Back Pain—Don’t I need an MRI?

Back Pain—Don’t I need an MRI?

Back Pain, Part 3                                                                         

It is very common for people with low back pain to ask whether they should get an MRI, especially when it is severe.  Logic would suggest that a good “picture” of the area would tell you EXACTLY what is causing the pain.  But research has shown that rarely is the case.

In fact, in 2007 the American College of Physicians and the American Pain Society had these recommendations about any imaging (x-rays, MRI, CT scan) for low back pain:

  • Recommendation 2:  Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain.
  • Recommendation 3:  Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination. [emphasis mine]
  • Recommendation 4:  Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy).1   [emphasis mine]

And then in 2015 research from Webster and company concluded:  “Early MRI without indication has a strong iatrogenic effect in acute LBP [getting the MRI “creates” more or worse low back pain (LBP)], . . . Providers and patients should be made aware that when early MRI is not indicated, it provides no benefits, and worse outcomes are likely.”2   Based on this research, not only does an MRI early in the treatment for low back pain not provide any benefit, it can reduce the likelihood of reducing or eliminating it.

How and why can a picture of the structures of the low back actually contribute to low back pain?

Fact 1—the same degenerative changes seen in MRI’s of people with low back pain are seen in people with no pain.  In other words, they are a normal part of the aging process.3

Fact 2—disc herniation (“slipped discs”, bulging discs) are frequently seen in MRI’s of  people with no back pain.3

Fact 3—herniated discs have been shown to “un-herniate” on their own.4

Fact 4—people worry more about their back pain and assume it’s something “serious” when they are told they have “abnormal” findings on MRI and x-ray.

Fact 5—Findings from an early MRI can lead to more invasive (but unnecessary) procedures like epidural injection or surgery.

I see evidence of these facts all the time in my practice.  Thankfully, even in the presence of degenerative changes, many patients become pain-free with treatment.

When is imaging helpful or necessary for low back pain?  It should be used to find conditions that are not neuromuscular in nature.  Imaging, particularly MRI, helps doctors get a better idea of what to expect as they prepare for invasive procedures or diagnose serious medical conditions.   You (or your doctor) should consider further imaging if/when:

  1. There is low back pain after an accident or fall that could have caused a fracture. (typically x-ray only)
  2. Back pain is occurring in someone with severe osteoporosis. (X-rays, CT, or bone scans typically)
  3. There is a personal history of cancer.
  4. Back pain is accompanied by fever and/or severe weight loss.
  5. Back pain is accompanied by decreased bowel or bladder control.
  6. There is rapidly increasing muscle weakness or leg numbness/tingling.
  7. Low back pain prevents any sleep (“unremitting night pain”)
  8. Conservative treatments (physical therapy, chiropractic, medication, acupuncture, etc.) have failed to decrease the pain.

Sometimes even when indicated, it’s not useful to get further imaging.  If someone is unable to have surgery or epidural injection due to other medical conditions, imaging often will not change the treatment.  It does expose them to radiation and chemicals that can cause adverse reactions.  In this case, referral to a physical therapist for recommendations in promoting optimal movement and/or to a doctor specializing in pain management are the best options.

Looking for information about low back pain, check out this post.

Or for my recommended exercises for back pain, read this one.

 

  1. http://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-from
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235393/
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464797/
  4. http://www.painphysicianjournal.com/linkout?issn=1533-3159&vol=20&page=E45

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