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An MRI, X-ray or other imaging study?

What is important to know is that an X-ray or MRI shows not only the current situation but also the past. So it may show abnormalities that have nothing to do with the current pain. Compare it to scars, these are signs of old injuries but no longer painful or necessary to treat. So the result of a scan or photo should always be compared to the current situation. Do the symptoms really match the results of the examination? Radiologists look very objectively at what can be seen on a photo and often do not know what the person's physical symptoms are. We know from research that our bodies are subject to aging. Just like gray hair and wrinkles, this effect also occurs in our body. So from a certain age onwards we are always going to see abnormalities! In this blog we will explain when it is wise to have further testing but also when it is better to wait.

The usefulness of an MRI 

Using an MRI at the right time is a fantastic tool to get clarity about someone's medical situation. But we also now know that we see different abnormalities in people without pain symptoms. In study from 2015 where 3110 subjects without pain symptoms had an MRI or CT scan of the low back we see that different abnormalities of the low back increase with age. So the older you are the more signs of wear and tear on the back. Again these individuals had NO symptoms. Just like getting wrinkles and gray hair on the outside, the body is also subject to aging on the inside.

inversion trauma

So the result also shows the past. However, it can possibly be a clue if the lesion that can be seen also corresponds with the current symptoms. So the results of your MRI or X-ray should be looked at with a bit more nuance. When this happens without any context of the story, unpleasant situations arise. It is dangerous to make a judgment about someone's symptoms without ever having seen that person. What can be seen on an image does not always correspond to the experienced complaints.

For serious conditions, an MRI is certainly a godsend. Today's technology allows for a clear picture of deeper structures. Necessary when quick action is required. Only problem is that they rather often sound false alarms. Again, when radiological reports are made without any context it goes wrong in the communication.... In this way, the results of an examination are often presented as a kind of diagnosis. With regard to low back pain, we can hardly find an explanation for the pain with the results of an MRI or X-ray (except for extreme cases).

In physical therapy, we use questionnaires to score the degree of pain and disability. Research shows that in a large group of people the experienced pain and disability actually increase after an MRI. This can be explained by the nocebo effect (opposite of placebo). The bottom line is that when we look for abnormalities in the lower back, they can always be found. If pain free people show all kinds of things on an MRI then people with back problems will too. The result of (too) much examination is that people become anxious and panic. In the long run this often causes unnecessary anxiety and panic.

When is it really necessary to look further? 

Guidelines indicate that an MRI is a logical choice in people with low back pain with the presence of red flags. There is always a small risk of reassuring people where further investigation is actually needed. But in 99% of cases, it is appropriate to wait and see. Most back pain feels worse than it is. 

When do you know if you are dealing with an exception? 

In 1% of low back pain cases, the condition is one where acute medical intervention is necessary. These serious conditions stand out and are therefore rarely missed. The rule of thumb is that further examination may be necessary when complaints persist longer than 6 weeks these complaints can absolutely NOT be reduced by adopting a different posture and the pain increases over time. 

When these symptoms are present, you should also not wait to investigate further: 

  1. Sensation of numbness in the pubic area and/or incontinence symptoms 
  2. When you have been in an accident where the forces are great enough to possibly cause a fracture of your spine 

In all other cases, further investigation is not necessary. Even when you experience pain in the leg along with numbness of the skin or tingling in the leg. Also when you have clearly strained your back while lifting your car for example. Your back is not as vulnerable as you think! Even when you suspect a hernia (based on the symptoms present), waiting is the best choice. In the first month of a herniated or stenosed disc we see that the symptoms decrease on average by 50%. If there are still significant symptoms after this month, it is always possible to have an MRI. In extreme cases, surgery or an injection may offer a solution. But in most cases a hernia or a similar image will recover within 3-4 months. What also plays a part in the decision whether or not to have an MRI/photo is that in most cases the treatment plan will not change. When you do or don't have an MRI or photo taken, pain medication, advice, exercise therapy along with possibly some treatment is the chosen treatment plan. So, with or without a result, the same thing happens in practice. When we know that the fear increases after an MRI, it is better NOT to do it. 

When there are serious signs of symptoms (red flags) or there are symptoms that do not decrease over time, or even get worse, an MRI is a good choice. The most important thing is that the results of the different scans should always be interpreted in the right context. It is NOT an abnormality if it does not match the person's experienced symptoms. Aging of the body is therefore normal.

But why don't we just put everyone under an MRI or X-ray? Why is it so important to do imaging studies at the right time for people with low back pain? 

No one likes a false alarm. X-rays and MRIs are often exciting. And there is nothing more dangerous for people with low back pain than fear! Fear of what might be going on in that back contributes negatively to low back pain. When you type low back pain into Google, we too become grim with what you see all over the place. 

It adds nothing in most cases. A mountain of scientific research shows that much examination of the low back actually leads to more symptoms and limitations(1). At this point, it becomes unpleasant for the person themselves and they are only further from home. This person is going to be treated or perhaps examined further for something that is not the reason for their symptoms. Low back pain is no longer being dealt with appropriately. This is why healthcare costs for people with low back pain are skyrocketing. 

Sure there are exceptions. Sometimes it's really necessary to have a scan or photo to prevent worse. As I explained above. But it is often a bad way to try to find an explanation for your symptoms.

What can you do yourself? 

Despite many new studies coming out indicating that x-rays and MRIs should be taken with a grain of salt, people still get all sorts of diagnoses thrown at them. Another example is a back scan that is usually done by a chiropractor. This scan says nothing about your back pain! Posture and certainly minimal deviations have nothing to do with pain or even health. In an ideal situation, all health professionals would be better trained in either advising, reading and explaining imaging studies. Unfortunately, these things always take time.

What you can do yourself: 

  • Refuse early imaging! When you get back pain and your physical therapist, primary care physician or chiropractor sends for imaging studies, thank them kindly but don't go for it. Most symptoms will subside structurally within 6-12 weeks. 
  • Take the results of imaging studies with a large grain of salt! Keep thinking logically and don't let yourself be talked into anything unnecessary. 
  • In specific cases, a dynamic recording of the back or a different position of the spine is possible. This will probably show a different image than the standard position of an MRI or X-ray. If you have pain with a convex back and the MRI is taken in a neutral position this does not give the correct picture of the painful structure.

Conclusion

Low back pain is often a difficult subject. If we really had a clear answer to low back pain there would not be so many people with back pain. Often we want to explain back pain bottom-up. This means that we think that the pain comes primarily from the back. While we have very much scientific evidence that the degree of back pain and especially chronic back pain is strongly influenced by our brain, top-down. Believe in recovery, keep moving and don't panic unnecessarily!

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