Red Flags in Radiology Reports: Reads, Over-reads, and What They Really Mean for Causation
Radiology reports shape first impressions. They also hide traps. Much of the language is safety-driven, not a verdict on injury. Your advantage comes from translating what a study can and cannot say, and then putting imaging in its proper place—supporting the clinical story rather than erasing it.
Start by separating the parts. The technique tells you what was imaged and how. The findings are the observations. The impression is the summary, often conservative and sometimes boilerplate. “No acute osseous abnormality” means no fracture was seen on that study. It does not speak to ligaments, discs, muscles, or nerves. “CT head normal” after a crash means no bleed or mass effect—good to know—but CT cannot diagnose concussion. When you see “degenerative changes,” remember that by midlife these are common. They lower tissue tolerance and can be aggravated by a new vector of force. That’s not a reach; it’s basic physiology.
Some phrases seem scary or unhelpful until you translate them. “Straightening of the cervical lordosis” often reflects muscle spasm or positioning. It is non-specific alone but can help when the rest of the story fits acute strain. “Clinical correlation recommended” isn’t a hedge against your case; it’s a radiologist saying that pictures should be read alongside real-world symptoms and exam findings. Over-reads and addenda are part of safe practice. A cautious preliminary read may soften later without changing your client’s pain, function, or need for care. Anchor back to the course.
Ask a simple question of every report: does anything in the findings match the mechanism and the symptom pattern? A right-sided foraminal narrowing with right arm tingling after a right-lateral impact is more helpful than a generic “degeneration” line. When imaging is normal, say exactly what it ruled out and why the clinical pathway still makes sense. Normal C-spine X-rays exclude fracture but tell you little about ligament or disc strain. If the ER documented limited rotation, paraspinal tenderness, and treated with NSAIDs or a muscle relaxant, the clinical picture holds.
MRI deserves nuance. It sees discs, ligaments, and marrow edema better than CT or X-ray, but timing matters. Very early studies can miss subtle changes; later studies can show resolution. Let symptoms and function guide the choice and timing of advanced imaging, not the other way around. If a preliminary CT suggested something that a final read retracts, pivot to what has been consistent all along: side, region, function, and the need for appropriate escalation.
In a demand, keep the radiology paragraph tight and honest: “The CT of the cervical spine showed no acute osseous injury, which appropriately excludes fracture. That does not evaluate ligaments or discs. His right-sided neck pain and limited rotation, documented in the ER, fit soft-tissue strain. The discharge plan—anti-inflammatories, a muscle relaxant, and follow-up—matches that pathway. ‘Degenerative changes’ are common at his age and lower tissue tolerance; the new vector explains why this level became symptomatic now.”
Radiology may rule out danger; it rarely rules out pain. Use it to clarify, not to concede.
Send the prelim, final, and any addenda. I’ll flag what supports causation, what’s safety language, and whether a focused follow-up study would help.
David Grundy, MD, FACEM
david@grundymdconsulting.com
(650) 649-5732