MRI for Back Pain - Should Your or Shouldn't You?

If you’re like me, you are terrified of disc pain. But knowledge is power! Read on.

Disc pain happens in the old and young alike – usually for different reasons. Just the same, it often marks the start of degenerative spinal changes that only get worse as we age.

A 2018 meta-analysis, which is a study that crunches numbers from other studies, found that worldwide, almost 4% of all people have low back pain and degenerative disc disease. Overall, though, between 30 and 80% of the planet’s population have some type of back pain on average, according to a 2023 review published in Health Science Report. (A review is a study that summarizes the findings of other studies.)

Anne's Mug. She is smiling at you.

From my perspective as a human helping humans who deal with back and joint pain, most of the time a combination of movement, exercise, and holistic or conservative therapies can work wonders. I find that a skilled movement approach is best: Once people learn about “tools that come with them because they’re human" like breathing, body alignment, simple but accurate joint movements and mental imagery, back pain can be resolved, and the person emerges more empowered physically and mentally than they were before their pain started.

A skilled movement approach to pain relief is appropriate, in my experience, when the pain is muscle or posture related. Disc issues are more involved and need medical attention.

Given the odds, should you have an MRI when your back hurts? Is it really necessary? Here's some research-based food for thought to help you decide.

Ask: What is the Pain Generator?

Our spinal discs are one type of back “pain generator.”

As the name suggests, a “pain generator” is a specific location to which the origin of pain you experience can be traced. Most of the time, an M.D. is the one who does the tracing, as she is licensed and qualified to run tests such as MRIs, CT scans and blood tests.

Pain generators tend to have some type of abnormal physiology. Again, disc problems certainly qualify, but your pain could be coming from a number of other structures from bones to organs. Doctors usually suggest having an MRI as well as other tests to try to sort that out.

A Lot of Money to Find Out You Strained a Muscle

MRIs are meant to show potential problems, or lesions, in soft tissues that may require medical management or surgery. (X-rays show problems in bones.) MRIs can detect lesions in both muscles and discs.

Problem is, the use of MRI, which is pretty standard when you go to the doctor for back pain, is not limited to assisting the diagnosis of serious conditions. They are also given for the “take 2 and call me in the morning” type of back pain. Generators for this type of pain include muscles: tension, weakness and imbalance. Just my opinion, but these are the kinds of conditions that, depending on cause and severity, you or I could handle ourselves when we take a skilled movement approach.

In fact, an MRI can’t show the presence of muscle imbalance in the body, but I find when that’s addressed well, most or all of a person’s pain resolves on its own.

Pickleball paddle resting on top of pickleball.

A published case study from a medical encounter illustrates my point: A few years ago, a 48-year-old pickleball player hurt his back while playing. After attempting to manage it himself, he went to see his doctor to try to get it fully resolved. He asked the doctor to take some films.

As it turns out, the films weren’t necessary: The honest doctor examined the pickleball player and determined there were no red flags or warning signs indicating something was amiss. The pickleball player agreed to skip the films and try an exercise program.

This story has a happy ending. The patient sent feedback to the doctor four weeks later saying his pain had improved and the study concluded that "the decision to forego imaging saved the patient healthcare costs and radiation exposure.”

What Experts Tell Experts

The American Academy of Family Practitioners tells their doctors not to order any type of imaging tests – X-rays, MRI, CT scans, etc. – for the first 6 weeks unless the doc sees specific warning signs for doing so during the physical examination and history taking, Numerous studies such as this systematic review and meta-analysis from Chou, et. al., back them up and the Agency for Healthcare Research and Quality (AHRQ) offers this research-based clinical guideline to all U.S. doctors.

Shell opened up to expose a round pearl.

One of the pearls in the guideline says that although patients in their study receiving films early on in the process, before the recommended wait time of six weeks, received “no clinical benefit,” their costs were 30% higher than patients who delayed their MRIs.

30%!!! Wow.

The last I checked, which was a few years ago, the standard battery of such tests (usually consisting of X-ray, MRI, physical exam and possibly a CT scan and/or EMG) costs you or your insurance around $3000.

And here’s the real kicker: Quality sources such as this one from the National Library of Medicine reminds us that most back pain goes away on its own.

MRI for Back Pain: Should You, or Shouldn't You?

Disc problems are regarded as more serious than muscle strain, and as such, may actually warrant MRI and subsequent medical treatment. It depends on the situation, but in general, the decision to have an MRI should be based on your symptoms and input from a doctor who follows the AHRQ's clinical guidelines. This information might be tricky to tease out from either the doctor or her staff, though. By understanding what research tells us, you can engage the doctor or her staff with specific questions, including "do you follow the AHRQ's guidelines?"

According to the AHRQ, other things to consider, and that you might consider conversing with your doctor about include:

The potential for being labeled by the health care provider, which may affect your self-efficacy. Self-efficacy, in this case, is belief in yourself that you can overcome the pain on your own.
The increased potential for unnecessary surgery. The AHRQ says there is a link between a higher rate of imaging and a higher rate of back surgery, especially if the pain is job-related.
The AHRQ recommends waiting 6 weeks - you can go to physical therapy during that time - before imaging, unless when your doctor examines you, she finds "red flags." Red flags indicate a serious condition or disease may be underlying your pain.
The AHRQ recommends imaging only after noninvasive treatment fails - that's the six-week waiting period they talk about and is mentioned above - to relieve symptoms and you are considering surgery.

Sources:

American Academy of Family Practitioners. Imaging for Low Back Pain. Choosing Wisely Recommendation. AAFP website.

Agency for Healthcare Research and Quality. Clinician Summary. Early Imaging for Back Pain and Clinical Outcomes in Older Adults: A brief Summary of Findings and Key Points for Clinician-Patient Discussions. AHRQ Pub. No. 16-EHC010-3-EF 2016.

Chou, R. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. Feb 2009.

InformedHealth.org[Internet]. Low back pain: Learn More - Medication for the treatment of non-specific back pain. National Library of Medicine. Last Updated: Dec 2022.

Lancaster, et. al. When is Imaging Appropriate for a Patient With Low Back Pain? Ochsner J. Fall 2020.

Ravindra, V. et. al. Degenerative Lumbar Spine Disease: Estimating Global Incidence and Worldwide Volume. Global Spine J. Dec 2018.

Shokri, P., et. Al. Non-Spinal low back pain: Global epidemiology, trends and risk factors. Health Sci Rep. Sept 2023.