When is a scan indicated for back pain?

back pain scan.png

When I was younger I woke one morning with a back that was in spasm and a nerve pain running down my right leg. It was recommended to me to visit a chiropractor (and no this isn’t a stab at chiro’s). What took place over that initial session is what I came to learn as the opposite of evidential best practice. The clinician did an X-ray of my spine – pointed out my discs were bulging (which is a miracle in retrospect due to an X-rays lack of sensitivity to showing soft tissue) and that my spine was out of alignment. I couldn’t see it but I took his word for it. He stood me on two scales, one under each foot. It showed I had more weight over one leg than the other and he said this wasn’t great. He then manipulated my lumbar spine and prescribed me magnesium tablets. I was told I would need to see him 3 times a week over the next 6 weeks. Suffice to say as a young adult I was unable to afford this and I never went back. This practitioner was my first experience of a retention based healthcare model and ensured that with my own practice I would not subject people to the same experience. Let’s talk about how this process of catastrophizing a simple mechanical pain can lead to increase revenue for a health care business but does not lead to best practice outcomes for the client.

One study demonstrated that 35% of people under 40 and almost every participant (except 1) over 60 was shown to have a disc bulge or spinal stenosis and were totally asymptomatic

As I’ve mentioned in previous posts back pain is ridiculously common – affecting 84% of us at one stage in our lives[1]. In these posts we have spoken about common treatments that can waste our time and money and how we can ensure we get back to doing our everyday activities as fast as possible. Today I want to talk about scans in every form – X-Ray, MRI, and CT scans and answer the question of when are they indicated? Usually we trust our GP to do the thinking, and at the end of the day you'd think being certain about what is happening under the skin is better? Not necessarily, in fact it can cause problems and cost a fortune for the individual and our health care system. This by no means is a dig at our general practitioner friends but alas, in a big generalisation, the research and guidelines suggest we go for the scan far too early and can create a great basis to form ongoing chronic pain and barriers to recovery[2].

Let’s start with when a scan may be indicated. Keep in mind this has been shown to be only 1-2% of low back pain incidents.

  1. There has been a traumatic incident – car accident, there is suspected fracture, dislocation etc.
  2. There may be suspected pathology from ‘red flags’ that could include cancer or cauda equina syndrome
  3. Once conservative assessment by an Exercise Physiologist, Physiotherapist, Osteopath or other allied health professional has been explored thoroughly.

Red flags include;

  • A previous history of cancer
  • Night pains that are unrelenting
  • Abnormal bowel and bladder control
  • Loss of sensation in the groin area
  • Previous or related surgery to the area
  • Recent sudden loss of weight
  • Progressive loss of strength, sensation and reflex in the lower limbs

So, if you have back pain and you bent over and felt it go, you woke up and it was sore, you lifted something, or did a movement at work or playing sport – a scan isn’t going to change anything. You need conservative treatment and you need to be involved. For this non traumatic group of back pain candidates there are a few goals to achieve optimal recovery;

As your discs’ age with time we call it degeneration, if your face wrinkles with age we don’t say you’ve got a degenerative face.

1.     You need to be actively involved. Understanding what is aggravating the pain and what eases symptoms is going to be the key for beginning self-management. The practitioner can’t always be there so it is important to know how to read your symptoms and how you should respond to them. A good practitioner will be able to educate you on this once you have been assessed. We know best outcomes for back pain are best when there isn’t a dependency on someone else. It will also ensure a lower cost will be involved with treatment which is ideal. Education is key.

2.     We need to address the psychological side of back pain[3]. If someone hurts their back bending forward to pick something up, it is very common for them to develop fear avoidance of performing that movement. To promote full recovery, we need to decrease symptoms and return to our usual activities without pain and discomfort. The psychological side is the biggest hurdle for this – not the tissue damage. This is where having a scan can further slow our progress. It is common that after the age of 20 a scan will show various changes in our body. This includes degeneration of discs and cartilage, bulging of discs and narrowing of the spinal canal. It does not mean that any of these things are symptomatic. In fact one study demonstrated that 35% of people under 40 and almost every participant (except 1) over 60 was shown to have a disc bulge or spinal stenosis and were totally asymptomatic[4]. Disc bulging is normal and our spine is designed to do it to an extent. As soon as we see these reports and scans we start linking our physical pain with what we see and plastic changes on a psychological level occur. The question is, is there correlation and causation or just correlation? I once had a mentor explain it to me in this way. “As your discs’ age with time we call it degeneration, if your face wrinkles with age we don’t say you’ve got a degenerative face.” As we saw before you can have degenerative disc but no symptom, so just because you do and you have pain, doesn’t mean they are necessarily linked. A thorough subjective and physical assessment will be able to more effectively determine the causation and/or treatment strategy.

3.     Get back to movement. Use it or lose it. Bed rest is still prescribed commonly for back episodes but it couldn’t be more wrong[5]. An active approach is the best thing you can be doing. Initially you may need some guidance for this. Once your symptoms have been addressed and you feel better, getting back into exercise that you enjoy in a graded gradual plan is important. Pilates isn’t better than gym or yoga, or visa-versa -- more than anything you need to enjoy it and get back to it gradually[6]. Your treating practitioner may advise a period of specific types of corrective or symptom relieving exercises but the goal is to get you back to enjoying movement again.   

4.     Prophylaxis – We also want to ensure the likelihood the back pain returns decreases and if it does, the individual needs to be educated and have an understanding of warning signs and how to start their recovery strategy. Once again a scan does not assist with this. Ensure you discuss this after your consult with your treating practitioner because we also know that the likelihood you experience another episode of back pain in your life is highly likely[7].

In summary, there is no replacement of a thorough assessment of your body from a skilful practitioner. How your body is assessed is going to be far more effective at determining an effective treatment plan then getting scans and having any kind of bed rest[6]. If you are in pain and want to understand how you can quickly and cost effectively move forward, please get in contact with us or call your closest exercise physiologist, physiotherapist, osteopath etc. and have a chat. 

1.         Balague, F., et al., Non-specific low back pain. Lancet, 2012. 379(9814): p. 482-91.

2.         Runciman, W.B., et al., CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust, 2012. 197(2): p. 100-5.

3.         Morley, S., C. Eccleston, and A. Williams, Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 1999. 80(1-2): p. 1-13.

4.         Boden, S.D., et al., Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am, 1990. 72(3): p. 403-8.

5.         Malmivaara, A., et al., The treatment of acute low back pain--bed rest, exercises, or ordinary activity? N Engl J Med, 1995. 332(6): p. 351-5.

6.         de Jager, J.P. and M.J. Ahern, Improved evidence-based management of acute musculoskeletal pain: guidelines from the National Health and Medical Research Council are now available. Med J Aust, 2004. 181(10): p. 527-8.

7.         Carey, T.S., et al., Recurrence and care seeking after acute back pain: results of a long-term follow-up study. North Carolina Back Pain Project. Med Care, 1999. 37(2): p. 157-64.