Imaging of the Back… Does It Give the Full Picture?
by Sean Gupanis
As a private practice physiotherapist, the main complaint coming into our treatment rooms is Low Back Pain. Now, most of us have had some lower back ‘niggles’ before, which we shrug off as we continue everyday life. However, when people finally attend physiotherapy, this pain has usually progressed to the extent of agonising and debilitating pain. As such, it is common thought to request an X-Ray or MRI, simply to “make sure nothing is permanently wrong.”
Abnormal findings on an MRI are common! Infact, this has been thoroughly tested and reported; that asymptomatic backs – with no HISTORY OF BACK PAIN – still have MRI findings that demonstrate ‘mild degenerative changes’, or ‘mild disc bulging’. Infact, it is still common that people attend physiotherapy with left sided back, hip and leg pain – yet their MRI demonstrates an impingement on the right side of the spine!
Put simply, just because an MRI gives you a result or a finding it does not guarantee that it is the cause of your low back pain.
Let’s dive into the literature…
A systematic literature review, completed in 2015 which focussed on imaging feature of spinal degeneration of asymptomatic populations showed quite telling and interesting results. They were able to conclude that findings from imaging are present in high percentages of asymptomatic individuals and this percentage increases with age. These findings are essentially a likely part of normal aging and have no association to pain.
In fact, to make it less wordy, the following table summarises the imaging findings in an asymptomatic population.
| Imaging Findings | 20s | 30s | 40s | 50s | 60s | 70s | 80s |
| Disc Degeneration | 37% | 52% | 68% | 80% | 88% | 93% | 96% |
| Disc bulge | 30% | 40% | 50% | 60% | 69% | 77% | 84% |
Does this mean that MRI studies are useless?
… Absolutely not!
MRI findings should be used predominantly to – rule out “red flag” presentations such as spinal cord compressions, cancers, tumours and more! They can also be helpful to confirm a diagnosis – for example, a radiculopathy, where sciatic pain may be associated with clinically tested signs of weakness and decreased sensations.
As such. at Move Physiotherapy, our first point of emphasis is to perform a detailed subjective examination and comprehensive assessment to gain a full clinical picture. Everyone is different so there is no blanket rule that says this is how we need to treat a type of condition etc. It’s our job to find out what makes you feel better… our job to find out what makes you feel worse… our job to find out what you can and can’t do. We are guided not simply by an MRI finding, but your full clinical presentation.
I’ve had friends from soccer and school come up to me saying how they have a disc bulge or disc degeneration following a MRI they’ve done. Whether its someone who comes through the Move Physiotherapy and Fitness door or one of my mates on the soccer field, I would do the same thing. Education. Education is vital to help calm any fears that people may have following this result of their MRI. Education that if you’re a fit and healthy 24 year old for example ( which MRI results will show 37% have disc degeneration and 30% disc bulge) that this does not define their pain or control what they can and can’t do movement wise.
It’s our job as a physio to ensure that when you walk through the doors that we can make you feel better, both physically and psychologically. So ask us questions when you come in and we will have the answers for you. It’s important for us to be able to emphasise that contextually the results of a MRI scan are normal and not associated to your pain and then derive an action plan with time-specific landmarks to ensure you can return pain free to your desired sport, activity or leisure.
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.
Matsumoto M, Okada E, Toyama Y, Fujiwara H, Momoshima S, Takahata T. Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects. Eur Spine J. 2013 Apr;22(4):708-13. doi: 10.1007/s00586-012-2500-z. Epub 2012 Sep 19. PMID: 22990606; PMCID: PMC3631032.