I need an MRI!
Following on from last week’s post when I talked about the fact that most of the time you really will not benefit from having an MRI scan of your shoulder – it is a similar story when you have low back pain.
Do You Have a Disc Problem?
Probably is the answer! Back pain can range from a bit of a niggle when you make certain movements to being so agonising that you are bent over and sideways and you can hardly walk. With the latter, you can’t be blamed for thinking that something really serious must be going on to give you THAT much pain. If you manage to get into the clinic to see one of the practitioners, you are often in too much pain to be treated with a ‘crack’. If you are in a lot of pain but you don’t have any symptoms in a leg – such as tingling, numbness, cold sensation, weakness or shooting pain – you may well be in the throes of developing a disc prolapse or herniation, whereby the disc material between your vertebrae is starting to bulge or tear or herniate. Given time it could well worsen and put pressure on part of the sciatic nerve to give you sciatica WHATEVER you do or don’t do!
What Can We Do For You
Treatment will in this case be very conservative. We will examine you of course (as far as we can when you can hardly move!) to see If there ARE any symptoms in your legs that you were not aware of – such as reduced reflexes or muscle weakness or loss of sensation that you hadn’t noticed. These will further show us that you are developing a disc problem. We will also ask you about bowel and bladder function and numbness around your bottom. If you have any issues like this then you will need to be sent straight to Accident and Emergency but this is quite rare. If we do treat you it will be to try to make you feel more comfortable by maybe using some therapeutic ultrasound, gentle massage, acupuncture, mobilisation or stretching but not manipulation. Then we will watch and see what develops and then IF necessary, we will send you for an MRI. This ‘waiting and seeing’ might seem less ‘proactive’ than you would like or expect but it really IS the most current advice based on the best research available.
Why We May Not Send You For an MRI Scan
We would like you to bear in mind the following figures obtained from research published in the American Journal of Neuroradiology April 2015, 36 (4) 811-816 whereby in a literature review of Imaging Features of Spinal Degeneration in Asymptomatic Populations by W. Brinjikji, P.H. Luetmer, B. Comstock et al, 33 articles were examined in which 3110 people with no symptoms had undergone MRI scans.
The following disc problems were found in these people – none of whom were experiencing any pain. DISC DEGENERATION (Drying out of the disc so it loses its shock absorbing capability.) In 20 year olds – 37% were found to have disc degeneration rising to 96% of 80 year olds.
DISC PROTRUSION (When some of the core of the disc pushes into the surrounding layers of the disc – involving less than 25% of the disc circumference) In 20 year olds – 29% were found to have disc protrusions rising to 43% of 80 year olds.
DISC BULGE (When more than 25% of the core of the disc the disc bulges out – usually at the back and usually towards a nerve as it exits the spine – therefore potentially leading to sciatica). In 20 year olds – 30% were found to have disc bulges rising to 84% of 80 year olds.
ANNULAR FISSURES (When the disc’s outer wall tears allowing the inner core to herniate or escape the normal walls of the disc) In 20 year olds – 19% were found to have tears or fissures in the walls of the disc material rising to 29% of 80 year olds. I am giving you all of these figures to illustrate that if you have NO pain or symptoms whatsoever, you could have a disc problem – and a quite significant disc problem! But you may NEVER develop back pain, sciatica or need surgery. Imagine if we immediately sent you for an MRI because you are in a lot of pain and you then see one or several of the above disc issues on the scan. You could decide to undergo unnecessary surgery out of fear when it could settle with treatment – never to return! Throughout the world a lot of adults undergo advanced imaging to help determine the cause of their back pain. By understanding what the disc changes noted in radiology reports actually mean, which is that most of the time, you have normal changes that we see in most backs as they age, we can help to reassure you that any ‘degeneration’ you have is not necessarily something that will cause you pain and sciatica at some time in your life – in truth it may well never bother you and if you do have symptoms, they may not be due to the disc damage that you can see but to some other structure!
The conclusion from the research is that MRI findings must be interpreted in the context of a patient’s clinical condition, which must also be studied in conjunction with the findings of a physical examination and then all the findings should be put together before making a diagnosis. Degeneration on MRI is generally part of the NORMAL aging process rather than pathologic processes requiring intervention, thus you should not be worried about it and you should certainly not rush to consider surgery immediately. Low back pain has a high prevalence in industrialized countries, affecting up to two-thirds of adults at some point in their lifetime. All of these people do not continue to have pain but they DO still walk around with the disc issues that they saw on their MRI! Research shows NO association between MRI findings and clinical outcomes, which means that the worse your back looks on that MRI does NOT mean you will not respond well to our treatment.
Perhaps most important, the relationship between imaging findings and surgical outcomes has not been well established, therefore even if you are in a lot of pain, it is better to consult one of us, have a proper examination; be treated if appropriate; allow time to heal and see what happens. You may be very glad you did you did if recover within weeks with our conservative care.