The Truth About X-Rays and MRI's
Early Use of Imaging Leads to More Surgery and A Longer Recovery Time
Thanks to advances in technology, modern medicine has the capability of detecting cancer at its earliest stages, has discovered specific parts of the brain being effected by depression, and can visualize circulation in real time around injured tissues. This ability to peer into the human body with Sci-Fi like technology has saved the lives of millions.
However, if used improperly, this same technology can have negative effects, especially in the realm of orthopedic pain, such as back pain. Not because the imaging process itself is harmful, but X-ray and MRI is so sensitive and they gather so much information, we can find “bad stuff” in almost all individuals.
And this is where the problem lies.
Treatment is often based on the assumption that findings of degeneration or disc bulges on an image is directly correlated to your pain. The classic story goes something like this; an image is taken, we see the “bad” things, and some version of this conversation ensues,
“Mary, do you see these two bones here?”
“Well the space between these two bones is decreased, which means there is degeneration at this segment. This degeneration is painful but my treatment will help. Now it’s taken a long time for this degeneration to get here, so it may take a long time to treat it.”
Yes, there is degeneration at that segment. Yes, it took a long time to get here. Yes, it needs treatment or it will get worse. Yes, it may take longer than the patient would like to resolve the problem. However, as counterintuitive as it may seem, those findings gave us zero information as how to approach treatment, how long treatment should be, or if there is any correlation between those findings and their symptoms. So, in short, they were worthless.
The reason these findings are worthless is because I could bring 100 25-45 year olds off the street with NO pain, and studies suggest up to 85 of them would have similar amounts of degeneration and 50 would have disc bulges identical to the painful population. How is it these people’s expensive pictures look exactly like those pictures of people with pain, but they are not? To make a long story short, it's because the body/mind connection is complex.
For starters, degeneration is inevitable and the most commonly used imaging practices don’t show how these affected segments move during locomotion. Degeneration and disc bulges on imaging are nothing but confirmation that certain segments are being stressed more than others due to poor movement patterns. The body is overloading certain tissues because in your day to day activities you are pushing, pulling, carrying, and squatting with poor compensation patterns.
With the knowledge that most people, regardless of pain, will have these “bad” findings on x-ray or MRI, we can confidently say that assessing movement, rather than static images, will give us a much better understanding of why those tissues are being overloaded. And here is the beautiful thing, you can coach a patient into better movement, you can’t coach a patient out of degeneration. This does amazing things for the patient’s psyche, because they are empowered with the knowledge that THEY can assist in treatment by practicing the movement homework.
Clearly there are reasons for taking such images. Some of the most decorated professionals in the imaging world put together practice guidelines for when imaging is indicated. These are the reasons for getting imaging prior to conservative management.
Patient history with “red flags”
4-6 weeks of no improvement or plateau in progress with conservative treatment
Pain stared with high velocity or blunt force trauma
Severe neurologic or vascular disturbances are present
Without the above scenarios, MOST patients will get quicker results, go to surgery less often, and have decreased risk of future pain if imaging is not done prior to treatment.
Treatment options, treatment plans, restrictions, and other professional advice should never be given based on early imaging alone. So if you’ve ever been told you can’t do something because you have “bad knees” or bulging discs, you have been misled. I don’t want to give the illusion that progress is easy and fast, but know with the right coaching and guidance, you have the ability to regain ease of movement without pain. Don’t let the thought of that scary picture lull you into the misconception that you have to deal with pain the rest of your life. It’s your choice to act or not act, but better care options are out there, and you have full control of what your future will look and feel like!
For those interested in links to the research used in this blog, here are the quotes and titles/authors of the papers:
1) “Surprisingly, with respect to the presence of DDD on MRI, there was virtually no difference between the symptomatic patients and the pain-free volunteers.”
Boos N, Rieder R, et al. '95 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations.'Spine. 1995 Dec 15;20(24):2613-25
2) “Spondylosis, disc degeneration, facet degeneration or osteoarthritis are not legitimate diagnoses of the cause or source of back pain. The correlations with pain are either nil or poor.
Professor Nikolai Bogduk, MD, Multiple Volvo Award Winner ‘Evidence-Based Clinical Guidelines For The Management Of Acute Low Back Pain’ The Australasian Faculty of Musculoskeletal Medicine November 1999; Chapter 9
3) “Perhaps more worryingly while those in the no-MRI groups had a surgery rate of less than 10%, the MRI groups had surgery rates of 80-100%.”
Webster BS1, Cifuentes M. ‘Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes.’ J Occup Environ Med. 2010 Sep;52(9):900-7
4) “Although it is true that some patients with DDD do have pain, it is also true that many patients without DDD have pain. Furthermore, high percentages of the normal, pain-free population have DDD. From the peer reviewed research in this area, DDD seems to be a normal part of the aging process and not “smoking gun” evidence of a pre-existing problem.”
C J Centeno, J Fleishman. Degenerative Disc Disease and pre-existing spinal pain. Ann Rheum Dis 2003;62:371-372
5) “Radiographs not initially indicated for non specific acute, subacute, or persistent back and neck pain (no red flags)”
Diagnotic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults – An Evidence-Based Approach – Part 3: Spinal Disorders
André E Bussieres, DC, Joahn A.M. Taylor, DC,, and Cynthia Peterson, DC, RN, MMedEd