MRI for Back Pain? You Might Want to Think Twice About That…

Ask the Magic 8 Ball !    “Doc, my back is killing me! I think I need an MRI.” 

I don’t know if you’ve ever uttered those words, but I can tell you I’ve sure heard them…more times than I can count.  And believe me, I get it. If you’re in pain, all you care about is finding out what’s causing that pain as soon as possible so that you can get rid of it as soon as possible. Seriously, I get it. Been there, done that. I’ve had my share of excruciating back pain, and I know it is tempting in those circumstances to believe that the elusive answer to all your back troubles can be revealed by a quick 30 minute nap in a magnetic tube, otherwise known as an MRI machine. But the frustrating truth is that it usually can’t. Worse than that, that magnetic nap often leads to unnecessary treatments including increased procedures, risks, costs, and ultimately, a delay in diagnosis and treatment for the real cause of your pain.

The current issue of The Back Letter (a monthly publication by Lippincott, Williams, and Wilkins) has an interesting update on this very topic. They note that:

“The American College of Physicians recently initiated a campaign to end routine imaging for low back pain on the premise that it has no clinical value and often leads to a harmful cascade of events for patients.”

The key phrase there is “routine imaging.” In other words, spine imaging (x-rays, CT scans, and especially MRIs) should not be the rule but the exception, as it is rarely needed or even helpful for back pain. Even in the face of severe pain, caution and rational, medically sound thinking still need to prevail.

The vast majority of adults will have spine abnormalities on MRI (e.g. bulging discs, degeneration changes) despite having no complaints of pain. And at the recent 11th International Forum for Primary Care Research on Low Back Pain in Australia, Barbara Webster, PA-C presented her study on the tremendous amount of largely unnecessary medical care that follows an MRI. She concluded:

…that decisions regarding future interventions were very much driven by the findings on the MRI—whether they were clinically relevant or not.”

The Back Letter notes further that:

“having an MRI appears to be a common pathway for most individuals who go on to have other procedures. And it seems likely that the visualization of anatomic abnormalities on MRI scans—abnormalities that are almost always present on the scans of middle-aged adults—is a significant driver of that process. Most of those abnormalities would have no clear relationship with back symptoms. Yet once they are discovered, they are difficult to forget—for patients and providers alike. [emphasis mine]”

Translation: the mere presence of findings on MRI makes both patients and doctors feel obliged to do something even though that something is usually unwarranted

This realization will come as a shock to many people now that the MRI has become so widely regarded as the Magic 8-Ball of medicine magically revealing the secret of what ails you.  The reality, however, is that an MRI is nothing more than a picture–one of the most detailed pictures available…but nonetheless just a picture. By revealing details of every nook and cranny of your spine–most if not all of which will have no relevance to your immediate problem–MRIs have a tendency to add to rather than lessen, the confusion of getting an accurate diagnosis. The more detail, the more confusion over what any of it means. For that reason, the MRI is useful only to the degree with which it correlates with other pieces of the puzzle (e.g. symptom details, physical examination findings, and results of other tests).  It is no better at providing a definitive answer than is opening up the hood of your car when you hear it making a funny sound. After all, you’re almost guaranteed to find a grimy engine block, a frayed fan belt, a missing oil cap, maybe some smoke around the radiator or any number of other “abnormalities,” but in and of themselves, these things don’t mean much and may have nothing to do with the sound. In fact, they do little more than prompt the same question that most findings on a spine MRI should: “OK, so what?” 

The bottom line is that spine MRIs can be very valuable tools but only if ordered for the appropriate reasons, put in proper clinical context, and correlated with other pieces of the puzzle. When it comes to back pain, they’re not the end all be all they’re cracked up to be. They’re barely the end some be some, as the American College of Physicians has made clear. You’re still left to decipher the actual cause of the immediate problem…which might be related to the abnormalities you see on the picture or might have absolutely nothing to do with them.  More often than not, it’s the latter. In most cases, routine MRIs are unnecessary and actually postpone the right treatment, and at worst, they lead to potentially harmful interventions. So the next time your doctor declines to order that back MRI you requested, try to avoid the tempting assumption that it’s just a callous attempt to contain costs. Odds are, it’s to spare you unnecessary testing, hassle, risk, and delayed treatment.  In other words, odds are it’s just the correct call. 

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