Back pain is becoming a rite of passage with roughly 80% of the population experiencing at least one episode in their lifetime. Nearly 8% of the working population will become disabled in any given year due to back pain.(1)
Accompanied with back pain comes the desire for an MRI. After all, you’d like to know what you’re dealing with, right? What if the MRI didn’t change your treatment plan? Would you still request an MRI? Second, what if your symptoms (back pain, arm or leg pain, etc) didn’t correlate with the findings of the MRI? Believe it or not, this is the reality. More often than not, an MRI will not determine the course of treatment for pain related to spine pathology and in some instances, the MRI findings fail to correlate with symptoms.
What findings should really be expected on an MRI? Well, I can tell you that having a clean MRI, particularly later in life is a unicorn of sorts. We talk about an MRI as being “normal;” however, our definition of normal and yours may differ. A normal MRI in the medical community can show disc bulging and degenerative disc disease. These positive findings are “normal.” You should understand that we expect that there is to be some abnormal findings. After all, your spine will age, we’re just aiming to not age faster than our chronological age.
The counter argument necessitating the need for an MRI to “better treat” your pain doesn’t hold much water, either. This is particularly true when a negative (clean) MRI is less likely. In most cases an MRI will not dictate the care you receive in physical therapy. Conservative treatment will forever based on your clinical presentation and how you respond to movements, positions, and tests during your evaluation.
A study by Nakashima et al was conducted to evaluate abnormal findings on MRIs in asymptomatic patients. In this case abnormal findings consisted of a disc bulge or some other finding typically not associated with a healthy spine. Of the approximately 1,200 subjects, 88% had evidence of some degree of disc bulging. This was the miniumum, too. Disc bulging became even more significant with advanced age as the frequency, severity, and number of levels increased.(2) The most important piece of this research is not the abnormal findings, it’s the fact that these individuals are without symptoms.
The extraordinarily high percentage of back and neck pain sufferers has equated to a great response from the research community. We know more about the presentation and treatment of spinal pathology than ever before. A better understanding has led to a decline in surgery, injection, and imaging rates—all good things when we weigh patient outcomes, the benefit, and the high costs associated with more invasive procedures and tests.
I have no intention of implying that MRI’s are never warranted, but to simply downplay their importance for the majority of low back and neck pain sufferers. MRI’s are most useful under certain conditions: failing conservative treatment, loss of bowel/bladder function, and lower extremity weakness. When an individual does not respond well to conservative treatment an MRI is useful in determining if a more aggressive approach (i.e. injections or surgery) is appropriate.(3)
Delaying treatment with the belief you should have an MRI first isn’t advised. In fact, in most circumstances your insurances won’t approve it. Your quickest path to regaining function and decreasing pain is conservative care (physical therapy). If your physical therapist believes an MRI is warranted he or she will recommend one to your referring physician, increasing the probability that your health insurance will improve it.
1 Manchikanti L. “Epidemiology of low back pain.” Pain Physician. 2000 Apr;3(2):167-92.
2 Emery, Derek J., et al. “Overuse of magnetic resonance imaging.” JAMA internal medicine 173.9 (2013): 823-825.
3 Nakashima, Hiroaki, et al. “Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1,211 Asymptomatic Subjects.” Spine (2015).