When it comes to diagnosing most back pain, MRI machines are at least as useless Monty Python’s medical machinery that goes “bing.” For back pain, MRI and X-ray are mainly machines that make false alarms — signs of trouble that are routinely red herrings.
But not for most low back pain! Low back pain experts have long understood that you simply cannot reliably diagnose low back pain either with MRI, or with X-ray3 — and trying causes false alarms that actually do harm!4 So they are actually often worse than useless.
Of course, the message has not yet reached many therapists and doctors, which is why it’s important that scientific journals are still publishing (and re-publishing) guidelines like these — eventually the message will get through!
Specifically, their recommendation was that doctors should avoid giving people X-rays and MRI unless the situation is dire, such as severe and persistent neurological symptoms (see When to Worry About Low Back Pain) The authors labelled this recommendation “strong,” and believe the evidence to support it is “moderate.”
I think that the recommendation should now be “stronger than strong, very strong, really extremely strong,” and the evidence supporting it can be considered “bullet proof.” Consider the results of a major 2014 review by Brinjikji et al: signs of degeneration are present in very high percentages of healthy people with no problem at all. “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.”6
No one wants a false alarm, but what’s the big deal about some diagnostic red herrings? It’s a worse problem than you might think in (at least) two major ways…
First, X-rays and MRIs genuinely spook people! It strongly reinforces the idea that something might is broken or crooked, a common and extremely misguided idea about back pain (and many, many other problems7). And nothing is worse for back pain than fear. Fear is the “back killer.”8
Second, X-rays and MRIs often simply fail to clarify the situation, or actually muddy the diagnostic waters. A mountain of scientific evidence clearly suggests that back pain correlates really, really badly with these test results. Many people with no pain have all kinds of things “wrong” with their backs, and vice versa. And so the diagnosis and treatment often goes spinning off in the wrong direction. This is a major part of the reason why there are such scary statistics about the economic costs of back pain.
There are exceptions — sometimes imaging finds something important — and that’s why these tests can be appropriate for some kinds of severe and persistent low back pain. But it’s just a generally lousy way to try to figure out why your back hurts.
Consider what happened when researchers tried to diagnose using only MRI — no clinical information about the patient. They looked for patients with stenosis — spinal canal narrowing — based on the assumption that stenosis is probably almost always painful. They failed, because so few patients with that kind of pain actually had narrowed spinal canals! And so many who actually did have narrow canals didn’t have any pain.9Scientific evidence clearly suggests that back pain correlates really badly with these MRI findings.
Yet it is still routine for me to see patients who have been X-rayed by their chiropractors and MRI-ed by their doctors in the early stages of back pain!
If you get back pain, and someone tries to beam rays through you prematurely, just say, “Thanks, but no thanks. The American Pain Society says it isn’t necessary unless I can’t feel my legs.”
Have you got chronic back pain? Visit my advanced patient tutorial, Save Yourself from Low Back Pain! Or for an interesting philosophical discussion of the general problem, see my article, Your Back Is Not Out of Alignment.
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
— Science update, added citation to Webster et al clearly supporting the claim that MRI results can actually cause harm with false alarms.
“There is something wonderfully compelling about new technology whether it comes in the shape of new cars, kitchen appliances or technological advancements in the modern clinic. I want to briefly explore how our values and beliefs concerning technology may contribute to some problematic aspects of modern medical practice.”BACK TO TEXT
From the abstract: “Of all the MRI scans requested by the self-referring physicians, 38 percent were found to be medically inappropriate…”BACK TO TEXT
Way back in 2001, Deyo and Weinstein were strongly critical of overmedicalization and excessive imaging and surgery for low back pain, the poor correlation between imaging results and symptoms, and the absence of any clear pathophysiological mechanism to explain most low back pain.BACK TO TEXT
Marvelously progressive, concise, and cogent guidelines for physicians on the treatment of low back pain. These guidelines almost entirely “get it right” in my opinion, and are completely consistent with recommendations I’ve been making for years on PainScience.com. They are particularly to be praised for strongly discouraging physicians from ordering imaging tests only “for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.”BACK TO TEXT
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I must not fear.A lot of back pain patients could benefit from the “litany against fear.”
Fear is the mind-killer.
Fear is the little-death that brings total obliteration.
I will face my fear.
I will permit it to pass over me and through me.
And when it has gone past I will turn the inner eye to see its path.
Where the fear has gone there will be nothing.
Only I will remain
In this study, about 150 people were assessed for back pain in different ways, including MRI, but “radiologic and clinical impression had no relation.” In other words, there was no useful similarity between evaluation of the patient with MRI, and evaluation by examination and taking a history. “The impression obtained from an MRI scan does not determine whether lumbar stenosis is a cause of pain.” Since MRI does in fact identify narrowing of the spinal canal, and this is the whole basis of diagnosing spinal stenosis with MRI, these results also strongly imply that a narrowed spinal canal does not (alone) cause back pain.BACK TO TEXT