MRI Findings in Low Back Pain
Hopefully we are all familiar with the current view that most lower back pain is “non-specific” in nature. What this means is that there is no obvious finding on imaging (MRI etc) that can explain a cause of the patients pain.
But what is some of evidence base in relation to MRI findings in low back pain that support this view?
Before I present some up-to-date information I thought I would rehash some information I had covered in a previous post.
Jarvik et al (2001) conducted a longitudinal study, with 148 subjects, assessing the prevalence of MRI findings in the lumbar spine. This study was done on subjects either without current low back pain or sciatica, or who had never experienced low back pain.
What did the results show?:
- 123 subjects (83%) had moderate to severe desiccation of one or more discs.
- 95 (64%) had one or more bulging discs.
- 83 (56%) had loss of disc height.
- 48 (32%) had at least one disc protrusion.
- 9 (6%) had one or more disc extrusions.
Study Conclusions:
Many MR imaging findings have a high prevalence in subjects without low back pain. These findings are therefore of limited diagnostic use.
The less common findings of moderate or severe central stenosis, root compression, and extrusions are likely to be diagnostically and clinically relevant.
McCullough et al (2011) then took the results from Jarvik et al (2001) and compiled the following table that, over 3 years, was routinely included in some lumbar spine MR imaging reports.
The end total being that out of 237 MRI reports, 71 (30%) included the above statement (statement group) and 166 (70%) did not (non-statement group). The results were interesting, but not all that surprising:
- Patients in the statement group were significantly less likely to receive a prescription for narcotics for their symptoms than patients in the non-statement group.
- Repeat cross-sectional imaging and physical therapy referrals were also less common in the statement group than in the nonstatement group but these differences were not statistically significant.
- Rates of steroid injections, surgical consultations, and surgeries were interestingly similar between groups.
Study Conclusions:
Patients were less likely to receive narcotics prescriptions from primary care providers when epidemiologic information was included in their lumbar spine MR imaging reports.
What does the above say to me? It would suggest that even primary care providers are not necessarily aware of the lack of evidence that findings, such as that reported in Jarvik et al (2001), are common in asymptomatic patients, and normal to see on MRI.
Back on track…..what are some of the more recent studies regarding MRI findings in relation to low back pain?
Endean et al (2011) conducted a systematic review and meta-analysis to assess how confidently low back pain (LBP) could be attributed to abnormalities on MRI. The authors assessed the published data on MRI abnormalities with the data being most commonly found for the findings of disc protrusion, nerve root displacement or compression, disc degeneration, and high intensity zone.
Following statistical analysis etc the key conclusions were:
MRI findings of disc protrusion, nerve root displacement or compression, disc degeneration, and high intensity zone are all associated with LBP, but individually, none of these abnormalities provides a strong indication that LBP is attributable to underlying pathology. This limits their value in refining epidemiological case definitions for LBP.
Lets push on to the next study….
Kovacs et al (2013). The aim of this study was to assess the association between severe disc degeneration (DD) and low back pain (LBP) on MRI.
- 304 subjects, aged 35-50, were recruited in routine clinical practice across six hospitals.
- 240 cases had chronic back pain.
- 64 patients were asymptomatic subjects without any lifetime history of significant LBP.
The authors calculated figures such as “crude odds ratios” in their results (No I don’t know what they are, but probably should…) with the key conclusions from the study being:
The association between severe DD and LBP ceases to be significant when adjusted for Modic change and disc protrusion/hernia.These results do not support DD as a major cause of chronic LBP.
Two studies to go……
Berg et al (2013) conducted a cross-sectional study on candidates for lumbar disc prothesis. The purpose was to examine whether combined MRI findings were related to the degree of disability and low back pain in candidates for lumbar disc prosthesis surgery.The following procedure was followed:
- 107 subjects.
- Radiologists rated Modic changes and disc findings at L4-S1 on pre-treatment MRIs. They gave each lumbar MRI a total score (0-10). This score (for findings at L4/L5 plus L5/S1) was calculated by taking into account:
- Modic type I and/or II changes.
- A posterior high intensity zone (HIZ) in the disc.
- Dark/black nucleus pulpous signal.
- ≥40 % disc height decrease.
- The authors also analyzed the relationship of the MRI total score to the Oswestry Disability Index (ODI) and LBP intensity scores, adjusting for age, gender, body mass index, smoking, and anxiety/depression.
So to summarise……the examiners gave each subject a score of “severity” of changes on MRI and compared it to the scores on the Oswestry and reported pain intensities. The higher the total MRI score the “worse and more severe” the findings were.
What did the results show?
- The MRI total score was not related to ODI or LBP intensity.
- Results remained unchanged after adding facet arthropathy to the MRI total score and adjusting also for physical workload and physical leisure-time activity.
Study Conclusions:
The combined MRI findings were not related to the degree of disability or the intensity of LBP. These degenerative MRI findings cannot explain variation in pre-treatment disability and pain in patients with chronic LBP accepted for disc prosthesis surgery.
Modic changes are interesting. Whilst some of the information above might suggest they are not critical in imaging findings there is conflicting information in the research, and hence I think this a topic to keep an eye on. This brings me to the last study…..
Jensen et al (2012) conducted a cohort study to investigate how Modic Changes (MCs) developed over a 14-month period and if changes in the size and/or the pathological type of MCs were associated with changes in clinical symptoms. The cohort was a group of patients with persistent LBP and MCs. The authors concluded that the presence of MCs type I at both baseline and follow-up was associated with a poor outcome in patients with persistent LBP and MCs.
On a side note, for those of you wanting to know more about the different types of modic changes I would suggest this article to be a useful start point.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556462/
My Final Thoughts?
So based on the above it would appear that most common findings on MRI are, to the best of our current knowledge, nothing that we can confidently suggest might be causing the patients pain. When we combine this with the generally poor diagnostic ability of our physical “tests” for identifying a spinal structure causing pain (see this post), I think we can confidently see that most back pain patients should be classified as having “non-specific” pain. In relation to this, I like the following views by Balague et al (2012) in their recommendations for assessment of spinal pain:
Many practitioners maintain that different underlying causes (eg, facetogenic, discogenic, or sacroiliac) exist and can be identified. Evidence to suggest that the characteristics that purportedly define subgroups can be identified with good accuracy, or that a specific type of management is available for each subgroup, is insufficient.
Once serious disease has been ruled out, the next priority is to identify patients with radicular pain. All other cases are classified as non-specific and the patient should be assessed for the severity of symptoms and functional limitations, and for risk factors for chronicity.
My Final, Final Thoughts?
I still firmly believe that the general population is still lacking very little knowledge regarding the “normal” findings that their MRI might show. This isn’t helped by many of us (health professionals of all areas) not being aware of this knowledge.
If we can educate patients, and fellow health professionals, regarding the above information we are much more likely to minimise the number of patients who read words like “disc degeneration” on their MRI’s and subsequently develop issues such as fear avoidance and other psychosocial problems due to faulty beliefs such as “my back is falling apart” or “I am one more injury away from a wheelchair”.
Thanks for reading.
References:
Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91.
Berg L, Hellum C, Gjertsen Ø, Neckelmann G, Johnsen LG, Storheim K, Brox JI, Eide GE, Espeland A. Do more MRI findings imply worse disability or more intense low back pain? A cross-sectional study of candidates for lumbar disc prosthesis. Skeletal Radiol. 2013 Nov;42(11):1593-602. doi: 10.1007/s00256-013-1700-x. Epub 2013 Aug 28.
Endean A, Palmer KT, Coggon D. Potential of magnetic resonance imaging findings to refine case definition for mechanical low back pain in epidemiological tudies: a systematic review. Spine (Phila Pa 1976) 2011; 36: 160–69.
Jarvik JJ, Hollingworth W, Heagerty P, Haynor DR, Deyo RA. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine (Phila Pa 1976). 2001 May 15;26(10):1158-66.
Jensen RK, Leboeuf-Yde C, Wedderkopp N, Sorensen JS, Jensen TS, Manniche C. Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI. Eur Spine J. 2012 Nov;21(11):2271-9.
Kovacs FM, Arana E, Royuela A, Estremera A, Amengual G, Asenjo B, Sarasíbar H, Galarraga I, Alonso A, Casillas C, Muriel A, Martínez C, Abraira V. Disc degeneration and chronic low back pain: an association which becomes nonsignificant when endplate changes and disc contour are taken into account. Neuroradiology. 2013 Nov 5. [Epub ahead of print].
McCullough BJ, Johnson GR, Martin BI, Jarvik JG. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology. 2012 Mar;262(3):941-6.
About the Author: Mark Gibson
Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.Subscribe
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Nice work as always, Gibbo.
Hopefully this info can get around and help people out.
Luke.
Thanks Luke. Great work over at your blog as well. Merry Xmas to you. Must catch up in the New Year.
Excellent summary of information will be helpful while examing evidence with chronic pain patients. These stats normalize findings which often get blown out if proportion due to psychosocial issues.
Thanks Leah. Well said.
Awesome summation. I usually quote the study from 1994 that showed similar findings to Jarvik.
Thanks for the feedback Jesse. Good to see others are aware of this and passing the information around.
Thanks for participating.
Cheers
Mark
Great post, I’m absolutely in accord!
…Martin Roland and Maurits van Tulder sayd, in 1998 at Lancet:
“Radiologists must take some responsibility for the way their reports are used and interpreted. At present, reports of plain radiographs of the spine are relayed in a manner that is unintentionally damaging to patients because they promote beliefs and patterns of behaviour that contravene current guidelines on the management of back pain. We believe that radiologists should use epidemiological information, when available, for three purposes: to convey more precise and useful information when reporting plain radiographs of the spine; to reduce some of the potential harm being done by inappropriate interpretation of these reports; and to educate their users.” http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)11499-4/fulltext
What did we do to change situation, from 1998?
Hi Denis. Thanks for the comment and the link.
Unfortunately I don’t think the situation has changed from 1998, certainly not here in Australia. Routine medical imaging reports here in Australia continue to report everything that can be noted/seen without providing any information in the report regarding the epidemiology etc as you have outlined in your comment.
I would like to see all radiology reports begin to include tables such as that used by McCullough et al as outlined in my blog post above. This would no doubt begin to achieve some of the important purposes that Roland and van Tulder outlined.
How do we change it? My thoughts:
1. Educate, educate and educate some more!
2. Hope that there are radiology groups that want to take measures to implement evidence based recommendations into clinical practice.
Unfortunately my skeptical views always come out, hence I wonder if radiology groups are hesitant to do the above as the more the epidemiological information becomes known then surely the less medical imaging they would requested/referred to perform. This obviously means less money in the radiology companies bank accounts! As the McCullough study also reported, when epidemiological information was included in reports the less medication was prescribed….not good for pharmaceutical companies!
Thanks again for the comment.
Cheers
Mark
Buongiorno dall’Italia!
Your reply is very hot!
But the most important thing is that you’re propositive. How many doctors, radiologyst, pharmaceutical companies… have the same features?? I think before the bad faith of the man there is a LAZINES of thus.
Study and work, work and study… is very expensive!!
But when a men think different, many other can follow him.
You said
1. Educate, educate and educate some more!
2. Hope that there are radiology groups that want to take measures to implement evidence based recommendations into clinical practice.
I think the same, for the 1. point.
But for the 2. point I’m dubt!
So, pheraps we have to write to radiologyst groups what we think and what the Evidence say. But after we should write to many medical specialists that when they prescribe an instrumental diagnostic exam they should also indicate the diagnostic question; becouse the radiologyst in this condition are the victims of the system, always after the patients!
But we can take all this responsibility?
This is only a provocation… In Italy the situation is worse as you can imagine!!
I really like this blog!!
Exuse for my bad english!!
Denis Pennella
Thanks again Denis. I am also very much in doubt about point 2, but agree that we need to “lead the charge” and not sit back and wait for change. Indicating the diagnostic question is a great idea!
Thanks again for your participation and feedback on this blog.
Cheers
Mark
Great post! Been reading a lot about back health lately. Thanks for the info!
Take care , your new grateful follower .
I was impressed recently to find that at least 2 radiologists in our health system in Northern California, USA have been including these references from McCullough and Jarvik in their reports. I was hunting for the original articles when I found my way here. Really insightful blog! Spreading the word will take a lot of patient and persistant education. We are in the process of educating our front line docs so that their messages to patients are more aligned with the message we are trying to teach them on the chronic side of pain. Articles like the ones you cited above will be very useful. Thank you!
Hi Lindyrower,
Thanks for the comment. Really pleased to hear your experience with the radiologists you mentioned. It would be really nice to see it become a standard protocol in radiology! Unfortunately I am yet to see it here in Australia, and I agree it will take patience and persistence. Kudos to you for the education your are providing to the front line.
Thanks for the feedback regarding the blog, and my apologies for not responding sooner to your comment. Been a tad busy and the blog has suffered from a lack of attention!
Cheers
Mark
Thank you for your info. It’s so hard to find out what self help there is for people with Modic type 2.I’m a healthy 70 year old female,not overweight with continual lbp,taking Napnisan when needed. I go to exercise class twice a week,try and fit yoga in,and play the odd game of golf.should I keep active or what?I dread to think what I will be like in 10 yrs time.
Hi Helen.
Sorry for the delayed reply and sorry to hear about your ongoing pain.
I would suggest catching up with a physiotherapist who can answer your questions and provide a thorough assessment and treatment plan.
If you have seen one already with no luck, then please feel free to contact me and I can see if I can find someone to help you (assuming you aren’t able to come and see me at either of my consulting location in Perth).
Cheers
Mark
Thanks for the reblog!