As you may or may not know, I specialize in getting people out of pain and back to living life to their fullest. In some cases, people ask if they should get an x-ray or an MRI. If you are just interested in the short answer and do not care about what the research says, the short answer is no. Or at least, probably not.

For low back pain, in particular, there is not much to suggest imaging improves outcomes. More on that in a bit.

Full disclosure, there are a lot of articles referenced in this post. Do not be afraid. Hold my hand and I will guide you through the scariness.

Understand what imaging is and isn’t.

If you are considering imaging of some kind, it is important to know what it can do and what it cannot do.

Imaging can help, but not usually if it is used in isolation. You also need some sort of an evaluation and the willingness to actually make some changes to get yourself out of pain.

Step one when after evaluating a person is to TREAT WHAT YOU FIND not what’s on the image. I have met plenty of people that had and MRI before we met yet their evaluation and associated symptoms did not match up with what the image was showing.

Blindly seeking out an image to solve your pain riddle is no different than hopping from exercise program to exercise program or from diet to diet and wondering why nothing is improving.

There is this belief that getting an x-ray or MRI will confirm something and validate your feelings and give you some sort of piece of mind. You believe that if you are given a diagnosis that someone the path to getting out of pain becomes clearer.

No, no and more no.

no no no.jpg

Unfortunately, the reasons in which imaging is often ordered are not based on improving your outcomes. Sadly, it is often more of a CYA technique. Physician self-referral, a patient’s desire for imaging and a physician’s concern over liability risk are all common reasons why imaging may be ordered [27-29].

It is also not surprising that surgery rates are highest where imaging rates are highest [18,23], yet this higher utilization rate was not associated with better patient outcome [18].

not cool bro.jpg

One of the first problems we run into that many people have pain that is movement-based.

Most images on done in static positions. Basically, you are not moving.

So, if your pain is based around movement and you are getting an image while you are just laying down, how can that possibly give you any useful information?

You think about it. I’ll wait.

It can’t.

A question of efficacy.

For argument’s sake, let’s define ‘efficacy’ as “the probability of benefit to individuals in a defined population from a medical technology applied for a given medical problem under ideal conditions of use” [30].

Assessing the efficacy of x-rays has been going on since the 1950’s (the first x-ray was done in 1895) [31].

In 1980 the annual costs of medical diagnostic imaging were estimated at $5-7.5 billion [32]. In 2005, just the direct medical costs of care for LBP exceeded $86 billion [34].

billion with a b.jpg

MRIs can be very good at detecting certain “problems” in and around the spine. MRI demonstrated high sensitivity for spinal soft tissue injuries. However, MRI showed a definite trend to overestimate interspinous ligament, intervertebral disc, and paraspinal muscle injuries [6].

Don’t get too wrapped up in googling the vocab words above. Here’s part of the problem with the above information. If the doctor is trying to appease the patient by ordering the MRI or the patient has demanded one, they will find something.

Whether that something is the actual problem is another discussion completely.

A whole bunch of false positives.

This is where imaging gets interesting for all the wrong reasons.

One of the main issues with using imaging for non-specific low back pain (LBP) is that you will often find things that are there, but have nothing to do with your pain.

What sort of cryptic message is that?

In studies of subjects without LBP, disc herniations are seen in approximately one third, disc bulges in half to two thirds, and disc degeneration in up to 90% of these individuals [8,14,15,16,20].

Let that sink in for a minute. Those numbers of from individuals that DO NOT have back pain. They are symptom-free.

Still not convinced? There are plenty of other studies [7,8,10,17,42,43,44,45,46,47,48,49,50] that show that MRI’s have a high prevalence of abnormal findings among individuals without LBP.

In one study [8] of 148 subjects who did not have any LBP or sciatica:

  • 123 had moderate to severe desiccation of one or more discs (basically, this is dehydration of your discs)

  • 95 had one or more bulging discs

  • 83 had loss of disc height

  • 48 had at least one disc protrusion (the disc is compressed and protrudes where it doesn’t belong — but the jelly stays in the doughnut, so to speak)

  • 9 had one or more disc extrusions (the gooey center of the disc which should be on the inside of the disc, is now on the outside — think of the jelly in a doughnut shooting out the side)

Identifying incidental abnormalities with early MRI might lead to unnecessary interventions that otherwise would not have been performed, potentially resulting in both worse patient outcomes and higher costs [1].

Getting imaging DOES NOT improve your outcome.

There is no evidence that routine plain radiography in patients with nonspecific low back pain is associated with a greater improvement in patient outcomes than selective imaging [2,13,21,22].

Don’t think MRIs are any better. Magnetic resonance imaging is also not associated with improved patient outcomes [1,10,36] and identifies many radiographic abnormalities that are poorly correlated with symptoms [9] but could lead to additional, possibly unnecessary interventions [1,23].

Without red flags in the history or physical examination, conservative care with patient education is the first step in pain management [2,7,9,37,38].

In addition to those studies, additional studies [1,10,11,12,13,22,39,40,41] have shown that among patients without red flags—clinical signs and symptoms indicating serious underlying condition — early imaging (instead of conservative treatment without imaging) does not improve patient outcomes.

Yikes. But it gets better.

Although radiography was not associated with improved patient functioning, severity of pain, or overall health status, patients undergoing radiography in this study [11] were more satisfied with their care.

Why are we so dumb?

Why are we so dumb?

One of the most frequently cited source of dissatisfaction among patients was failure to receive an adequate explanation [55]. So, people are ok with getting an image that won’t improve their outcome just to get some form of explanation even if that explanation has nothing to do with their pain?

Interesting. It’s really no surprise people cannot get out of pain.

Clinician: What brings you in today?

Patient: My head hurts and I have headaches daily.

Clinician: I see. Any idea what is going on.

Patient: Well, it seems to hurt more when I bang my head against the wall for awhile.

Clinician: [stunned] Well, maybe you should stop banging your head against the wall.

Patient: No, that’s not my problem. Can we get an MRI?


When should you get imaging done?

You can utilize imaging to make sure there is not something more sinister going on that is causing your pain. Using imaging early on could help reassuring both patient and physician that there is no serious disease [1] or to identify rare but high-consequence conditions, such as metastases or infection. However, in the primary care population, fewer than 1% of all LBP patients have these conditions [35].

Getting an x-ray is recommended for initial evaluation of possible vertebral compression fracture in selected higher-risk patients, such as those with a history of osteoporosis or steroid use [9].

Imaging is recommended for individuals who have severe or progressive neurologic deficits or are suspected of having a serious underlying condition [24-26].

The one area that getting an MRI makes the most sense is if there is any concern of spinal infection. There are studies [51-54] that show an MRI to one of the best ways to make this determination.

Summary

Still with me? That was a bit messy, but I am glad we got through it together.

Whether or not to get imaging is not an easy decision to make. Hopefully, this information can help you find true resolution to your pain and not just a picture commemorating it.

In most cases, you will probably be better off not getting the image. If you do decide to get some form of imaging, just make sure you have a thorough evaluation to go with it.


Until next time,

Dr. Tom


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