When we say “back pain,” what we’re really talking about—unless otherwise specified—is low back pain. The two main types are acute and chronic:
Acute back pain occurs as an isolated episode, usually lasting less than a few weeks. It is often (but not always) relatively intense and can make normal activities (driving a car, going to work, walking, standing and so on) unpleasant or difficult, if not impossible. Some people will have only one episode of acute back pain in their life, whereas others may have repeated episodes, with long or short pain-free periods in between.
Chronic back pain is persistent and lasts for longer than three months—sometimes for years. Symptoms may ease during periods of rest, but the problem never seems to go away completely and is often quick to flare up under certain conditions. The intensity of the pain can wax and wane over time and can range from mild, nagging discomfort to debilitating agony.
However, whether your pain is acute or chronic, be clear about one thing: Back pain is not, unto itself, a diagnosis. It is a symptom of some underlying problem. Discovering the nature of the underlying problem can be an important first step to getting effective treatment and, ultimately, relief.
Although an MRI scan can be useful in identifying abnormalities that may be the cause of back pain, the most recent guidelines on low back pain from the American College of Physicians and the American Pain Society emphasize the importance of talking to and examining the person with back pain rather than relying on imaging tests. Your doctor will also make note of any signs of emotional distress, such as depression, that you may be experiencing. That’s because people who are depressed or unhappy with their job are less likely to recover from back pain.
Getting the right diagnosis: A challenge
With back pain, obtaining the proper diagnosis can be notoriously difficult and elusive. Why? Because we do not understand the reason—or reasons—for back pain in most people. Furthermore, disruptions in normal function elsewhere in the body, including the bones and ligaments of the pelvis, and muscles in the legs, buttocks, trunk and shoulders, can affect how the spine moves and functions. So many different and interrelated variables are in play that pinpointing a single, cut-and-dried cause for back pain can all too often be an exasperating challenge. Unless one of the medical or surgical conditions mentioned above is identified, it may not be possible to do so—resulting in the ever-so-common diagnosis of “nonspecific back pain.”
The imaging tools that are sometimes used to evaluate back pain require the person to remain motionless. But the spine is a moving, changing, dynamic structure. Observing the body in motion would serve as a valuable piece of the puzzle in determining what’s wrong, but such imaging technology is generally not available.
Another problem with getting a clear diagnosis is the tendency to rely too much on imaging technology. A primary care doctor may refer you to a physical therapist to “evaluate and treat” nonspecific back pain, but if standard therapeutic measures don’t help, the next step frequently involves ordering an MRI scan, often done in conjunction with an evaluation by a specialist.
The Problem with MRIs
Although excellent for confirming certain diagnoses, MRIs of the spine yield far too many “false-positive” results to be considered a good screening test. That is, the scans often reveal an abnormality that’s assumed to be the underlying cause of back pain—yet may not be the cause. Studies have shown that, according to MRI records, the vast majority of asymptomatic (pain-free) adults have spinal abnormalities such as a bulging or herniated intervertebral disc.
If a bulging disc doesn’t cause problems in the majority of asymptomatic people, it’s possible that someone with symptoms who also happens to have a bulging disc is experiencing pain caused by another (often less obvious) cause—potentially a cause that is not even detectable on an MRI. Yet it’s only natural for the doctors involved to assume that any abnormality visible on an MRI must be the source of the pain.
Depending on the presumptive cause, the person may be advised to undergo back surgery. The statistics on surgical outcomes, however, tell a cautionary tale: Fewer than half of all people who undergo back surgery report “excellent” or even “good” results in terms of pain relief, improved mobility and reduction in their need for pain-relieving drugs. In other words, a significant number of back surgeries—which are risky and expensive—do little if anything to help in the long run. In some cases, it would seem, the procedure may be correcting a “problem” that is unrelated or incidental to the root cause of the person’s symptoms.
It’s no surprise then that clinical guidelines from the American College of Physicians declare that MRI scans are unnecessary in most cases of low back pain. They may, in fact, do more harm than good, as they may lead to expensive or even injurious treatments that have no benefit.
Unfortunately, a 2011 study published in Health Services Research showed that when doctors own or lease their own MRI equipment, they are significantly more likely to order MRI scans for their patients with low back pain. According to the study, which involved more than 2,300 people, the rate of ordering an MRI increased by 13 percent for orthopedists’ patients and 32 percent for patients of primary care doctors who owned or leased MRI equipment, compared with those who didn’t. Furthermore, people who visited an orthopedist who had an MRI machine were 34 percent more likely to undergo back surgery within six months.
Financial incentives “seem to have an influence on physician behavior that we can’t ignore, and an impact on patient care in the long run,” concluded the study’s lead author, Jacqueline Baras Shreibati, M.D., of Stanford University School of Medicine. The study reiterated previous research findings indicating that there is no definitive evidence that either MRI or surgery for low back pain actually improves people’s outcomes.
The bottom line:If your doctor recommends an MRI and/or back surgery, be sure to get a second opinion before you proceed—ideally from a doctor who stands to gain nothing from either procedure. As suggested by the clinical guidelines from the American College of Physicians, the most crucial part of the diagnostic process, initially, is a thorough and detailed patient history and physical examination. Insisting on an MRI or other diagnostic scan may be tempting to you—but don’t push for one unless it appears to be absolutely necessary. You could be saving yourself a lot of time, money and needless suffering.
Guidelines: diagnosis and treatment of low back pain
The following is a summary of clinical guidelines from the American College of Physicians and the American Pain Society, published in the Annals of Internal Medicine.
- First and foremost, doctors should obtain diagnostic information by conducting a focused patient history and physical examination. Patients can be grouped into one of three broad categories: (1) those with nonspecific low back pain; (2) those with back pain associated with radiculopathy (pain radiating from a compressed nerve root) or spinal stenosis; (3) those with pain associated with some other spinal problem.
- Doctors should not order imaging tests (such as MRIs, X-rays and CT [computed tomography] scans) or other diagnostic tests for people with nonspecific low back pain.
- Doctors should order imaging tests only when pain is severe and there is evidence of progressive neurological impairment or when serious underlying conditions are suspected on the basis of patient history and physical exam.
- MRI or CT scans are appropriate for patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis, and only if they are potential candidates for surgery or spinal steroid injection.
- Doctors should provide patients with reliable, evidence-based information on low back pain, advise them to remain active and provide information about self-care options.
- Doctors are advised to advocate the use of medications with proven benefits in conjunction with back care information and self-care. Doctors should assess the severity of the patient’s pain and functional impairment, and then weigh the potential risks, benefits and relative lack of long-term efficacy and safety data before initiating therapy. Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are an advisable first line of therapy for most patients.
- When patients do not improve with self-care measures, doctors should consider nondrug, nonsurgical options with proven benefits. For acute low back pain: spinal manipulation. For chronic or subacute low back pain: intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy or progressive relaxation.