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Tempting tech for patients & professionals, but against the guidelines for most back pain

MRI and X-Ray Often Worse than Useless for Back Pain

Medical guidelines “strongly” discourage the use of MRI and X-ray in diagnosing low back pain, because they produce so many false alarms

updated (first published 2007)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com
Got low back pain? See the advanced low back pain tutorial. Or When to Worry About Low Back Pain.

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.

MRI is a miracle technology, no doubt about it — the ability to get clear images of soft tissues deep inside the body is incredibly valuable, and extremely tempting for everyone involved.12

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.

It’s official, and it has been for years

The lameness of MRI point was pointed out firmly by the American College of Physicians and the American Pain Society in their 2007 guidelines for the management of low back pain.5

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 2015 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

What’s the big deal? Why is it so important to actually avoid using X-ray and MRI to diagnose back pain?

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. Many problems revealed by scans that seem like “obvious” problems are not. For instance, not only do at least half of “slipped” discs return to where they belong just fine on their own,9 but it’s actually the worst ones that are the most likely to resolve on their own.10 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.11

Or consider the 2016 experiment that sent the same woman with back pain and sciatica to ten different MRI facilities, producing such a variety of conflicting diagnoses that it would be laughable if it weren’t so tragic.12

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.

Save Yourself from Low Back Pain!

There are thousands of low back pain books — what’s special about this one? The problem is that 90% of doctors and therapists assume that back pain is structural, in spite of mountains of scientific evidence showing … exactly the opposite. Only a few medical experts understand this, and fewer still are writing for patients and therapists. Supported by 418 footnotes, this tutorial is the most credible and clarifying low back pain information you can find. Ships with a free copy of PainScience.com’s trigger point tutorial! Add it to your shopping cart now ($19.95) or read the first few sections for free!


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

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.

What’s new in this article?

JuneScience update, added references to Zhong et al and Chiu et al about herniated disc resorption.

JanuaryScience update, added a reference to Herzog et al’s remarkable MRI reliability results.

2016Science update, added citation to Webster et al clearly supporting the claim that MRI results can actually cause harm with false alarms.

2007Publication.

Notes

  1. Trentu.ca [Internet]. Coughlan R. Technology Idolatory: An Exploration of Healthcare's Love Affair with Machines That Go "Bing"; 2004 Jan [cited 15 Mar 17].

    “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.”

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  2. Swedlow A, Johnson G, Smithline N, Milstein A. Increased costs and rates of use in the California workers’ compensation system as a result of self-referral by physicians. N Engl J Med. 1992;327:1502–6. PubMed #1406882.

    From the abstract: “Of all the MRI scans requested by the self-referring physicians, 38 percent were found to be medically inappropriate…”

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  3. Deyo RA, Weinstein DO. Low Back Pain. N Engl J Med. 2001 Feb;344(5):363–70. PubMed #11172169.

    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.

    (See more detailed commentary on this paper.)

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  4. Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine (Phila Pa 1976). 2013 Oct;38(22):1939–46. PubMed #23883826. PainSci #53341. “Early MRI without indication has a strong iatrogenic effect in acute LBP, regardless of radiculopathy status. Providers and patients should be made aware that when early MRI is not indicated, it provides no benefits, and worse outcomes are likely.” BACK TO TEXT
  5. Chou R, Qaseem A, Snow V, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478–491. PubMed #17909209. PainSci #56029.

    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.”

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  6. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811–6. PubMed #25430861. PainSci #53872. BACK TO TEXT
  7. “Structuralism” is the excessive focus on causes of pain like crookedness and biomechanical problems. It’s an old and inadequate view of how pain works, but it persists because it offers comforting, marketable simplicity that is the mainstay of entire styles of therapy. For more information, see Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain. BACK TO TEXT
  8. In the the classic science fiction novel Dune, the Jedi-like Bene Gesserit use the “litany against fear” to focus their minds and calm themselves:

    I must not 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

    A lot of back pain patients could benefit from the “litany against fear.”
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  9. Zhong M, Liu JT, Jiang H, et al. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician. 2017;20(1):E45–E52. PubMed #28072796. PainSci #53529.

    Several studies — like Kjaer 2016, which followed dozens of patients for eight years — have suggested that herniated discs spontaneously de-herniate. This is the first meta-analysis of those studies. The pooled data from eleven studies shows an extremely high overall incidence of disk resorption: a whopping 66% in patients who received conservative therapy (anything but surgery). The number is unreliable due to low data quality, but so high that it’s safe to assume that approximately “lots” of herniations resolve on their own.

    (See more detailed commentary on this paper.)

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  10. Chiu CC, Chuang TY, Chang KH, et al. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015 Feb;29(2):184–95. PubMed #25009200.

    Not only do many lumbar disc herniations resolve on their own, or with just a little help from conservative therapy, but the worse the herniation the more likely it is to regress: exactly the opposite of what common sense predicts! This systematic review of 31 studies revealed a strong pattern of better regression from the worst cases: “Patients with disc extrusion and sequestration had a significantly higher possibility of having spontaneous regression than did those with bulging or protruding discs.”

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  11. Haig AJ, Tong HC, Yamakawa KS, et al. 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 & Rehabilitation. 2006 Jul;87(7):897–903. PubMed #16813774.

    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.

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  12. Herzog R, Elgort DR, Flanders AE, Moley PJ. 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. 2016 Nov. PubMed #27867079.

    People mostly assume that MRI is a reliable technology, but if you send the same patient to get ten different MRIs, interpreted by ten different radiologists from different facilities, apparently you get ten markedly different explanations for her symptoms. A 63-year-old volunteer with sciatica allowed herself to be scanned again and again and again for science. The radiologists — who did not know they were being tested — cooked up forty-nine distinct “findings.” Sixteen were unique; not one was found in all ten reports, and only one was found in nine of the ten. On average, each radiologist made about a dozen errors, seeing one or two things that weren’t there and missing about ten things that were. That’s a lot of errors, and not a lot of reliability. The authors clearly believe that some MRI providers are better than others, and that’s probably true, but we also need to ask the question: is any MRI reliable?

    (See also my more informal description of this study, which includes an amazing personal example of an imaging error.)

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