MRI for Back Pain

Back pain is the leading cause of disability globally, and is estimated to affect approximately 540 million people worldwide at any given time so it is not surprising that low back pain is one of the most common issues that bring patients into our clinic. Low back pain can be extremely debilitating and quite terrifying.  It can make you feel broken, helpless, and lead you to believe that there is something seriously wrong with your spine.

Do I Need an MRI for my Back Pain?

The short answer to this question for the vast majority of situations is a resounding “no”. The most recent clinical practice guidelines for the management of low back pain state that imaging is not only not necessary, but actually discouraged as a routine part of assessment and treatment of acute low back pain. This may be a bit surprising, but there are very good reasons for this recommendation.

Firstly, all spines change with age, and these changes will show up on imaging, just like wrinkles in the skin show up on a photograph. This does not mean, however, that any of the observed changes correlate to your pain. Secondly, it has actually been shown that patients with back pain who have had MRIs done and explained to them in detail tend to have worse outcomes (more pain and poorer function) than those who were treated without having done any imaging. And third, while an MRI is a gold standard tool for picking up serious pathology (e.g. tumors and spinal cord compression) in the spine, the incidence of such pathology is less than 1% in those with low back pain. This form of examination is absolutely not necessary, and is actually harmful, in the vast majority of low back pain cases.

What Does an MRI Actually Show?

Magnetic Resonance Imaging (or MRI) is a very sensitive imaging technology that produces detailed images of the soft tissues of the body. It allows for detailed examination of the brain, spinal cord, nerves, as well as muscles, tendons, and ligaments. An MRI of the back will pick up any changes in the discs of the spine (like disc degeneration and disc herniations) as well as degenerative changes in the joints of the spine (facet joints). The problem with using these findings to determine the source of back pain is that they occur in pain-free individuals at high rates as well. They are a natural part of the aging process. In fact, “disc degeneration” is found in 37% of healthy, pain-free 20-year olds, and 96% of pain free 80-year olds. The findings that you would see on your MRI report are incidental in most cases. They occur as part of the natural aging process and do not have a direct effect on the pain you are experiencing.

Maybe an MRI Won’t Show What’s Causing the Pain, Why Not Get One Just in Case?

This is a logical next question, and one that I hear a lot from patients. The issue is that once you get that MRI report, filled with words like “degeneration”, “tear”, “rupture” (all common medical jargon routinely used in reporting), it can change the way you view your injury. These types of terms are what we call nocebic; they suggest to the patient that they are damaged and imply poor prognosis. This can actually lead to worse outcomes in the long run. They create negative expectations, lower patients’ confidence in their ability to get better, and provide absolutely no useful information to the treating clinician.

This study examined two groups of patients with low back pain. Both groups had an MRI done, group 1 had the image explained using the standard medical jargon (degeneration, rupture etc.); group 2 was explained that the MRI findings were normal for their age group, and findings were incidental. Both groups then underwent 6 weeks of therapy, and were evaluated for pain, function, and perception of the illness at the end of 6 weeks. Group 2 scored better on all variables (less pain, better function, better outlook) than group 1, which highlights the strong negative impact of nocebic language on patient recovery.

Another point worth mentioning is that unnecessary imaging can lead to unnecessary surgery with no improvement in patient outcomes. Low back pain is a nasty, sometimes debilitating symptom, but in the vast majority of cases, it is not a disease that requires surgery. Unnecessary imaging and unnecessary surgery cost the healthcare system millions of dollars every year. This money would be better utilized towards helping those in pain undergo productive conservative management such as physiotherapy or chiropractic care, however this is a very complex discussion we will save for another time.

If Not Imaging, What Does my Physiotherapist and or Chiropractor use to Diagnose and Treat my Pain?

Your Physiotherapist and/or Chiropractor will obtain a comprehensive history from you, including the history of the current episode of pain along with a history of previous injuries. They will also perform a thorough physical assessment, using a variety of movements and orthopedic tests. You will be asked about your goals for treatment, and you and the therapist will work as a team to determine the best treatment plan to help you reach your goals and attain a meaningful recovery. Every individual is unique, and every injury requires an individualized approach, so listening to your personal story and seeing how your body responds to certain movements and tests provides a lot more useful information to a clinician than an image ever could.

Is There a Time When it is Appropriate to Get an MRI?

Yes, absolutely. If there is any suspicion of serious pathology such as a tumor or spinal cord compression, an MRI is necessary. Your Physiotherapist and or Chiropractor will ask you a series of questions in the subjective portion of your assessment to determine if there is any possibility that this is the case. Fortunately, this occurs in only about 1% of low back pain cases, and can be successfully screened for with a specific set of questions. Another case for imaging is if you and your therapist are considering spinal injections as part of your treatment. This is usually only a consideration for patients who present with a specific set of symptoms that have not responded to conservative management. If spinal injection is being considered, you will need an MRI before the procedure can occur.

As you can see, low back pain is a complex condition that requires an individualized treatment approach and can be very scary for those who experience it. I hope that I’ve been able to clear up some misconceptions for you here. If you’re one of the millions of people currently suffering with low back pain, contact us today and let us help you on your journey to recovery.

References:

1. Brinjikji, W., et al. “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations.” American Journal of Neuroradiology, vol. 36, no. 4, 2014, pp. 811–816., doi:10.3174/ajnr.a4173.
2. Delitto, Anthony. “Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association.” Journal of Orthopaedic & Sports Physical Therapy, vol. 42, no. 4, Apr. 2012, doi:10.2519/jospt.2012.42.4.A1.
3. Flynn, Timothy W., et al. “Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm as Good.” Journal of Orthopaedic & Sports Physical Therapy, vol. 41, no. 11, 2011, pp. 838–846., doi:10.2519/jospt.2011.3618.
4. Hartvigsen, Jan. “What Low Back Pain Is and Why We Need to Pay Attention.” The Lancet, vol. 391, 21 Mar. 2018, pp. 2356–2367. Low Back Pain 1, doi:http://dx.doi.org/10.1016/ S0140-6736(18)30480-X.
5. Oliveira, Crystian B., et al. “Clinical Practice Guidelines for the Management of Non-Specific Low Back Pain in Primary Care: an Updated Overview.” European Spine Journal, vol. 27, no. 11, 2018, pp. 2791–2803., doi:10.1007/s00586-018-5673-2.
6. Rajasekaran, S., et al. “The Catastrophization Effects of an MRI Report on the Patient and Surgeon and the Benefits of ‘Clinical Reporting’: Results from an RCT and Blinded Trials.” European Spine Journal, 2021, doi:10.1007/s00586-021-06809-0.