If you see this image below and it scares you, you aren't alone. If you have been looking at your MRI results and getting depressed thinking there is no hope, I have hope for you. If you have back pain, but haven’t had an MRI, you may be among the fortunate few. Why?
Reason #1. Quite literally, your results may be wrong.
Researchers had a 63 year-old woman with a history of low back pain and right sided pain/numbness that radiated down the leg visit ten different MRI centers over a three week period.
They compared the MRI results and found a high prevalence of interpretive errors. The idea most of us have, of course, is that as a patient we expect to receive the same diagnosis regardless of where we get our MRI or which radiologist reads it. This study showed that this is not the case. No single finding was reported in all ten MRIs. And 32.7% of the findings appeared in only one in all ten of the studies.
When a doctor asks you to bring the actual scan and not just a report, there is a darn good reason for it. And that is because the report may be wrong or at least how he interprets it may be different. The researchers concluded that where you have your MRI and who reads it may impact diagnosis, treatment choice and outcome.
Reason #2. Even if your MRI results are right, they don’t mean much.
What? With this reality, we can start paring down healthcare costs one MRI at a time.
Let’s start with a systematic review done in 2014 and published in Spine¹. The researchers looked at 33 studies which had examined 3110 people that had no back pain related symptoms. What they found is stunning to say the least. In each situation they looked at two age ranges. Twenty year-olds which most of us would define as healthy and relatively injury free, and eighty year-olds which by contrast many of us would define as infirmed or at least a bit worn.
Bulging or Herniated Disc
Having been told one has a bulging disc is extremely common in the people that I work with, and while it is the least innocuous finding of those listed in this article, it is often credited as the cause of back pain. Disc protrusion or herniation - sometimes more commonly called a “slipped disc” - is a less common finding; but when found, it is given credit as the cause of back pain even years after the original injury.
Here is what the researchers found in people with NO back injury, symptoms or pain.
Degenerative Disc Disease
I personally thought degenerative disc disease would be an exception. The structure of the spine isn’t holding up over time, surely the loss of height and integrity will have a direct correlation to pain. In a previously referenced study of asymptomatic people, researchers found it did not.
Stenosis is a narrowing of either the central canal through which the spinal cord runs or at either side of the vertebral process where a peripheral nerve branches off the spinal cord and runs outward to innervate a special area of the body. The spinal cord and nerves are understandably touchy about being touched. They are designed to slide and glide with relative freedom. It intuitively makes sense that if this isn’t available, we might get back pain or peripheral radiculopathy.
In a study² of 150 people between 55 and 80 years old with or without back pain, stenosis in the lumbar spine was found in 50 people, back pain in 44 people and no pain in 32 people. When looking at the MRI results, they were unable to find a correlation between the results and whether the person experienced pain.
Surely if a person’s spine is really shaped less than ideal, they will have back pain. Researchers³ looked at people that had been diagnosed fifty years prior with scoliosis and gone untreated for the fifty intervening years. They found them functional, although there was some back pain. By the way, I have worked with folks with significant scoliosis quite a lot and found bringing them out of pain quite doable. This is particularly true when the person is highly engaged at home with the movements.
There are several studies 4,5,6 that support the finding that spondylolisthesis is not an indicator for long term back pain. Overtime, people learn to do well with this condition.
Reason #3. MRI results lead to unnecessary and risky procedures.
We now know that patients nor doctors are good at ignoring abnormalities found on an MRI. We tend to think “fixing” these items will be the answer. We will talk more in the future about how procedures help or hurt but for now we will leave it with this finding 7: MRIs result in more surgeries and less likelihood of returning to work.
It means MRI results should be held lightly. They are not unimportant, but they are also not very important. When they are held as the primary evidence of a pain source, they lead to unnecessary and risky invasive and surgical procedures and poor outcomes. That is another topic I will cover in the near future. But for now, I hope to leave you with this encouragement: There is a great likelihood that you are one of the many, many people who do not need invasive procedures. A few people need them, and it probably isn’t you.
Follow a program of gradual reeducation of your movement habits, nervous system, and how you respond to the world, and you will find a healthy, vital life again. The process of learning how to come out of back pain is what really counts.
1 Herzog R, Elgort DR, Flanders AE, Moley PJ. (2017). Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J, 17(4):554-561.
2 Haig AJ, Tong HC, Yamakawa KS, Quint DJ, Hoff JT, Chiodo A, Miner JA, Choksi VR, Geisser ME, Parres CM. (2006). Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. Archives of Physical Medicine and Rehabilitation, 87(7):897-903
3 Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV.(2003). Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. JAMA 289(5):559-67.
4 Andrade NS, Ashton CM, Wray NP, Brown C, Bartanusz V. (2015). Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis. European Spine Journal, 24(6):1289-95.
5 Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. (2009). Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine, 34(2), 199-205.
6 Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA, Grant WD, Baker D. (2003). The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation.
7 Webster, B. S., Bauer, A. Z., Choi, Y., Cifuentes, M., & Pransky, G. S. (2013). Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain. Spine