This is a question I get asked quite often in my clinic and not one with a simple, quick answer, so I used it as inspiration to get my blog started. The answer depends on a number of factors, of course, and while there is no doubt that there is much you can see with an MRI scan that you cannot with the naked eye (or x-ray), there is also much you can ‘feel’ (through palpation), which you cannot see with an MRI! It’s important to note here that your GP or consultant is unlikely to have the refined soft-tissue palpation skills required to feel smaller myofascial/scar tissue adhesion’s, trigger points and subtle soft tissue pathology. To be an expert at assessing these you need to be a soft-tissue (massage/bodywork) specialist, with advanced training in trigger point therapy and myofascial release.
Other, common, ‘pain-causing’ musculoskeletal issues, which don’t generally show up on an MRI scan, are better assessed by case history, orthopedic testing and movement observation (eg. fixated joints, muscle imbalances, facet joint irritation); an Osteopath, chiropractor or Physiotherapist can better assess these than an MRI. So, MRI’s are great for identifying disc & vertebral pathology, bone spurs, narrow spinal foramen etc, but what CAN’T they see?
Pain causing musculoskeletal issues, which are unlikely to show up on an MRI scan:
- Myofascial trigger points
- Myofascial tension or adhesions
- Smaller scar tissue adhesions
- Muscle imbalences
- Muscular hypertonicity or acute spasm
- Fixated facets, costovertebral and sacroileac joints.
- Facet joint irritation
…the majority of chronic (long-standing) back pain, would in fact be due to a combination of the above musculoskeletal issues, all of which would probably not show up on an MRI! So if they don’t show up the majority of pain causing back/neck issues, why have one?
Factors to consider:
Type, severity and length of pain
Dull-achey pain tends to be muscular or myofascial (soft-tissue) in origin. Not only will the likely causes of this not show up on an MRI scan, but also conventional medicine has little to offer in regards of effective treatment of soft-tissue pain (painkilling drugs to mask symptoms, ineffective injections, poor NHS access to specialist massage/bodywork treatment, & surgery not indicated). If the pain is mild to moderate, and dull-achey, I would therefore advise that there is little point in having an MRI scan. If the dull-achey pain is severe, especially if long lasting (over 1 year) it may then be worth having an MRI to see if it can shed any light on your pain, which assessment and palpation cannot. Extreme lower back stiffness and difficulty bending forwards or standing up can also indicate disc issues, so this further indicates an MRI, even with dull-achey pain.
The type of pain MRI scans are far more useful (indicated) for is neuralogical, ‘nerve root’ (or severe pain). This type of pain tends to be more acute, sharper and ‘stabbing’. Numbness, burning, electric/pins and needles indicate nerve pain and an MRI can identify causes such as disk pathology, bone or cartilage impinging nerves, larger scar tissue issues and spinal pathologies. If you have moderate to severe nerve-type neck/back pain then I would say an MRI scan would be wise. If the pain is very severe and disabling you then it might be prudent to get an MRI regardless of ‘pain type’. However, if your back/neck pain is due to an injury, an MRI is not indicated unless the severe pain persists past 2-3 months as the severe pain is likely to be due to the tissue not yet having healed fully (& resultant inflammation/muscle spasm pain).
Cost of an MRI scan
MRI scans are expensive (£200 > £700, average £350), so ‘is it worth it?’ is an important consideration, less so if the NHS or your health insurance is footing the bill. Can you afford this expense? Even if you can, you could get 7-10 treatments for this price, which might do your back/neck allot of good, perhaps fix it! If you are hoping to get an NHS referral for an MRI scan, you should also be aware your GP can no longer refer you directly for this (to save the expense of unnecessary MRI’s). GP’s have to first refer you to a consultant, it it their decision whether an MRI is an appropriate scanning technique for your back/neck. You may also be required to try a course (possibly 6 appointments?) with an NHS Physio, to try and ease/resolve your back/neck pain before they refer you to a consultant. Most of my patients report this does not help their symptoms much, but either way you will have a delay while you wait for a consultant appointment and/or have your course of physio (perhaps 2-4 months?). Going private skips much of the delay, but it will cost you! Other points to consider regarding funding a private MRI:
- Will you be gutted if they find nothing? If the MRI scan does not find the ’cause’ of your pain, will you be upset, feel like a fraud? Maybe not, now you know many issues which cause back pain wont show up on MRI.
- Will you be in the same situation as before? So finally you have your coveted diagnosis, so the doctor can fix it, right? It may well be your treatment options are similar to before, are undesirable to you, or non-NHS ‘hands on’ treatment is more effective at bringing relief.
Is the MRI discovered pathology ‘really’ the cause of my pain?
Is what they find the ‘real’ cause of your pain? MRI scans will probably find something, and one of the problems with medical scans is it can be assumed the ‘found’ issue is the cause of your back pain! But what about all the other causes of back pain the MRI cant see which we discussed earlier?
Studies on asymptomatic individuals (people without back pain) have shown high levels of disc bulges and spinal degeneration, as discussed in the following studies:
Magnetic resonance imaging of the lumbar spine in people without back pain
Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations
This means the pathology/s the MRI finds may not be the cause of your pain, but will likely be assumed as the cause, and pursued medically. An important point to note here, however, is that if your pain is obviously neorological (eg. true sciatica), and the MRI finds something pushing on the nerve corresponding with your pain pattern, it is pretty damn likely to be the main cause of your pain! Dull-achey pain is more likely to be due to musculoskeletal issues which wont show up on an MRI scan. Also, the vast majority of back pain (even neurological/disc) is due to a combination of musculoskeletal issues (9/10 times), not just the ‘1 pathology’ (eg. disc bulge, bone spur, facet joint) conventional medicine aims to identify & treat.
Likely outcome regarding treatment
Before you see your GP about back/neck pain, see a pain/orthopedic consultant or have an MRI scan, consider what treatment conventional medicine has to ‘fix’ your pain. Conventional medicine for musculoskeletal issues/pain is generally based on medication, operations, therapeutic injections and rehabilitation exercise (Physio). If these treatment options don’t seem appealing, or have proven ineffective in the past, then you really should go elsewhere for treatment as this is whats on offer! Just because the MRI has shown up something, and/or you have a diagnosis, does not mean they can fix you in other, non-medical ways…
You could be offered painkillers, anti-inflammatorys or other pain relieving medication (you don’t want long term pain medication). You might be offered a course of Physio (you tried this and it didn’t help much). You might be offered an operation (you don’t want risky, invasive, spinal surgery). You might be offered spinal injections (these didn’t work, or wore off after 3 months). You might be offered a sensory nerve block (you want they cause treated, not the nerve fried).
However, although you might not be exited with the medical treatments on offer, after your MRI results/diagnosis, this information can still be very useful for a non-medical ‘hands on’ therapists (few NHS Physios are proficient at ‘hands on’ treatment, in my opinion), to inform their treatment! I have found MRI results very useful for my treatment plans when they have identified disc issues, spondylolisthesis and severe spondylosis, for instance. I have been able to tailor more effective treatment protocols and avoid possibly aggravating techniques in my clinic.
I hope you find this blog informative and helpful in your decision as to whether have/fund an MRI, and you have a better understanding of the possible outcomes and treatment options.
Kipp Clark JACSMT
Chronic Pain Specialist 