When low back pain strikes, it is natural to want a clear explanation for the discomfort. Patients often arrive at a clinical assessment asking for a referral for an MRI or X-ray, believing that a picture will provide the 'fix' they need. While imaging is a valuable diagnostic tool in specific circumstances, evidence-based guidelines consistently suggest that for the majority of people, routine imaging for low back pain is not only unnecessary but can sometimes be counterproductive.
What is Imaging Used For?
Medical imaging, including X-rays, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI), allows clinicians to see the internal structures of the body. In the context of the spine, X-rays are typically used to look at bone health, fractures, or significant structural changes like advanced osteoarthritis. MRIs provide a more detailed look at soft tissues, such as intervertebral discs, nerves, and ligaments. While these tools provide high-resolution data, they do not always explain the 'why' behind a patient's pain. Pain is a complex experience influenced by biological, psychological, and social factors; a static image cannot capture the dynamic nature of how a person moves or how their nervous system processes discomfort.
What Current Evidence Says About Routine Imaging
Major health organizations, including Choosing Wisely Canada, emphasize that most people with low back pain do not need an MRI or X-ray (Choosing Wisely Canada, 2022). Research has shown that early imaging for non-specific low back pain (pain not caused by a serious underlying condition) does not lead to faster recovery or better long-term outcomes. In fact, a landmark systematic review published in the Annals of Internal Medicine found that patients who received routine imaging for low back pain did not experience less pain or better function than those who received conservative care without imaging (Chou et al., 2009).
One reason for this is the high prevalence of 'abnormal' findings in people who have no pain at all. A systematic review of imaging features in asymptomatic populations found that disc bulges were present in 30% of 20-year-olds and 80% of 80-year-olds who had no back symptoms (Brinjikji et al., 2015). This suggests that findings like 'disc degeneration' or 'bulging discs' are often normal age-related changes, much like wrinkles on the skin or grey hair, and may not be the actual source of a patient's current episode of pain.
Contributing Factors to Low Back Pain
Low back pain is rarely caused by a single 'broken' part. Instead, it is often a combination of factors that sensitize the tissues in the low back. These can include:
Physical Factors: Sudden increases in activity levels, lack of movement variety, or prolonged postures that exceed the body's current tolerance. *
Lifestyle Factors: Poor sleep quality, high stress levels, and smoking can all influence how the body perceives and recovers from pain. *
Psychological Factors: Fear of movement (kinesiopathey) or 'catastrophizing' (focusing on the worst possible outcome) can actually amplify the pain signal sent to the brain.
Understanding these factors is why a clinical assessment is often more valuable than a scan. An assessment looks at the whole person, whereas a scan only looks at the anatomy.
What a Clinical Assessment at Union Health Network Includes
At our clinic in Richmond Hill, an assessment for low back pain and sciatica begins with a thorough clinical history. Dr. Shahab Entezami and our team focus on understanding the onset of your symptoms, your activity levels, and your personal goals for recovery.
The physical portion of the assessment typically includes:
Neurological Screening: Testing reflexes, muscle strength, and sensation to ensure the nerves are functioning correctly. 2.
Movement Analysis: Observing how you bend, twist, and move to identify patterns that might be contributing to your discomfort. 3.
Special Orthopedic Tests: Manual tests designed to provoke or relieve symptoms, helping to clarify the nature of the issue. 4.
Triage: Identifying any 'red flags' that would indicate a need for immediate medical referral or imaging.
Conservative Management Options
Once a diagnosis is established, the focus shifts to conservative management. The goal is to reduce sensitivity, improve function, and build resilience. Treatment may include:
Patient Education: Helping you understand the nature of your pain to reduce anxiety and improve self-efficacy. *
Structured Exercise: Gradually reintroducing movements that help the back become stronger and more flexible. *
Manual Therapy: Joint mobilizations or soft tissue work to help improve range of motion and decrease localized sensitivity. *
Acupuncture: Some patients find that neuro-functional acupuncture helps in managing the neurological aspects of back and leg pain.
Self-Management and Staying Active
One of the most evidence-based pieces of advice for low back pain is to stay active. While it may feel intuitive to rest until the pain is gone, prolonged bed rest is generally discouraged. Light walking, swimming, or gentle mobility work—even if there is some mild discomfort—is often better for recovery than total inactivity. Additionally, optimizing your environment, such as following ergonomic workstation strategies, can help manage strain during the workday.
When is Imaging or Medical Referral Appropriate?
While most low back pain resolves with conservative care, imaging or medical referral is necessary when specific 'red flags' are present. These signs may indicate serious underlying conditions like infection, fracture, or significant nerve compression. Referral to a physician or emergency services is appropriate if you experience:
Sudden, unexplained weight loss. *
History of cancer. *
Fever or chills accompanying back pain. *
Changes in bowel or bladder control (e.g., incontinence or inability to go). *
Numbness in the 'saddle' area (groin/inner thighs). *
Progressive weakness in the legs that makes walking difficult.
Frequently Asked Questions
If my MRI shows a disc bulge, do I need surgery? In the vast majority of cases, no. Many disc bulges naturally resorb over time, and most people can successfully manage their symptoms through conservative care and exercise without ever needing surgical intervention.
Can a chiropractor order an MRI in Ontario? In Ontario, chiropractors do not have the authority to order MRIs directly under the current provincial health framework; this must be done by a physician or nurse practitioner. However, chiropractors are trained to perform the clinical assessments required to determine if an MRI is medically necessary and can communicate these findings to your primary care provider.
Why does my back hurt so much if the MRI is normal? Pain is not always correlated with structural damage. You can have significant pain with a 'normal' MRI because the scan cannot see inflammation, nerve sensitivity, or the way your muscles are bracing. Conversely, you can have a 'messy' MRI with no pain at all.
References
- Choosing Wisely Canada. "Low Back Pain: When you need X-rays, MRIs, or CT scans—and when you don’t." Choosing Wisely Canada, 2022. [https://choosingwiselycanada.org/low-back-pain/]
- Chou, R., et al. "Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians." Annals of Internal Medicine, 2009. [https://pubmed.ncbi.nlm.nih.gov/21282698/]
- Brinjikji, W., et al. "Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations." AJNR American Journal of Neuroradiology, 2015. [https://pubmed.ncbi.nlm.nih.gov/25430861/]
If jaw, back or joint symptoms are affecting your daily activities, a clinical assessment may help clarify the possible contributing factors and appropriate care options. Union Health Network is accepting new patients in Richmond Hill.