If you have back pain, you might think you need a lumbar spine MRI.
Imaging is commonly ordered by GPs in high income countries.
The rates of imaging are still high considering routine imaging is contrary to the recommendations of many clinical practice guidelines for non-specific low back pain, including in Australia.
In fact, according to a study by Haas et al (2023) a quarter of people presenting to a GP with back pain are referred for imaging.
(It was also interesting to read in this article that MRI and CT have 23 and 12 times the carbon footprint of plain XRay respectively.)
We have been conditioned to thinking that MRI and other forms of imaging are infallible and indispensable.
After all, an AFL player gets injured and seem to always have one the next day, regardless of the injury.
The aim of this article is to highlight a fabulous study by Brinjikji et al from 2015.
It’s a great way of putting the results of MRI in perspective, and equally applies to other forms of imaging, whether XRay or CT.
We refer to this study regularly in the clinic, and it always astounds patients.
It is also useful to show patients before they have imaging done, so that it pre-warns them and helps reduce their dread when they get their results.
Everyone wants a lumbar MRI
If you develop musculoskeletal pain, it seems instinctive to want to see an image to diagnose ‘what is wrong’ inside your body.
‘A picture says a thousand words’ is the adage that springs to mind.
So why don’t the medical guidelines reflect that?
In fact, why is there such a push away from radiology for everyone with back pain unless there are really good clinical reasons for getting it done?
Unnecessary imaging costs our healthcare system millions every year (Docking et al, 2022).
But you may be surprised to hear that it’s not just about cost and resources.
It can actually cause patients harm.
Let me explain …
The study
This study by Brinjikji and co-authors was a fabulous example of why imaging isn’t as useful as you might think.
It is an amalgamation of 33 articles, providing a sample of 3110 people. Now that’s a good sample size!
What is most interesting is that the subjects in the study are all asymptomatic.
That is, they have no pain.
From the data, the investigators worked out the prevalence of particular imaging findings for specific age groups.
The results are profound.
The findings
The findings suggest that many imaging-based degenerative features may be a part of normal ageing and unassociated with low back pain, especially when incidentally seen.
It really drives home the idea that any imaging findings must be interpreted in the context of the patient’s clinical condition.
For example, a finding of disc degeneration at the age of 60 years old must be considered to be quite expected if the rate is 88% in a pain-free population.
Find your age and prevalence on the graph – it makes for interesting reading!!
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Does this mean that imaging is useless?
Absolutely not.
Imaging has its place in diagnosis and treatment planning. It is especially useful for elimination of red flag conditions.
For example, if there is concern for spinal cord compression, cauda equina compression, infection or a suspicion of cancer, imaging is warranted.
However, the overuse of spinal MRI (and other imaging tests) is common due to beliefs of both patients and clinicians.
The biggest misconception is that imaging can identify the source of pain. The study by Brinjikji helps to show that isn’t the case.
It also doesn’t mean that the findings on an MRI are always irrelevant. They just must be viewed in context of the problem.
You don’t treat an MRI – you treat a person.
Consider this common lower back scenario
You are 60 years old and you develop back pain.
You have an MRI that shows degenerative changes including a disc protrusion.
You have no way of knowing if the disc protrusion was there one day, one week or one month before your pain started, because a 38% of people your age have one and aren’t aware of it.
In asymptomatic people at the age of 60, 88% have degenerative changes in their back.
Does it give you any useful information that you can use in terms of treatment planning?
Not really, because it’s not like you would jump into surgery or injections in the first instance (or at least you shouldn’t!).
Risks of an MRI
Instead, now you know you have a disc protrusion and degenerative changes on imaging and you can’t ‘unknow’ that.
You have a different perception of your disc and your back for ever.
Thoughts of vulnerability will inevitably enter your mind and they are hard to shake.
There is a good chance your pain will settle, but you will be left with that new perception about your back.
It may well increase your chance of future pain. Because of the processing and calculation of threat that your body does, this knowledge that there is a disc protrusion and degenerative changes will be part of it’s assessment in future.
It might lower your threshold to have something done surgically in the future.
These are potentially profound effects of an MRI that shouldn’t have been done, according to the guidelines.
The ‘downstream’ unintended harms to imaging include the risk of disease-labelling, catastrophising, overdiagnosis and overtreatment (Sharma et al 2020).
To read more about who should have imaging and who shouldn’t, check out this article.
Summary - Imaging isn't always best
Imaging will show the ‘landscape’ in amazing detail. It will show every wrinkle, every nook and cranny, every bulge.
- The presence of these features on an MRI often do not correlate with pain
- Incidental imaging findings are incredibly common
- Any imaging findings MUST be correlated with what is found on the patient in front of you
- Don’t treat the MRI – treat the person.
- There are good arguments that having an MRI can be harmful in terms of ‘downstream’ effects.
So don’t try to tell your doctor to order one if they say you don’t need it! They are following medical guidelines.
References
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797. [Link]
Docking S, Haddock R, Buchbinder R. Australian health policies related to diagnostic imaging: too much of a good thing? Aust Health Rev. 2022 Oct;46(5):635-638. doi: 10.1071/AH22064. PMID: 35896165. [Link]
Haas, R., Gorelik, A., O’Connor, D.A., Pearce, C., Mazza, D. and Buchbinder, R. (2024), Patterns of Imaging Requests By General Practitioners for People With Musculoskeletal Complaints: An Analysis From a Primary Care Database. Arthritis Care Res. [Link]
Sharma S, Traeger AC, Reed B, Hamilton M, O’Connor DA, Hoffmann TC, Bonner C, Buchbinder R, Maher CG. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open. 2020 Aug 23;10(8):e037820. doi: 10.1136/bmjopen-2020-037820. PMID: 32830105; PMCID: PMC7451538. [Link]
Further reading
The Back Surgery Controversy – Learn about why there has been increased scrutiny around back surgery lately, and how certain procedures are being increasingly performed despite a lack of evidence.
Fit For Purpose Model – The optimum approach for treating low back pain
The Ultimate Guide To Low Back Pain – What do you do if the usual treatments fall short? There is hope, and there is a blueprint to follow.
Our Back Pain Service Is Different
You might feel like you have tried it all. You might feel at the end of your tether.
BEFORE you jump on another therapy roundabout, please read about our back pain service at Adelaide West Physio.
You’ll see immediately that it is not your typical physio treatment.
Our approaches are based on best practices and the latest science.
We can save you unnecessary time, expense and frustration.
It might even save you from surgery.
