This is a hard one. There have been many times I’ve heard from patients with chronic back symptoms, “I just want to get an MRI so that I know what is wrong with my back.” We all have a desire for understanding and clarity. Our brains are wired to close loops. We like to read to the end of the story or listen all the way to the end of the song. Therefore, an MRI is meant to close the loop on our back pain, right? Unfortunately, no, it is not, and it may actually end up making things worse.
The dilemma lies in this:
- Over 99% of patients with low back pain do not have a serious condition (look back at the blog on Red Flags)
- We still only can speculate on the anatomic source of low back pain
- There are numerous anatomic variations on MRI findings that aren’t associated with symptoms (Look back at the table under Causes of Low Back Pain)
- When a patient is told these anatomic variations were found (e.g. they have a bulging disk or degenerative disk disease) it creates a false sense of belief that they have a serious problem.
- That may lead them to buy into advertising for expensive or unnecessary treatments or surgeries. The American Academy of Family Physicians cited a study that showed that if people had an MRI early on after hurting their back at work , they were 8 times more likely to end up having surgery than those who didn’t have an MRI.
They also go on to cite a few more studies showing that there is no difference in outcomes between those who had an immediate low back imaging versus usual care. Also imaging before 6 weeks of onset did not improve outcomes but it does increase healthcare costs.
So who should get an MRI? Across the board the answer is the same
American Academy of Family Physicians: Don’t do imaging for low back pain within the first six weeks, unless red flags are present. (Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected.)
Annals of Internal Medicine: Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. In other patients, evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms.
Clinical Practice Guideline from American Physical Therapy Association: In patients with severe or progressive neurologic deficits, prompt workup with MRI or CT is recommended because delayed treatment in patients with progressive neurologic involvement is associated with poorer outcomes. In addition, if the patients are potential candidates for surgery or epidural steroid injections, MRI (or CT if unable to undergo MRI) may be indicated. In the absence of these findings, there is no evidence that routine imaging affects treatment decisions or outcomes in these patients.
APTA Current Concepts of Orthopaedic Physical Therapy: Magnetic resonance imaging of the spine is not indicated in the absence of red flags or worsening neurologic signs. Early, inappropriate use of magnetic resonance imaging of the spine may increase patient anxiety and lead to false beliefs regarding the severity of diagnosis.
American Association of Neurological Surgeons: Don’t obtain imaging (plain radiographs, magnetic resonance imaging, computed tomography [CT], or other advanced imaging) of the spine in patients with non-specific acute low back pain and without red flags.
Key Takeaway: most people with low back pain do not require imaging. Getting an MRI just for the sake of “knowing what is going on in your back” will not help you feel better. Unless you have red flags or severe or worsening neurological signs then you should avoid imaging to lower health care costs and fear associated with normal anatomic variations. Be comforted that most back pain gets better naturally overtime, try to stay as active as possible, reduce stress, and maintain a healthy and balanced diet.