Do you really need an MRI for your back pain?
The evidence for usefulness of scans
A turning point in understanding the value of magnetic-resonance imaging (MRI) came in 1990 when researchers (Boden and colleagues1) investigated an important question: “How do the spines of people with no symptoms of lower back pain or sciatica look on MRI?”Before then, researchers had mostly looked at scans of people who had symptoms.
What they found was surprising. The older the person, the more common it was to have spinal degeneration in the lower back. 57% of subjects over 60 years of age had abnormal scans of their lower back such as a herniated (bulging) disc or degeneration of the spine. Of the people under the age of 60, 20% showed disc herniations. Only a third of the subjects were found to have no abnormality on MRI. And these were people without any history of back pain or sciatica!
These findings were supported some 8 years later by researchers in Japan (Matsumoto and colleagues2)who looked at the MRIs of the necks of 497 people. None of these people reported ever having neck pain. The Japanese researchers found it was common to have degeneration of the neck: 86% of men over the age of 60 and 89% of women over the age of 60 showed signs of degeneration in their cervical spines. Even in those people in their 20s there was degeneration on MIR: 17% of men and 12 % of women.
How do we make sense of this information? From this and other research, it is known that degenerative changes of the spine as viewed on scans such as MRI are common, often not causing pain and are part of the normal ageing process. For this reason, osteopaths avoid routinely requesting imaging.
What is the Osteopath’s view?
In osteopathic practice, it is common for the osteopath to be presented with a white folder of X-rays and/or MRI scans, which the patient’s GP ordered for them. Osteopaths use their clinical skills and keep themselves informed of the evidence. Thus, they can decide when scans are useful and when they are not. If the patient has not already had a scan, they may not need to spend time and money getting one.
Where imaging would be useful is in situations where it would change the way the patient’s symptoms would be managed. Imaging may be useful when a patient is not recovering from acute back pain as expected or when surgery is a likely pathway. In some cases of chronic pain, imaging may be helpful. Osteopaths also may refer for further imaging when there is evidence of other contributing factors to the presentation of back or neck pain.
When is imaging not useful?
Most acute episodes of back or neck pain tend to settle within 1-2 months with skilful osteopathic management and active recovery. Evidence-based osteopathic practice guidelines do not recommend imaging as it can potentially have a twofold effect. Firstly, we now know that changes to the spine are common and may exist prior to the acute episode or injury and so are not relevant. Secondly the results could confound the recovery process potentially doing more harm than good. This is evident with chronic back pain where we now understand complex neuroplastic changes occur both in the brain and nervous system.
As always, if in doubt, have a conversation with your osteopath.
By Vincent King – Sydney Osteopath, Wholistic Medical Centre
1 Boden, S., Davis, D., Dina, T., Patronas, N. and Wiesel, S. (1990). “Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation”. The Journal of Bone & Joint Surgery, 72(3), pp.403-408.
2 Matsumoto, M., Fujimura, Y., Suzuki, N., Nishi, Y., Nakamura, M., Yabe, Y. and Shiga, H. (1998). “MRI of cervical intervertebral discs in asymptomatic subjects.” The Journal of Bone and Joint Surgery, 80(1), pp.19-24.