The Myths of Bad Discs and Getting an MRI

What about getting an MRI? Could this help clarify your situation? Maybe, but maybe not.

First, let’s talk about an MRI versus a plain old x-ray. An x-ray helps us see the bones, and can detect arthritic changes, fractures, or a malalignment from trauma. If you’re not a gymnast or fresh out of an auto accident, this likely won’t tell you anything new about your body that hasn’t already been there. An MRI is good at looking at soft tissues, such as muscles, discs, or nerves. This could detect arthritic change in the form of bone spurs, disc bulges, or pinched nerves. But is this information always necessary? Will it guide us clinically with how to treat your condition?

The first question I ask when someone wants an MRI (or xray) for the low back is: what are you going to do with the information? There are 4 levels of intervention with bad back and/or nerve pain.

1. Therapeutic (a PT, chiropractor, acupuncture, etc)
2. Oral Pharmacologic (antiinflammatories- non-steroidal or steroidal)
3. Invasive Pharmacologic (steroid injection to the nerve or muscle to reduce inflammation)
4. Invasive Surgical (surgical correction of the problem)

Things need to be pretty bad to get to numbers 3 or 4. For these interventions, a physician needs to see what’s going on because he/she is physically going in to address it. Here, an MRI is appropriate. However, for the majority of people living in categories 1 and 2, we probably don’t need it. Here’s why:

What is the Goal, Anyway?

Surgical correction has poor outcomes, and should be a last resort. A doctor would want you to see a PT or chiropractor first to help you improve your alignment, flexibility, and strength. The goal is to get you out of pain and functional. If you’re improving and know how to stay out of pain, do you need the MRI any more than you did before all this started?

Don’t we want to see what is going on?

Information is good, but we need it to be useful. Diagnostic imaging may help a surgeon, but it does little to direct the treatment for a chiropractor or PT, who should know where to work by using his eyes, hands, and mind. Paying for an x-ray to detect an “alignment issue” isn’t just clinically unnecessary, it’s also diagnostically inaccurate. The MRI, for its part, may show abnormalities in bones (spurs), ligaments (hypertrophy), or discs (bulging), but the truth is that we can’t say definitively which of these structure(s) is responsible for the pain. Just because there is an abnormality doesn’t mean that it is generating pain; one third of all adults are walking around with at least one significant disc abnormality, and many of these people are asymptomatic.

What about something like a tumor?

This is important to consider, but here are the facts: 97% of low back issues are purely musculoskeletal. 2% are stemming from a visceral issue (kidneys, reproductive organs, etc.), and 1% are insidious (infection, cancer, etc). Physicians and PTs are trained in properly screening these conditions and ruling them out with a very high degree of certainty. The MRI should be our last line of defense in diagnosis here.