The MRI Dilemma

I thought I had to have an MRI?

Typically, no. We have what I call an MRI dilemma. MRI is a tool, but you must correlate the MRI findings with physical exam findings. Rushing people out for MRI’s can lead to unnecessary cost and even misdiagnosis.

lumbar stenosis

Dilemma 1 – Disc herniations are seen in people without symptoms

If you did and MRI on every person in the US, you would find that over half of them have disc herniations but no pain. One study found disc herniations in 76% of the normal asymptomatic population.

Boos, Norbert, MD*,†; Rieder, Rico, MD*; Schade, Volker, Dipl Psych; Spratt, Kevin F., PhD§; Semmer, Norbert, Dipl Psych, PhD; Aebi, Max, MD

Spine: December 15, 1995 – Volume 20 – Issue 24 – p 2613-2625

Dilemma 2 – Discs often do not change on MRI after treatment 

Patient who have had an MRI and been successfully treated, sometimes ask me if we should do a follow up MRI? The short answer is no.  Erly et al studied patients with pain and disc herniation on MRI. They were treated and then follow-up MRI was performed to look for changes in the disc.  They found that in 57% of the cases, the disc herniation had reduced in size. In 39% of the cases, the size of the disc was unchanged. In 2% of the cases, the herniations increased in size.

Erly WK, Munoz D, Beaton R. Can MRI signal characteristics of lumbar disk herniations predict disk regression?. J Comput Assist Tomogr. 2006;30(3):486-489. 

Dilemma 3 – You can’t determine if surgery is necessary by the size disc 

Studies have shown there is no relationship between the herniation type, size and behavior over time with outcome. In typical patients, MRI does not appear to have measurable value in terms of planning conservative care. (1), (2)

Benson et al conclude that It is safe to adopt a ‘wait-and-watch’ policy for cases of massive disc herniation if there is any early sign of clinical improvement. Where clinical progress is evident, 83% of cases of massive disc herniation will have sustained improvement. Only 17% of cases will have recurring crises of back pain and sciatica. If there is evidence of clinical improvement, massive disc prolapses do not appear to carry a risk of major nerve damage or cauda equina syndrome. Massive disc herniations usually reduce in volume and by 6 months most are only a third of their original size. (3)

  1. Modic MT, Obuchowski NA, Ross JS, et al. Radiology Volume 237, Issue 2 Nov 1 2005
  2. Gupta A, Upadhyaya S, Yeung CM, et al. Does Size Matter? An Analysis of the Effect of Lumbar Disc Herniation Size on the Success of Nonoperative Treatment. Global Spine J. 2020;10(7):881-887. doi:10.1177/2192568219880822
  3. Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW. Conservatively treated massive prolapsed discs: a 7-year follow-up. Ann R Coll Surg Engl. 2010;92(2):147-153. doi:10.1308/003588410X12518836438840

When would you order an MRI?

If a patient is experiencing red flags such as severe or progressive neurological deficits, loss of bowel or bladder control, or suspected infection, we will request an MRI.

In the absence of red flags, the 2021 American College of Radiology does not recommend any imaging for low back pain until the patient has had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in symptoms.

We generally start with 1 month of care. If a patient is not 50% improved within 30 days, then MRI is considered.

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