Low Back Imaging: What It Doesn’t Tell Us

Almost everyone owns a car. They have either bought one new, used, salvaged, or they have leased one, borrowed their parent’s, their friend’s or hitched a ride in one. Almost everyone on this earth with the ability to tie their shoes has an idea of the concept of a car. We can assume that everyone has had to deal with at one time or another needing to have their car fixed/worked on/taken to the mechanic. There is a funny creaking noise, a banging noise, a rumbling feeling, or if you’re really unlucky, smoke or some foreign matter leaking from some place that it wasn’t before. Due to the commonality of this occurring in our culture, there is a comparison between our own bodies and these machines, or any machines, in that 1) when something is wrong, we will feel, see, or hear it and 2) once the source of those symptoms are found, replacing the source will fix the problem. It just makes sense, right?

What ends up happening is that due to this seemingly easy connection between symptoms and our ideas of machines, people tend to go to see their primary care manager, be it a physician, chiropractor, physical therapist or their copy of “Becoming a Supple Leopard”, and they look for sources of symptoms and ways to “fix” said symptoms. The issue furthers itself when primary care managers that are just trying to provide the best care for their patients give them a specific answer that may or may not be helpful or accurate. If you read the previous two articles, “Nocebo Effect Vs. Placebo Effect: Language Can Affect Outcomes“ and “Shoulder Pain: A New Outlook On Treating Impingement”, you can see how this leads down a path that is often hard to backtrack from.

Back Pain (Or Lack of) And Structural Abnormalities

The spine is an often demonized structure in the human body due to the prevalence of low back pain in the world, coming in at a considerable 7.3% (540 million people) of the world population having activity limiting low back pain at one time in their life(?)¹. There have been many conflations of low back pain with structural changes such as facet joint degeneration (degenerative changes of small spinal joints), disc herniations, stenosis (narrowing of the certain spaces within the spine), disc narrowing, sciatica, and arthritis, to name a few. If we can take one step deeper into this thought, we should be able to say that anyone with these changes should have low back pain, considering that these changes that are bringing the spine away from “normal” are what is causing the pain. The problem with this thought process comes when we take images (MRI, X-Ray, CT Scan) of people who show these types of structural changes and they have no symptoms at all. 

One of the more notable studies done on this topic is done by Brinjikji et al in 2015² where they looked at 33 articles across 3110 patients that had either an MR or a CT scan showing structural change and were asymptomatic for low back pain. 

“The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.”²

Age-specific prevalence estimates of degenerative spine imaging findings in asymptomatic patients

Here we can see a very decent number of people with a large range of structural abnormalities within their low backs that had no symptoms whatsoever. The authors go on to conclude that “Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient’s clinical condition.”² We can also see in the chart above that as people age, the prevalence of spine degeneration gets higher, despite the patient still being asymptomatic.

Along similar lines, Eno et al in 2015 found that “sacroiliac joint degeneration was highly prevalent in the asymptomatic population and is associated with age”, and that “caution must be exercised when attributing lower back or pelvic girdle pain to sacroiliac joint degeneration seen on imaging.”³ 

These studies exist for the knee⁴, the hips⁵, facet joints⁶ and the shoulder⁷. As you can see there is a significant amount of research with a large number of participants that are having no pain but still have degenerative, or as we should be referring to them, age-related changes. 

Treating Back Pain

These changes, if represented inappropriately⁸, can be costly to the patient’s sense of resilience and can lead to increased disability, decreased quality of life, and decreased activity levels. If represented appropriately, symptoms that spur patients to seek help can be managed with slight modifications in training or in movements valuable to the patient and training can stay close to or on track for a short period of time until symptoms lessen. The period of uncertainty between initial report of symptoms and return to sport can either be a harsh time of fear, catastrophizing and detraining if not managed appropriately, or it can be a chance for the coach/provider to build resilience in a client/patient, to teach them a lesson on training through pain and overcoming obstacles and how to manage future symptoms on their own. 

If you are in a period of uncertainty yourself and are looking for appropriate management of symptoms so you too can learn these helpful tactics, reach out so we can help.

References

1. Hartvigsen J, Hancock MJ, Kongstead A et al. What low back pain is and why we need to pay attention. The Lancet 2018; 391: 2356–67 
2. Brinjikji W,  Luetmer PH, Comstock B et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015 April ; 36(4): 811–816. doi:10.3174/ajnr.A4173.
3. Eno JJ, Boone CR, Bellino MJ et al. The Prevalence of Sacroiliac Joint Degeneration in Asymptomatic Adults.J Bone Joint Surg Am. 2015;97:932-6 d http://dx.doi.org/10.2106/JBJS.N.01101 
4. Culvenor AG, et al. Br J Sports Med 2019;53:1268–1278. doi:10.1136/bjsports-2018-099257
5. Kim C, Linsenmeyer KD, Vlad S et al. Prevalence of Radiographic and Symptomatic Hip Osteoarthritis in an urban US Community: the Framingham Osteoarthritis Study. Arthritis Rheumatol. 2014 November ; 66(11): 3013–3017. doi:10.1002/art.38795. 
6. Kalichman L, Li L, Kim D et al. Facet joint osteoarthritis and low back pain in the community- based population. Spine (Phila Pa 1976). 2008 November 1; 33(23): 2560–2565. doi:10.1097/BRS.0b013e318184ef95.
7. Teunis T, Lubberts B, Reilly BT et al. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg (2014) 23, 1913-1921
8. Darlow B, Dowell A, Baxter D et al. The Enduring Impact of What Clinicians Say to People With Low Back Pain. ANNALS OF FAMILY MEDICINE. WWW.ANNFAMMED.ORG. VOL. 11, NO. 6. NOVEMBER/DECEMBER 2013