Having pain can be frightening, but there is something specifically about having BACK pain which really makes people anxious. This is probably due to the fact that people with back pain are often told that ” their spine is crumbling” or their disc has “slipped out of place” or their spine is ” out of alignment” (none of which can be true of course)
Patients with back pain often want a diagnosis and specifically request MRI scans as they show detailed images of the spine and surrounding tissue. Recently however, there is growing evidence that MRI’s can not only be a waste of time, money and resources, but can also lead to worse patient outcomes.
There are a variety of reasons for this. We know that MANY people have evidence of degenerative changes on MRI but have no pain at all. This fantastic article published very recently shows that 87% of people who had no back pain at all had abnormal findings on MRI. Most of these patients had “slipped discs” better known disc bulges. Another major review done in 2014 (Brinjikji et el) concluded that “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain” As an example, just like our skin wrinkles as we get older, so does our spine undergo normal age related changes.
Now imagine this scenario. Mr Jones comes to the doctor with a 3 week history of low back pain (which may be the result of a simple muscle spasm) and asks for a scan. A scan is performed and lo and behold, Mr Jones has 3 levels of disc bulges seen on his MRI. Mr Jones and his doctor blame the disc prolapses for his back pain! Mr Jones doctor may even suggest surgery. Mr Jones has heard that slipped discs are a serious matter and realizes that his situation is very very bad. He stops doing anything that remotely hurts. Everytime he feels pain he pictures his discs slipping out and he feels very stressed. This stress causes his muscles to go into more spasm and his pain worsens. Mr Jones is now in a vicious cycle of fear, avoidance, stress and pain. Its no wonder why his pain levels are not improving. This common scenario shows how MRI scans can have a nocebo affect (the opposite of placebo) and have a detrimental effect on a patients condition
Most people who have back pain should NOT have an MRI scan. In fact most cases of back pain will clear on their own with the right advice . Even if your back is very very painful, this is still not an indicator for having an MRI. Pain intensity is often a poor indicator of pathology, a complicated topic which will be discussed another time.
There are some rare cases of back pain which definitely do need an MRI to help with diagnosis. One example is something called Cauda Equina syndrome. The symptoms of which are sudden unexplained incontinence with numbness around the groin and buttocks area. This requires immediate surgery and is a medical emergency
Another scenario where an MRI may be considered is someone involved in a major accident where a spinal fracture may be a concern (often an Xray is done first).
One last scenario where an MRI may be considered is someone who has unremitting constant high levels of pain. In this scenario the level of pain does not vary in intensity with movement or rest and it may be worsening
In conclusion, although MRI is a highly sensitive diagnostic tool, it is also highly unspecific and its results are often poorly correlated with a patient’s symptoms. MRI’s can also make pain worse by instilling fear and anxiety in patients who conclude that the cause of their pain is what is seen in their scan.
What other options exist that may help improve my back pain
1) Stay active: Many years ago it doctors advocated bed rest for back pain, but we now know that this is not the right treatment. It is very important to stay active. You may want to reduce your activity levels for a few days and then gradually build them up when you are feeling better
2) Get your back moving: It is recommended to gently move your back and not to keep it still. Moving your back may hurt however, it is important to note that just because you feel pain it does not mean that you are damaging your back. Pain and damage are not the same thing and hurt does not equal harm.
3) Don’t panic: Remember that back pain is very common and most cases will improve with time. Even if back pain persists for longer than a few weeks – this does necessarily mean that something serious is going on. Your thoughts and beliefs about what is going on in your back has been shown to affect your pain levels. Stress and anxiety can increase pain levels.
4) Medication: Don’t be afraid to take pain relief especially if it helps you to keep active
5) Physiotherapy, osteopathy and other health care experts offer various techniques that in conjunction with specific exercise and advice can help improve your back pain
6) Hot and cold packs may be useful. Try both and see what works better for you
7) Diagnosis is not important when it comes to back pain. Most back pain is nowadays classified as “non-specific low back pain” which means that the exact cause is not clear
8) Find a balance: Don’t overdo it but also try to avoid long periods of inactivity
9) Try not to take too much time off of work. Keeping your mind active will help you not focus to much on your back pain
10) Relaxation and Meditation can reduce muscle tension and may improve your levels of pain
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