Do You Need A Low Back MRI?
If you’ve been dealing with low back pain for any extended period of time, you’ve probably had someone in your life suggest an MRI. It can often feel like the right next step, “if I know what’s wrong, I can fix it, right?” The truth of this isn’t as straightforward as we would like it to be.
Words like “bulging disc” and “sciatica” can scare people (rightfully so). However, these words don’t have to be scary, and hopefully, after reading this, they will be less alarming. At the end of the day, there is a time and a place for getting imaging. However, many people who get MRIs don’t actually need them, and it can lead to unnecessary medical costs, stress, and anxiety over big medical words like “bulging discs” that are actually completely normal.
As a medical community, we “over-image.”
A study published by Emery et al. found that out of 1000 requests for an MRI of the lumbar spine, only 443 were considered medically appropriate (Emery et al. 2013). This is a problem because there is resounding research stating that the correlation between lumbar spine MRI findings and patients’ clinical symptoms is poor.
What does this mean? What your MRI says about your low back potentially isn’t why you actually have pain. In fact, a study by Brinjikji et al. (2015) found that almost one-third of 20-year-olds without low back pain show a disk protrusion on MRI. Likewise, up to 43% of people at the age of 80 show a disk herniation without low back pain.
The message? Low back pain can be tricky, and imaging may not be the best path forward. Since so many people without low back pain have disc degeneration and bulging discs, it means that just because your image says you have that, it may not be why you are in pain. You may have had that for years with no issues, and it was only caught because you had an image. We have to treat the symptoms and the person in front of us, not the image.
When Imaging Is Appropriate
Of course, there’s a time and a place for MRIs and other imaging. They are most helpful and appropriate when:
New trauma (fall, accident, etc).
Progressive weakness, numbness, or neurological symptoms.
Pain is constant, severe, and worsening despite conservative treatment.
Red flags such as fever, unexplained weight loss, or a change in bowel/bladder.
When Imaging Isn’t Always Appropriate
For most musculoskeletal or orthopedic complaints, the image doesn’t change the treatment protocol because any good therapist is going to treat the person and symptoms in front of them, not 100% what the image says.
Conditions such as bulging discs, herniations, and arthritis are normal, age-related changes and are no reason to signal the red flags. When imaging is ordered too early or too often, it can create confusion, fear, or unnecessary restrictions. One of the best things we can do for these conditions is graded exercise with load (using weights), which is what we would do with or without an image.
Treat the Person, Not the Image
An MRI only gives a tiny snapshot. It doesn’t show how you move, strength deficits, load tolerance, or your exercise programming. A thorough subjective and physical exam often provides more actionable information than an MRI alone. This can also help us understand why you have pain and help to develop a solid plan for you moving forward that is guided by function rather than fear.
Conclusion - Do I really need an MRI?
Sometimes, yes! If there are red flags, a sudden trauma, or worsening neurological symptoms, then an MRI is likely needed and appropriate. If your pain is musculoskeletal in nature, often not. Imaging won’t change the treatment, and a physical therapist is trained on if/when it is appropriate to send a patient out for imaging.
