered under Medicare and Worker's Comp. It is covered as a form of soft tissue MRI under most other insurance plans.

The phone number for physician referrals to the Neurography Institute is:

1-866-664-3944 (or 1-310-664-3944)

Requests for information or scheduling can be sent by mail to:

The Neurography Institute
2716 Ocean Park Blvd. Suite 3035
Santa Monica, California 90405

Completed referral forms may be faxed to:

1-888-500-0054

E-mail can be sent to: Contact@Neurography.com
Is Neurography well accepted in the medical community?
Magnetic Resonance Neurography is an important advance in diagnostic imaging with demonstrated utility in the diagnosis and management of a variety of patients.

This technique has been the subject of nearly three dozen publications in major medical journals including The Lancet, Journal of Neurosurgery, Radiology, American Journal of Neuroradiology, Neurosurgery, and others. These studies range from laboratory studies on physics done in 1992 to well controlled prospective outcome trials which began appearing in 1996. Presentations have been made at a wide variety of major medical meetings, including both submitted and invited papers, courses and symposia at the RSNA, AANS, NASS, CNS, ASNR, AAEM, ISMRM, AAOS and other major society meetings.

Although it is new and not widely available, it is not considered experimental. The clinical utility and efficacy of MR Neurography is now better documented in the medical literature than many other imaging techniques in regular use.
What are the indications?
MR Neurography should be considered as the principal diagnostic method for peripheral nerve entrapments which are not readily diagnosed by physical exam or electrodiagnostic studies. This includes neurogenic thoracic outlet syndrome, brachial plexus injuries (including birth injuries), sciatica with no convincing spinal cause, and any suspected nerve impingement or possible nerve tumor occurring in any location.

Neurography may be a useful secondary technique to supplement electrodiagnostic studies in many situations where the diagnosis is ambiguous. In particular, patients who suffer pain from nerve entrapment may not have a sufficiently severe compression to cause motor abnormalities seen readily on EMG and MRN should be considered when this situation arises.

For patients who have failed to improve after spine surgery, it may be helpful to use MRN to assess any possible causes for extremity pain which do not arise directly in the spine. In patients with sciatica, this may include abnormalities affecting the lumbosacral plexus, the piriformis muscle region, or entrapments at the level of the ischial tuberosity/hamstrings causing pain with sitting.

Even when the diagnosis seems clear from electrophysiology, MR Neurography may be useful in surgical planning. This is because a direct image of the lesion may allow for a smaller incision and hence more rapid recovery from any operation which may be required.
We've gotten along fine without this in the past, why add a new type of study?
Physicians understand the importance of chest X-rays to supplement the physical exam and pulmonary function tests, bone X-rays for fractures, brain MRI for suspected tumors, and numerous other examples. Essentially, the tradition of western medicine is observational and empirical; the physician inspects the body part or tissue suspected as the source of any disorder. As each tissue of the body has become accessible to imaging, advances in diagnosis and treatment have followed.

Nerves are involved in the chief complaint behind millions of new patient visits each year. However nerves are one of the few remaining tissues where the physician has remained unable to either inspect or image. Since we understand that many nerve related pain syndromes are due to mechanical impingements on nerves, the case for being able to inspect nerves through imaging is compelling.

The lack of reliable imaging of nerves is a large problem. Each year 100,000 spine surgeries fail because, in many cases, a nerve impingement at a distance from the spine may have caused the symptoms. Hundreds of thousands of patients are referred to pain clinics and face disability, and lifelong narcotic dependency for no reason other than inability of physicians to adequately diagnose peripheral nerve problems.
What kind of pathology can be seen in MR Neurography Images?
Images of nerves obtained through MRN can demonstrate a variety of types of pathology. At the most general level, an image can demonstrate a deviation from the normal course of a nerve which can reflect the effect of an entrapping band, an adhesion, or a bone spur.

For more severe pathology, MRN can detect changes in the image intensity of the nerve. Nerve swelling affecting nerve caliber and edema content are readily seen. These types of abnormality are common when nerve impingements are sufficiently severe to cause motor abnormalities and marked EMG changes

In very severe injuries, MRN can confirm the presence of a nerve laceration or the formation of a neuroma. Such information is often extremely helpful in planning the timing of surgical interventions. In the past, the tradition has been to wait several months to learn whether the nerve will recover on its own. An image obtained early on proving a complete transection can lead to an early suture repair without the risk of losing muscle receptivity to any regrowing axons arriving many months after the injury.
What are the limitations?
Although MR Neurography is very effective for large proximal nerves, its effectiveness is variable for smaller nerves. In some patients, in particular body regions, very small nerves can be seen, but this is not yet reliable. As with any imaging modality, there are limits to sensitivity and individual variation.

To be effective, it is often necessary to image a very limited area of the body. If the imaging test is to be effective, the ordering physician must have a very strong suspicion of the particular area of the body most worth imaging.

In many cases, the MRN technique does not adequately suppress images from small blood vessels and this can lead to lack of certainty in nerve identification. This problem is an area of very active research and a number of good solutions will be available soon.

False positives can occur. It is essential for any abnormality observed on an MRN imaging study to be carefully correlated with the patient's symptoms, exam and possibly also electrophysiologic findings. In many cases, image directed injections are required to confirm the relevance of a pathology suspected from an image finding.

Finally, it is most important for physician and patient to understand the MR Neurography is optimized for the imaging of nerves as a single tissue. Although nerve tumors are well seen, other types of tumors, bone degenerative disease, and other conditions are best evaluated by existing traditional methods optimized for those tissue. MR Neurography is the best way to obtain images of nerves but is not the best way to observe other tissues.
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