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Nine out of ten people over sixty may have this abnormality

Tracy Woolrich's picture
Low back pain

The correlation between abnormalities within the lumbar spine and low back pain can be deceiving. A bulging disc on an MRI can be seen in as many as 90% of individuals over 60 yet they may have no back pain. Should that lead to additional testing, or should we leave well enough alone?


I remember when Magnetic Resonance Imaging (MRI) became popular. What a marvel it was. Anyone that has experienced a MRI probably thinks less about the circular magnet above your body, that is strong enough to pick up a Buick, and more about the confinement and noise. You are equipped with ill equipped ear protectors and then squished into a tube. Even if you have an open MRI, what seems like never ending jungle drum banging is unnerving. Yet the images are astounding and can be lifesaving. At the same time, if they discover a benign finding, it can cause undue stress and sometimes unnecessary procedures.

In one study printed in the New England Journal of Medicine, MRI examinations were preformed on 98 people without any symptoms. There was a tremendous amount of preplanning in place to reduce bias. The scans were read independently by two different radiologists who did not know the reason for the scans nor the clinical status of the patients. In addition, abnormal MRI scans from 27 additional people with back pain were mixed in randomly along with the scans from the asymptomatic people. They described the results using common radiological terms to classify the condition of the patient’s lumbar spine. These terms included normal, bulge, protrusion and extrusion

Thirty-six percent of the asymptomatic 98 patients had normal discs. Fifty-two percent had a bulge in at least one level, twenty-seven percent had a protrusion, and one percent even had had an extrusion which is the most serious. Yet they had no reported pain.

Some of the patients had issues in more than one area. Thirty-eight percent had an abnormality involving more than one disc. The prevalence of bulges, but not of protrusions, increased with age and the finding were similar in men and women.

The conclusion of the study was that the discovery by MRI of bulges or protrusions in people with low back pain may frequently be just coincidental. So what do you do? And if you do develop a degree of low back pain as you age, do you immediately have surgery?

In 2011, there were new guidelines developed by the American College of Physicians. It suggested that imaging with X-rays, CT scans and MRIs for patients with acute low back pain is not recommended for all patients. The guidelines that were printed in the Feb. 1 issue of the Annals of Internal Medicine, suggested instead that such tests are more appropriate for people with low back pain when there is suspicion for cancer, infection or nerve damage. Also it was considered wise to test when the pain worsens despite initial treatment.

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“Unnecessary imaging exposes patients to preventable harms, may lead to additional unnecessary interventions, and results in unnecessary cost,” concludes Roger Chou, MD, of Oregon Health and Science University in Portland.


Before you insist on an MRI, perhaps it would be better to see a specialist that may be able to diagnose your back pain and treat it without the need for a MRI. According to research, seeing a back pain specialist such as a physiatrist may help reduce unnecessary tests and spinal surgeries by as much as one-third.

According to the American Academy of Physical Medicine and Rehabilitation, physiatrists are nerve, muscle, and bone experts who treat injuries or illnesses that affect how you move. They are medical doctors who specialize in physical medicine and rehabilitation (PM&R). They excel at diagnosing and treating pain and are holistic in their approach by treating the whole person and not just the symptom. Their goal is to restore maximum function and help to develop a treatment plan that helps to eradicate the issue non-surgically as well as prevent further injury.

Don’t know where to find a physiatrist? Try this link.

Take home message:
Don’t ignore any pain. This is especially true if your back pain worsens or persists despite a trial of therapy. Tell your healthcare provider of any injuries, change in pain, change in mobility or bowel/bladder function. Seek the advice of a physiatrist if there is one local to you and always keep your medical team advised as to the outcomes of any treatment plan.


Chou, R. Annals of Internal Medicine, 2011; vol 154: pp 181-189.


American Academy of Physical Medicine and Rehabilitation