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MRI, X-rays and Back Pain

X-rays and MRI’s can be harmful for people with low back pain.  This may sound ridiculous to the average person.  Two common medical misconceptions are that more tests lead to better care and that imaging studies allow us to see the “problem.” Wrong and wrong.  When it comes to low back pain, more tests don’t necessarily mean better care and seeing the problem means practically nothing because the reality is, often times we are not actually seeing the problem.  Pain can be the result of findings such as disc protrusions and spinal joint arthritis found on imaging studies, although oftentimes people without pain have these same problems.  In people who do NOT have low back pain, disc protrusions and spinal joint arthritis are seen on imaging studies just as frequently as the same findings are seen on imaging studies of people WITH low back pain.  The question then arises:   If these findings are present in people WITHOUT low back pain, what do the findings mean in people WITH low back pain?  They mean maybe the findings are correlated with the person’s low back pain and maybe they are not.

Spinal imaging studies such as x-ray and MRI are best used to rule in or out serious medical pathology.  They are not best used, as they generally are, to determine the cause of pain when the findings that are said to cause pain are normal and occur frequently in painfree people.   Serious medical issues including malignancy, infection, ankylosing spondylitis, and epidural abscess, when combined, account for fewer than one percent of cases involving back pain.  The remaining ninety-nine percent are benign and musculoskeletal in nature.  This means that ninety-nine percent of low back pain is due to muscles, joints, and connective tissues.  Unless you are part of the small percentage who has a spinal tumor, an infection, or a systemic issue that affects the spine, your pain is from muscles, joints, and/or connective tissue dysfunction, or all of these.
Imaging studies, commonly called X-ray and MRI, are best used to detect anomalies such as tumors, a fracture, or an epidural abscess.  These conditions are unlikely and quite rare statistically, as a cause of low back pain.  Even though this is the case many people with low back pain feel it’s necessary to have X-rays and MRI’s done to show “what’s wrong.”  Ninety-nine percent of the time there will not be a pressing medical issue that must be addressed.  Only slightly less than one percent of the time there will be.  Usually when this is the case, there is already a good idea that something more serious is going on and the imaging studies are done to confirm this suspicion.  The problem is, the majority of people who have no pressing medical issue as a cause of their low back pain will have what is called ‘positive findings’ on imaging studies.  These findings range from arthritis of the spinal joints to narrowing of the disc spaces between vertebrae to bulging discs, all of which can occur WITHOUT pain.

Patients, especially, put a lot of stock into what X-ray and MRI results show. The imaging study itself is almost a type of validation as to why they are in pain.  Once a patient is told of problems found on imaging results, they often internalize the information and believe they now have a, commonly referred to, bad back and have to do something to “fix” the problem.  What is never disclosed are the statistical facts regarding findings on imaging studies.  I’ll keep the facts simple and to the point.

First, 50% of individuals WITHOUT low back pain have at least one bulging disc (These are individuals without low back pain!).   Secondly, of individuals without low back pain, only 36% have a “normal” spine, meaning there is no obvious spinal joint arthritis or bulging discs.  What I’m saying is that normal is actually the people who have bulging discs and signs of mild spinal joint arthritis.  The majority of people WITHOUT pain have these findings on imaging studies.  It is only a small minority who do not have positive findings or the so called “problems” on imaging results.  In reality it’s normal to have these findings on imaging studies even if you DON’T have low back pain, and just as normal to have the same findings if you do have low back pain.
This is the reason the American College of Physicians does not recommend X-ray or MRI for low back pain.  In fact, the American College of Physicians recommends that X-ray, MRI, or CT should NOT be ordered unless a serious cause of low back pain is suspected, which is only the case less than one percent of the time.  The American College of Physicians goes on to note that imaging studies often lead to unnecessary surgery due to positive findings on imaging studies.  It’s now understood these findings are due to normal aging and normal wear on the spine and by no means constitute surgery.
Overwhelmingly, the majority of the time, conservative treatment is effective. Physicians are not completely to blame as patients see more testing as better care.

In the case of low back pain, the opposite is true.  Less testing with less invasive or conservative treatment results in better care.  Unfortunately, patients are never told any of these facts and it’s very important they understand the truth as healthcare consumers.
If you are part of the 99% of individuals with low back pain from muscles, bones, joints, and connective tissue, don’t even consider  x-ray or MRI.  These imaging modalities will definitely show some arthritis, bulging discs, and disc space narrowing, but it is important for you to know:  This is NORMAL!  Due to wear and tear on your body over the years, you will have these changes and an imaging study is not going to dictate a direction your pain treatment should take.  The imaging study is only going to make you think something is wrong with you when, in fact, you’re normal.  You are asking, ‘Now what?’

Figure out what makes your back hurt more. Change your movement patterns so you can function without increasing your back pain.  Sit less, sit correctly when sitting, learn to hip hinge, improve strength and endurance of your trunk musculature.  Doing these things will alleviate low back pain more than ninety percent of the time.