Best practice guidelines have for many years now advised against routine MRI scanning for non-specific back pain as it is not an accurate diagnostic tool. Clinicians though regularly have requests from patients concerned that their back pain is not improving and that they wish to have an MRI to diagnose their condition. There is a common belief that you need a MRI confirmed diagnosis to be able to move towards recovery, and that without it the clinicians “do not know what they are doing”. This belief is often so strong that engagement in a recovery program will be dampened by the doubt of not having an MRI scan, and there are even some patients that refuse to engage in an evidence-based recovery program until they have this “diagnosis”.

NICE guidelines state that MRI scans are exceedingly useful when patients present with potentially serious pathology or require surgery. Many diagnoses that have been given to chronic back pain sufferers over the years as a result of these scans are now demonstrated to be normal in the asymptomatic population and so one has to question the validity of the diagnosis. For instance many patients have been told that they have disc degeneration and that it will not get better. Recent research work has demonstrated that around 80% of the over 50 years old population has disc degeneration and these people live completely asymptomatically. So how can disc degeneration be given as a diagnosis to explain why somebody has chronic pain, and even worse from this diagnosis be told that they will never recover?

As can be seen from the table below many of the common diagnoses that are given to patients to explain their pain, are normal in the population, and to make it worse these diagnoses are often given with the message that recovery is impossible. The evidence points to far more mundane factors which are the greatest predictors of chronic back pain, but these are a rather inconvenient truth to many patients. These factors are;

  • Obesity
  • Sedentary living
  • Smoking
  • Poor job satisfaction

The real diagnoses that we should be giving is that sedentary living is bad for you. There is slowly emerging an acknowledgement in the western world that the real problem with the pandemic of back pain as is the case for diabetes is actually our lifestyles.

The question is how do we get this message across to our patients? The answer to this must be partly with public awareness that sedentary living is damaging us and also in educating practitioners of all disciplines to ensure that we give out a consistent message that movement is good and will resolve most chronic back pain. We must never give out messages that there is no hope on the evidence of an MRI scan under the pressure of patient who is demanding a diagnosis.

As practitioners we need be confident to inform our patients of the truth that their symptoms are in part due to lifestyle choices and are avoidable, and stop giving out messages of doom to our patients.

Stuart Nottingham

Registered occupational health physiotherapist.

 

Age-specific prevalence estimates of degenerative spine imaging findings in asymptomatic patients

Age (yr)
Imaging Finding 20 30 40 50 60 70 80
Disk degeneration 37% 52% 68% 80% 88% 93% 96%
Disk signal loss 17% 33% 54% 73% 86% 94% 97%
Disk height loss 24% 34% 45% 56% 67% 76% 84%
Disk bulge 30% 40% 50% 60% 69% 77% 84%
Disk protrusion 29% 31% 33% 36% 38% 40% 43%
Annular fissure 19% 20% 22% 23% 25% 27% 29%
Facet degeneration 4% 9% 18% 32% 50% 69% 83%
Spondylolisthesis 3% 5% 8% 14% 23% 35% 50%

 

References

Brinjikji.W et al, (2015)Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations, AJNR Am J Neuroradiol. 2015 Apr; 36(4): 811–816.

Published online 2014 Nov 27. doi:  10.3174/ajnr.A4173

Nice guidelines for management of low back pain. (2009) https://www.nice.org.uk/guidance/cg88

OrthoFracs. Discal back pain. http://www.orthofracs.com/adult/elective/spine/lumbar-disc-prolapse/epidemiology.html