Low Back Imaging: How Useful Is It?

I see a lot of people in my clinic who are suffering from low back pain. This is not unexpected given that low back pain is the most common of all musculoskeletal conditions that people will seek care for. In addition, from a cost perspective in the United States, low back pain ranks third in money spent to treat it, only behind the cost of treatment for Cancer and Cardiac (heart) conditions. Given that it is so common, costly, and at times debilitating, it is important that the information about the causes, treatments, and prevention are accurate and based on the the most recent research that we have about the condition. [...]

I see a lot of people in my clinic who are suffering from low back pain. This is not unexpected given that low back pain is the most common of all musculoskeletal conditions that people will seek care for. In addition, from a cost perspective in the United States, low back pain ranks third in money spent to treat it, only behind the cost of treatment for Cancer and Cardiac (heart) conditions. Given that it is so common, costly, and at times debilitating, it is important that the information about the causes, treatments, and prevention are accurate and based on the the most recent research that we have about the condition. In this Blog, I want to talk a bit about imaging (x-rays, MRIs, and CT scans) and what we can conclude from the results obtained from these tests as it relates to low back pain.

As technology for imaging has improved over the years, our ability to see the internal parts of our bodies in great detail has improved. This has turned out to be a blessing and a curse, depending on the condition that you are looking to diagnose. In the case of a suspected cancer for instance, you want as much detail as possible so that the presence of cancer is not missed and the appropriate treatment can be implemented.  In the case of cancer, the presence of it and its effect on the patient’s symptoms are highly correlated and the imaging diagnosis should guide the treatment.

In the management of most low back pain, the detail with which we can see the structures of the spine has turned out to be a curse. The reason for this is because there is not a strong cause and effect relationship between what is seen on imaging and the patient’s symptoms.

For most low back pain symptoms, what is seen on MRI, X-Ray, or CT scan has a very poor correlation with the symptoms that a patient might be experiencing. In fact, because of this, current clinical practice guidelines do not recommend having immediate imaging done on the spine for an onset of low back pain. Now, before I get into this in more detail,  I want to clarify that there are certainly situations when imaging should be done sooner rather than later. If someone has had a fairly sudden change in balance, has lost the ability to control their bowel and/or bladder function, has symptoms down both legs, or has a history of cancer, imaging should be done sooner rather than later. For all other cases, early imaging should not be prescribed and here’s why:

When we look at the research on “abnormalities” found on imaging of the low back, we find that there is no difference between people in pain and those who do not have pain. In the graph to the above, we see the percentage of “abnormal” imaging findings in people without pain. As you can see, for every decade of life, the chance of finding something that would be considered abnormal increases-even in individuals not having any pain. Therefore, if these findings are so prevalent in people without pain, then we cannot conclude that these findings are the cause of the symptoms for people who are having pain.

If you look at the graph closely, you will see that for each decade of life we live, ‘abnormalities’ become more and more common. This is analogous to what happens on the outside of our bodies-the older we get, the less things look like they did when we were younger. Researchers are now saying that these things we see in the spine as we get older are basically “grey hairs on the inside.” We would not expect that we would have head pain because our hair is turning grey (or in my case falling out), so we should not expect that just because a spine shows some age-related changes that we should have pain!

Now the unfortunate thing with most people in the medical profession nowadays, is that they do not read this type of research. Because of this, imaging is ordered way too early and way too often with the belief that we will be able to find the exact cause of a person’s symptoms. Treatments, whether it be medication, injections, or surgery are then recommended to “correct” something that is likely not the cause of the problem. The other negative to this type of approach to “diagnosing” the cause of low back pain, is that now you have a label.

Whether that be degenerative disc disease, a bulging disc, arthritis, etc, the fact is these sound scary and when you read about them, you might feel you are doomed. This is not a good situation to be in.

Now, the thing to remember is that these are common in everyone and with a treatment approach that utilizes evidence-based education about your pain combined with manual, hands-on treatment, and exercises, you can get back to doing all of the things that you want to be able to do-despite what is shown on your x-ray or MRI!

I hope you find this information helpful. As always, let me know if you have any questions.

Thanks for reading,

​Bob