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Once Again Research Shows MRIs Not Helpful in Understanding Low Back Pain

In March, 2013, the New Eng­land Jour­nal of Med­i­cine pub­lished the results of a Dutch study on the value of MRI in assess­ing patients with sciatica.

Sci­en­tists took MRI’s of patients with sci­at­ica and fol­lowed up with a sec­ond MRI one year later. They also charted patients’ recov­ery from back pain. Mean­while, some of the patients had under­gone disc surgery. Oth­ers hadn’t.

Those who had had surgery were less likely to have a her­ni­ated disc show up on their follow-up MRI. But the MRI pic­ture of the discs didn’t cor­re­late with free­dom from pain. After one year, those who still had a vis­i­bly her­ni­ated disc were equally likely to be pain-free.

Even if the MRI showed the disc bulging out and pinch­ing a nerve, it didn’t mean that the per­son was more likely to have pain.

Here’s a quote from study author Wilco C. Peul, MD, PhD, Depart­ment of Neu­ro­surgery, Lei­den Uni­ver­sity Med­ical Cen­ter, The Nether­lands:

In the past, we were very happy with MRI scans because we thought they had great dis­crim­i­na­tory power, but this study is telling us that we should be more care­ful about tak­ing our con­clu­sions from MRI, in rela­tion to the com­plaints of patients.”

Scar Tis­sue May Not Be Sig­nif­i­cant Either

The research also casts doubt on the sig­nif­i­cance of find­ing scar tis­sue on an MRI a year after surgery. Scar tis­sue at the sur­gi­cal site is often blamed for con­tin­u­ing pain in patients who have had unsuc­cess­ful surgery, and sec­ond surg­eries are some­times rec­om­mended to clean up the scar left from a first surgery.

But the Dutch researchers were unable to cor­re­late the pres­ence of scar tis­sue with the per­sis­tence of pain. With or with­out scar tis­sue, sub­jects were equally likely to be in pain one year later. Given the dimin­ished pos­i­tive response rate to a sec­ond surgery, this find­ing should call into ques­tion the value of a repeat surgery for those who con­tinue to have prob­lems after their first procedure.

The arti­cle was not an explicit cri­tique of the use of surgery for those with sci­atic pain. But the arti­cle fur­ther strength­ens one of the major argu­ments against the wide­spread use of disc surgery – that the MRI appear­ance of the inter­ver­te­bral disc does not cor­re­late with symptoms.

Lack of Sci­en­tific Jus­ti­fi­ca­tion for Back Surgery

The effec­tive­ness of disc surgery is scant­ily researched. There are very few (if any) truly ran­dom­ized con­trolled tri­als. That’s because to run a proper study, the researchers would have to per­form sham surgery on the con­trol group – they’d have to anes­thetize them and make some type of inci­sion to mimic the scar that would exist if true disc surgery had been per­formed. Most ethics review boards would (rightly) block this type of study from tak­ing place.

I do believe there are some sit­u­a­tions in which surgery is war­ranted. One exam­ple would be for some­one with pro­gres­sive neu­ro­log­i­cal deficit. That would mean your leg is numb (and get­ting num­ber) and you’re los­ing mus­cle power (and get­ting weaker). For­tu­nately, this is a van­ish­ingly small per­cent­age of peo­ple with back problems.

Beyond this group, there are other patients who seem to ben­e­fit from disc surgery. Good for them. I would never dis­credit the path that some­one chooses to recover health. But eval­u­at­ing the appro­pri­ate­ness of surgery in these sit­u­a­tions is extremely difficult.

On the other hand, there is a rich body of evi­dence for the effec­tive­ness of man­ual ther­apy and reha­bil­i­ta­tive exer­cise for those with low back prob­lems. Neg­a­tive side-effects are rare. In today’s world of evidence-based, cost-effective med­i­cine, these trusted meth­ods should be the first choice for those with low back pain.

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