MRI and Low Back Pain: Relevance vs. Prevalence

A patient’s imaging results are one of the most popular topics of conversation within the first 15 minutes of almost every evaluation with a new client experiencing low back pain. The client will either be questioning going for an MRI or be describing what was found when they received one in the past. I listen to them, I hear them out, then I drop the knowledge bomb on them…

The prevalence of an abnormal finding is high in people without symptoms and this increases with age. This means that most findings on images are normal and do not always correlate with pain. So, bulging discs, degenerative disc disease, and disc protrusions are like the gray hairs of the spine? Wrinkles on the inside?  Pretty much.

A systematic review by Brinjikji et al went through articles that analyzed the imaging findings of 3110 asymptomatic individuals. The findings were outstanding:

  • 30% of people at the age of 20 had disc bulges, this increased to 60% at age 50, and 84% at age 80.
  • 23% of people at age 20 had disc protrusions and up to 43% at age 80

So, how relevant are the findings on MRI? Not always very relevant at all. This raises the discussion about how imaging findings impact the management of patients with low back pain. Is it very important for clinicians to know what a MRI will reveal? Imaging of the lumbar spine has not been shown to improve clinical outcomes. Why would we want to pay for a very expensive exam that will not change the course of care, management or outcome of treatment of low back pain? I know I sure wouldn’t.

Yet, I do empathize with patients wanting to “…just want to know what is going on inside.” However, what you must understand is that over half of 50 year olds imaged in the study discussed above, had a bulging disc and they did not have pain. Are you over 50? There is a high probability that you have one, too.

I do want to note that there are definitely circumstances when imaging is warranted. Images are necessary when we want to rule out red flag conditions such as cancer or fractures. So, before you jump to conclusions about what was found when you got that MRI, or push your doctor to order that image, remember that prevalence and relevance of abnormal findings are not synonymous. Pain is an experience that has sensory, cognitive and emotional components. What is found on the image is only a portion of what we as clinicians factor into the plan to help you feel better. Abnormal image findings and pain are not necessarily correlated and are likely part of the aging process.

 

Reference

Brinjikji et al. A Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Radiology. 24 Nov 2014.

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