X-ray, back scan, lumbar MRI: All you need to know

medical imaging to clarify the diagnosis of back pain

Article reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine 

Here is the phone conversation I had this week about medical imaging with one of my patients with lower back pain:

Patient: Anas (me, the physiotherapist), I have terrible news for you. I had a lot of back pain this weekend, in the lumbar region, and I had to go to the hospital.

Me (Anas): Really sorry to hear that! What happened exactly?

Patient: I woke up with severe back pain. It's weird because it was fine the day before! It didn't pass despite taking 2 anti-inflammatories, so I had to go to the emergency room. I had an MRI and they detected 2 herniated discs! My heart is broken. I could never play sports again. My life just changed all of a sudden! I don't know what to say, I'm so sad!

Myself: We need to talk…

Yeah, I had to talk to that patient. In person. And as soon as possible! I would like to share with you the concepts covered during this conversation… In case you find yourself in the same situation as my patient.

The limitedtes medical imaging

Let me guess. You've had back pain for a while now. At the beginning, the pains were tolerable, and passed relatively quickly with time and/or taking medication.

But as time went by, the pain appeared more frequently. In addition to being more intense, it took several weeks to recover. By consulting your doctor, he deemed it necessary to undergo medical imaging to clarify the diagnostic.

Is it a herniated disc ? Or one lumbago ? Or even worse, a cancer ? You were impatiently awaiting this medical imaging, to finally understand what was wrong with your back.

X-ray, scanner, MRI, scintigraphy, EMG, you may have had one of the following tests. The problem is that they did not necessarily provide all the answers to your questions!

But why doesn't medical imaging help me as much as I would have thought?

This is probably the question that bothers you. The first thing to understand is that medical imaging is not enough to explain the real cause of your back pain. Moreover, it may even have deleterious effects in certain specific cases. 

For example, a extensive study of people with back pain found that those who had imaging scans shortly after consultation did not recover any faster. On the contrary, some people saw their condition heal more slowly than those who applied the basic advice (i.e. staying active, taking over-the-counter medications, etc.).

A other study found that people with lower back pain who had an MRI in the first month were eight times more likely to have surgery. What's worse is that the recovery was not necessarily accelerated in comparison to those who followed a more conservative approach.

Moreover, x-rays and CT scans expose patients to potential radiation that theoretically increases cancer risk. This particularly concerns men and women of childbearing age, because irradiation of the testicles or ovaries can affect fertility.

Medical imaging and pain

It is easy to think that low back pain is due to a “mechanical” problem such as a intervertebral disc worn out, a torn ligament, or a vertebrate damaged (and not moved as we tried to make you believe!). 

Unfortunately, this is far from the case!

Why ? Because it has been noticed that some people have problems on the MRI (such as herniated discs ou degenerative disc disease) without experiencing any pain. Surprisingly, other people had “normal” MRIs and x-rays but suffered a lot!

I will repeat myself at the risk of boring you.

Some people have NO pain but full of findings on medical imaging, while others suffer martyrdom when their MRI / scanner or other indicates absolutely nothing abnormal! Yes yes, you read that right! But why, you ask me?

that imagery medical cannot detect

The answer is complex and depends on the person. Just remember that pain is multifactorial, especially when it's chronic. And above all, the influence of the central nervous system (ie. your brain) is decisive in modulating the intensity of the pain felt.

In addition to mechanical factors, back pain is modulated by other factors such as your anxiety, your family and/or professional situation, etc. This may sound strange to you, but I'm sure your back pain may increase after a hard day's work.

This is also the reason why it is necessary to take into consideration the factors emotional, psychological and cognitive when dealing with back problems (and not just mechanical factors).

And that, no medical imaging can explain.

When to have recourse to medical imaging?

Well, I must admit that until now I have held a rather pessimistic speech in connection with medical imaging. I may be exaggerating a little, but it is clear that X-rays, CT scans and others are sometimes prescribed excessively, and without valid reasons.

Medical imaging definitely has its place to play in the treatment of low back pain. For example, here are some situations where it makes sense to use imagery:

  • To eliminate a serious harm for the spine (like a tumor, a infection or an fracture).
  • When the pain is refractory and unresponsive to conservative treatment.
  • When the symptoms radiate into the leg or arm, and are accompanied by paresthesias.
  • To serve as a comparison with an imaging test taken previously.
  • To serve as a guide during a back infiltration.
  • To prepare for a possible surgery.
  • When symptoms persist despite surgery.

The medical imaging contraindications

Before concluding, it is appropriate to present the contexts where medical imaging would be contraindicated. Indeed, if you find yourself in one of the following situations, the doctor may prefer to avoid using imaging (especially for MRI):

  • You have a pacemaker, defibrillator, etc.
  • You have a foreign body of a metallic nature in the eye
  • You have a cochlear implant
  • You use an insulin pump
  • You suffer from severe claustrophobia (in these cases, Open field MRI can help)
  • If you have metallic devices in the spine (such as screws, cages, etc.), MRI is permitted but the resolution of the exam will be affected.
  • It is important to remove any jewelry before the procedure

Conclusion

Remember this: Medical imaging will not help you heal faster. And will not always help you clarify the diagnosis. These exams can even cause stress for some patients, and confusion for others. 

Medical imaging definitely has its place to play in the treatment of low back pain. On the other hand, it must be used in a specific context, and not automatically after an episode of low back pain.

Remember that this is a static test where it is impossible to observe the dynamic movements of your spine. For this reason, your health professional will weigh the pros and cons, and will be able to tell you whether it is better to have any test.

He will also know how to reassure you when you show him your imaging report filled with complex and potentially frightening terms!

Good recovery!

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References

  • https://www.jospt.org/doi/10.2519/jospt.2011.3618
  • https://www.spineuniverse.com/exams-tests/do-really-need-ray-or-mri-lower-back-pain
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