- What you should know about MRI and Xray when you have low back pain -

Most of typical imaging (making an mri, ct or xray) findings of people with LBP are part of normal aging and are not related to back pain. Using these images to explain your pain without an accurate examination and a carefully guided clinical history interview, is not supported by current scientific evidence! 

Clinical guidelines say imaging should be avoided unless signs that raise suspicion for a serious underlying condition like malignancy, spinal fracture, infection of the spine, or cauda equina syndrome are present.1,2,3,4 

These signs are usually called 'red flags'. And only a very small percentage of LBP categorises for this group of severe pathology, usually around 1% -> Most people do not show such signs.

Are you having serious disease? (red flags)

A potential serious disease is identified by your medical doctor while taking a focused history and looking/listening for so called "red flags". "Red flags are features from the patient’s clinical history and physical examination which are thought to be associated with a higher risk of serious pathology."5 There is no definite list of red flags, but the most commonly used are2:

• aged over 50 years old
• history of cancer
• steroid use

Other commonly suggested “red flags” in clinical practice guidelines are5,2:

• faecal incontinence
• urinary retention
• widespread neurologic symptoms (could be a palsy, marked weakness of muscles, decreased sensation (feeling numb on your skin), something seriously wrong with your reflexes and your medical doctor will know how to look for that)
• no improvement in symptoms after one month
• unexplained weight loss
• fever
• being systematically unwell

Whilst the use of red flags is recommended by all clinical guidelines there is still little empirical data for its diagnostic accuracy.5,6 If a combination of red flags raises the suspicion of your clinician he or she should assess prognostic factors such as X-rays and blood tests or magnetic resonance imaging to rule out or identify serious disease (malignancy, spinal fracture, infection of the spine, cauda equina syndrome). The so often mentioned slipped disc by itself is not considered a severe pathology!

So why is imaging of your spine not recomended in the absence of red flags?

To put it simple: People with no LBP can have worse mri´s, ct`s or xray´s  than people with LBP. 

Most of typical imaging findings of people with LBP (such as disk degeneration, disk signal loss, disk height loss, disk protrusion, and facet arthropathy) are part of normal aging and are also present in 90% of individuals 60 years of age or older without even having LBP. Also more than 50% of people without any LBP between 30-39 years of age have disk degeneration, height loss, or bulging in their imaging findings.7

Furthermore no association was identified between findings like spondylolysis, isthmic spondylolisthesis, or degenerative spondylolisthesis, and the the occurrence of LBP.8 No association between lumbar spine facet joint osteoarthritis, identified by multi-detector CT, at any spinal level and LBP.9

Findings on mri are also not predictive of the development or duration of low-back pain.10 Individuals with the longest duration of LBP did not have the greatest degree of anatomical abnormality.11

A recent systematic review concluded that in the acute setting of sciatica (pain radiating down the leg), evidence for the diagnostic accuracy of MRI is not conclusive.12

Let´s put in an example:

If you randomly choose 100 people above 30 years of age that do not have LBP and feel perfectly fine, more than 50 of them will show the typical signs of degeneration that are often (mis)used to explain the cause of LBP.

The same stands true for people with LBP. They too have a good chance to show those signs, but it is just a normal picture, your skin too does not look like the skin of a 10 year old. It´s in most cases a normal part of aging and has no corelation with pain.

So getting an xray, ct or mri not only will not help you (if you lack signs of serious pathology) in treating your back pain but there are even studies that suggest that having an MRI can make things worse for people with LBP. In a study done with 3264 workers compensation cases, people with MRI came off of disability 200% slower than those who didn´t have an MRI scan.13

What really should make one think is that 80-100% of the MRI group had surgery while

the no-MRI group had a surgery rate of less than 10%, still having a much faster recovery. Another study brings further evidence for worse outcomes of people with LBP that have early MRI´s regardless of radiculopathy (back and/or leg pain with muscle weakness. On average, the rate of going off disability for those who received an early MRI was approximately one-third the rate of those who did not receive MRI. "hThis evidence reinforces that both providers and patients should be made aware that when early MRI is not indicated, its use provides no benefits and could result in worse out- comes such as iatrogenic work disability and unnecessary medical procedures."14

Iatrogenic work disability means, work disability caused by health professionals.

As researcher Neil o´Connell points out in an article he wrote for www.bodyinmind.org: "(...) it’s not really the scans that are the problem, it’s the way that they are (mis)used by clinicians. Powerful images of bulging discs, degenerating joints, partial dislocations or instability are evoked to help explain the patient’s symptoms (...)"

Using these images to explain your pain without an accurate examination and a carefully guided clinical history interview, is not supported by current scientific evidence! Instead of helping you in your recovery, it could create fear, fear of movement, and probably will even contribute to your pain-condition because of that.

Remember: If you already have a mri, ct or xray of your back and worry about those "abnormalities" described by the radiologist, many people without LBP would have similiar results in their mri´s or xrays. It´s perfectly normal for a spine to show osteoarthritis, disc narrowing, spondylolisthesis discs bulging aso. It´s like having wrinkels on our skin as we are getting older.

For LBP with substantial neurologic involvement, CPGs generally did not recommend conducting any further assessment until appropriate conservative management (which was rarely defined) had failed, after which MRI or CT was generally recommended.2 Imaging is sometimes recommended where sufficient progress is not being made but the time cut-off varies from 4 to 7 weeks.1

Find out more: www.mybackrecovery.com

Literatur:

1. Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-2094. doi:10.1007/s00586-010-1502-y.
2. Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J. 2010;10(6):514-529. doi:10.1016/j.spinee.2010.03.032.
3. Pillastrini P, Gardenghi I, Bonetti F, et al. An updated overview of clinical guidelines for chronic low back pain management in primary care. Jt Bone Spine. 2012;79(2):176-185. doi:10.1016/j.jbspin.2011.03.019.
4. B.K. C, J.L. B. Appropriate and safe use of diagnostic imaging. Am Fam Physician. 2013;87:494-501. http://www.aafp.org/afp/2013/0401/p494.pdf\nhttp://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed11&NEWS=N&AN=2013206181.
5. Henschke N, Cg M, Rwjg O, et al. Red flags to screen for malignancy in patients with low-back pain ( Review ). Program. 2013;(2). doi:10.1002/14651858.CD008686.pub2.Copyright.
6. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. Bmj. 2013;347(dec11 1):f7095-f7095. doi:10.1136/bmj.f7095.
7. 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;36(4):811-816. doi:10.3174/ajnr.A4173.
8. Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009;34(2):199-205. doi:10.1097/BRS.0b013e31818edcfd.
9. Kalichman L, Li L, Kim DH, et al. Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976). 2008;33(23):2560-2565. doi:10.1097/BRS.0b013e318184ef95.
10. Borenstein DG, O’Mara JW, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. J Bone Joint Surg Am. 2001;83-A(9):1306-1311. http://www.ncbi.nlm.nih.gov/pubmed/11568190.
11. el Barzouhi A, Vleggeert-Lankamp CL a M, Lycklama à Nijeholt GJ, et al. Magnetic resonance imaging in follow-up assessment of sciatica. N Engl J Med. 2013;368(11):999-1007. doi:10.1056/NEJMoa1209250.
12. Wassenaar M, van Rijn RM, van Tulder MW, et al. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J. 2012;21(2):220-227. doi:10.1007/s00586-011-2019-8.
13. Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52(9):900-907. doi:10.1097/JOM.0b013e3181ef7e53.
14. 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;38(22):1939-1946. doi:10.1097/BRS.0b013e3182a42eb6.