The role of MRI in spinal pain remains controversial. It is certainly appropriate in cases of suspected ‘red flags’, but outside of this we should be judicious in its use.
I will often tell patients that their story and their examination is much more helpful than a scan, which is typically the least important part of the diagnostic process. We should only request it if it is likely to shape the management strategy; ‘imaging with intent’. Without appropriate context scans can ‘muddy the clinical waters’, and for some patients the results can generate more anxiety rather than reassure – the patient can’t ‘unsee their scan’.
However, we also have to be realistic. MRI will be used either appropriately or inappropriately by clinicians, or indeed patients will self-refer for MRI. This is happening more and more frequently, especially during Covid times with restricted access to musculoskeletal services.
Patients often attend physiotherapy clinics with MRI images and reports looking for advice, potentially concerned about scaremongering medical language. They will look to you as therapists for insight and guidance. You are in a key position to have an influence on a patient’s insight about their back pain and alter their trajectory in a positive sense.
I frequently get asked how I manage the scan follow up consults and handle patient questions. So, this blog sums up how I like to approach this. Some of you reading this may nod sagely, others may roll their eyes; I recognise that different clinicians have different approaches. It is certainly not ‘one size fits all’ in terms of the communication approach from patient to patient – much like rehabilitation! I do feel this is an opportunity to promote health literacy and engage the patient positively as part of a shared journey.
My take may be more applicable to patients with short term or low-level pain, or an acute flare (or indeed no symptoms by the time they see you, but are still haunted by the report and its implications!).
I am keen to point out that complex patients or those with persistent pain may find my perspective ‘reductive’. I’ll admit there is a fine line between trying to reassure and instilling confidence, and invalidating a patient’s symptoms.
Finally, I would add that it is crucial to consider the wider psychosocial influences. This blog is ‘pathoanatomically’ orientated. A holistic approach is key to optimising outcomes and the ‘complete consultation’; but we also need to be mindful of not overwhelming patients with information. Biopsychosocial prioritisation will be revealed in a thorough history and getting to know the patient and acknowledging prior experiences; understand them and adapt. It doesn’t have to be done in one session.
Without further ado – here is how I tend to communicate different scan results to patients.
Normal Scan
“This is great news – there is no evidence of damage or injury …you don’t have a ‘bad back’ – it is just unhappy at the moment. There’s no reason why we shouldn’t be able to help you get back to the sport you love & crack on with work”.
Patient – “So why am I in pain…?”
“An MRI isn’t a ‘pain scan’ – your pain can come from other structures – very often the muscle or it’s lining (fascia). We can’t see muscle pain on a scan. Joints & discs can cause discomfort / stiffness without being damaged. They are just irritable”.
“A normal scan demonstrates that your pain over the years has not represented cumulative harm or damage. Pain can become unhelpful over time & disproportionate to what is going on underneath. This should give you confidence to work through discomfort to a degree”.
Normal Age-Related Changes (NARC)
“We anticipated that the MRI would show changes that occur in lots of pain-free people fit & active in the general population. Think of them as ‘wrinkles’ – they don’t look great – but they don’t hurt”.
“When we get to 40, 50% of people have disc bulging or signs of ‘wear’. It’s common & nothing to be concerned about; your back is still stable & strong and with support we can help you move towards getting on with life as normal”.
Disc Herniation
“The MRI confirms what we discussed in the first appointment – a bulge has likely happened slowly over time – the disc isn’t weak & vulnerable and hasn’t just ‘slipped’ – it’s just got to the point where it is causing mischief & irritating the nerve next to it”.
“Most sciatic flare ups get better after 6 weeks. Don’t be afraid to keep moving – it’s safe! – you can take meds to help with this”.
“If the pain doesn’t improve and your quality of life is affected, the scan allows us to safely organise an injection to calm the nerve down, which will help you work with your physiotherapist more effectively”.
“Although very rare, a tiny proportion of people with disc bulges can experience changes in the ability to control passing urine or stool, or develop numbness around the back passage when you wipe. If you notice this, or pain in your other leg, it is important to seek urgent medical advice”.
Patient – “Does the bulge go away – surely it needs removing?”
“Sometimes big bulges shrivel up but that’s not necessary for your pain to go away. The nerve is inflamed & will settle in most cases without removing the disc or it disappearing. The nerve is rarely damaged by the bulge either, but we will keep a close eye on your pain / strength. Repeat scans are not needed to assess whether you are getting better; all we are interested in is your pain level and function”.
Modic 1 Changes
“Some feel these can suggest the disc is ‘unhappy’ – it might well explain the pain that wraps around your hips & into your buttocks… it just means we may need to pare things back a little & then build up in a graded fashion. It helps us understand that although your pain is felt in a different place, we don’t need to do extra scans of your hips or pelvis”.
Lumbar Spinal Stenosis
“Over time the joints & discs have caused some narrowing of the nerve tunnels, which is why you get aching in the legs when walking & in certain positions such as leaning back. It’s still safe to exercise but we just need to be clever in how we approach it”.
Patient – “Will an injection help?”
“Injections don’t work that well in lumbar stenosis. But it’s been shown that certain exercises & strength work can improve your pain & endurance – the aim is to tailor the exercises to your needs & give you the tools to manage your symptoms on your own”.
Spondylolisthesis
“I can see how the scan might look a bit scary – but they are surprisingly common & your back is still very stable. I have professional rugby players with these changes & it is absolutely safe for them to play high level contact sport”.
I hope this blog has helped share some insights into my approach when communicating lumbar spine MRI results to patients. Once again, I recognise that different clinicians have different approaches, and it is certainly not ‘one size fits all’ in terms of how we should communicate from patient to patient.
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