What MRI can't tell you about your back pain

Who doesn’t know Miss Ruth?

At 86, she’s the reassuring voice that’s coaxed generations of Westlake toddlers to jump into the water. Recently, Ruth's sciatica acted up again. The pain starts at her buttock and radiates to her ankle. It’s been months. When she wakes up, the pain could make her cry. There’s no rhyme or reason to how the pain catches during the day.

And this pain has landed her in a crossfire between specialists.

To start, her back MRI shows four levels of herniated discs among other unpronounceable, multi-syllabic findings. Her neurosurgeon offers surgery; her cardiologist says nobody pokes her because the drug she takes for an irregular heart rhythm may put her at an increased risk of bleeding.

She’s tripping over these MRI findings.

While I can’t (and shouldn’t) help with her decision making, I reassure her – the MRI findings needn’t be on her worry list.

The thing about MRI: It shows problems – almost always there are problems – but not necessarily problems in need of a solution.

A 2014 study published in the journal Spine, which looked at spine CT and MRI of 3,110 people who had no back pain (who are these freakishly lucky people, anyway?), found that by age 20, over one-third have evidence of degenerative disc disease; by age 80, the rate is 96 percent. 

As doctors dig more and more into pain, we understand less and less. What’s clear: pain is more than what’s visible on MRI: the multi-level disc herniation, bone spurs, pinched nerves, calcified tendons, cracks or fissures – the results of usual wear and tear and the body’s compensation and overcompensation for stress.

Pain is also what’s not visible on MRI: posture and back mechanics, genetic predisposition, old and new injuries, inflammation, occupational stress, mental stress, weight gain or loss, and physical conditioning. 

It follows that we have a hard time validating pain solely based on MRI findings; that is, people can have awful pain with relatively normal-looking MRI or no pain with awful-looking MRI. Approaching back pain based on MRI findings is like diagnosing an elephant by its trunk. Yes it helps to put a name to it, but there’s still the rest of the flapping-ear mammoth to deal with.

The good news: most sciatica resolves within one year. Intervention or no intervention, the long-term prognosis is similar.  

While contemplating her options, Miss Ruth stays active.

It’s 9 o’clock, she’s about to start her first swim lesson. Three times a week, she teaches for four hours straight, and, curiously, during those four hours, she’s completely pain-free. Kids in shark-print shorts and tutu swimsuits form a loose circle around her. It’s been over 12 years since I sat and watched my own kids. It brings back such memories. One kid refuses to get in the water, about to start a nifty little nuclear tantrum. I look on fondly, thinking, “Thank God, for once, this one’s not mine!”  

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Volume 9, Issue 7, Posted 9:20 AM, 04.04.2017