Do You Need Imaging For Lower Back Pain Or Sciatica?

Issue 34

When you have any problem in life, what’s the first thing that you want to do, if it’s a broken sink, a damaged chair, even if it’s raining outside, you go and have a look at the problem. Seeing the issue, specifically gives you the opportunity to better understand what the best course of action is, especially if you are the one who has to fix it. For example, even for  something as mundane as checking the rain outside, seeing the status quo allows you to either, just go outside because it’s just spitting, or, call the venture off because it’s a torrential downpour.

Sometimes our ability to know something comes into question, when it comes to a back injury or sciatica, it can be difficult to “see the issue”, and even if we could see the issue, we require an expert to be able to interpret what it all means. Let’s face it MRI’s and X-ray’s of the spine may as well be abstract paintings on the wall in an art gallery, it’s just a mix of colours that, to the untrained eye, often means little. Having someone who knows what they’re looking at to interpret what’s going on and make it actionable in plain language is vital.

Now more than ever, especially in the UK, we’re being told that you don’t need imaging to fix lower back pain, and there is some truth to that, but to state that imaging has no value whatsoever, is to miss the point entirely. Hopefully in today’s issue, we can give you a fresh perspective so you can draw your own conclusions. 

As opposed to the usual, “you don’t need images and that’s that, it’s just muscle spasm!” that you’ll hear from the various professionals. Only to find 6 months later when you end up getting the MRI, a rather awkward conversation awaits about the disc bulge that’s been there the whole time at L4/5…

Why you keep hearing that you don’t need imaging for your lower back pain or sciatica

This idea comes, in my opinion, from 2 main sources and perhaps a third lesser source. Firstly, imaging costs money, and quite frankly, there is the feeling that if we can get by without it, all the better. Yes, that is very cynical, but it seems to be the case, even if it is not stated outwardly by the individual practitioner, the system here in the UK seems to be set up with that ethos in mind. At the same time, we would typically spend a 45 to 60 minute appointment in the clinic or virtually, going through the scans, and the implications. Do you really think you’ll get that kind of appointment from the NHS?

That’s not a reflection on the individual doctors, nurses and other medical staff within the system, it is a criticism of the system and its suitability to provide what’s required. We can live in fairyland or we can accept the reality that the system is not capable of serving patients in the best way for many conditions that are not immediately life threatening.

Secondly, research is frequently quoted, whereby pain free people were scanned using MRI’s. Researchers found numerous issues that people were walking around with, without pain, disc injuries, rotator cuff tears, bad knees, hip arthritis, the list goes on. This is used as justification in many cases to say essentially, there are lots of people with disc bulges that have no pain, and seems a way of dismissing the issue. Just like there are lots of people driving around with car tyres that are illegally bald, brake pads worn out it’s not a problem. At least it’s not a problem at the time, it might be if you need to break suddenly to avoid a crash. 

When tested, the compromised structure is more likely to fail than the one intact. 

This is a very short sighted way of looking at things, ultimately we have a structure in the back, and the absence of pain is not an indication that everything is perfect. Many with back pain injuries will move into a pain free recovery period where they’re still vulnerable but healing, this does not mean everything is fixed yet. Another example is in the many serious conditions that affect us originally showing without pain or much in the way of symptoms. 

It is not a problem… until it is.

The third reason is a little more subconscious. Many practitioners do not routinely look at the images, and when they do have images sent for, they frequently read from a written MRI or X-Ray report. In the event they are actually going through the images, they simply lack the experience through lack of frequent practice to make best use of the rich source of data available. To be fair to the competent practitioner too, clinically it is very often the case that you know pretty much what region or tissues are injured if you have a good understanding of the symptoms, aggravating factors, and the case history in general. You appreciate that it most likely is a disc injury of some sort, with some muscle spasm in the region, and some referral of pain to the low back, hip region or down the leg. 

For example, if you walk in the kitchen, and the place is flooded, you don’t need to see the water pipe to know that the pipe is compromised (know what’s wrong), you formulate a plan that a leak needs to be fixed, the precise steps you might take then vary depending on the severity of the leak.  

You observe general truths like fixing the water pipe so it can bear the strain of the tasks it is designed to carry out is the objective. For your low back, the truth is that your spine should be able to deal with the load of gravity, an immediate plan should involve that attribute of restoring the ability to load bear as a foundational approach, regardless of what the minutiae of detail reveal on a scan.  

So in that respect, the imaging didn’t perhaps reveal an awful lot else. 

Another example, will your rehabilitation plan meaningfully change if the disc bulge is a fraction to the left or right. No, it wont.

A good reason why imaging is not essential for your back injury recovery.

Granted, if you’re happy to pay for your own MRI or X-ray’s to be done in a timely manner and are not beholden to the NHS then that’s always helpful. All too often, we see people paralyzed psychologically, unwilling to do anything until they get their MRI done in 6 weeks time, and get the report back 6 weeks after that. 

They fail to see that doing nothing is doing something. 

There is a fear of moving forwards with proper exercises, yet simultaneously, they carry on problematic daily activities which only worsen the issues and mean more ground is there to make back up again when they do eventually start.

When patients are solely focused on the need for imaging, it rarely is the panacea of resolution it is built up to be, and often leaves the individual thinking “well if only i’d started working on things sooner…”

This is not to say that imaging is not helpful, but in most cases, when you get your imaging through an NHS appointment, and unfortunately sometimes a private one too, all you get is a sheet of paper with some scary sounding terms, or worse still, “normal wear and tear for your age”.

Expectations on how imaging can be used to enhance your recovery process should be discussed much more clearly as a general rule, and the imaging itself used as a teaching aid to help the patient further understand their own body and how things they’ve been doing have had an impact on their body.

Imaging can inform the recovery process and help you move forward positively. 

When used properly. 

Over thousands of patients clinically and many more members of the program, there is yet to be a scenario where someone’s imaging results made the need for strengthening and mobility work irrelevant. 

If we think of the arguably “worse case scenario”, your back has to have surgery to fix it. Why on earth would you not do some robust physical Pre-habilitation work ahead of time, rarely surgery is booked today for tomorrow. We know that the more errors you fix, the stronger you become, the better you move, before surgery, the smoother your recovery will be after, and the better chance you have of being a great responder, rather than an under-responder to surgical intervention. 

It is tantamount to madness and/or self sabotage not to do strength based exercises ahead of time, and you might think that’s a bit extreme, it is not. If you were really bed bound, the surgery would be an emergency and it would be done tomorrow, and if it’s “booked” for weeks or months ahead, or still a question mark, you certainly have time to get some productive work done. Let’s face it, in these scenarios, you’re likely still “doing things” on a daily basis, so instead of the general activities of daily living, do something useful.

Please!

The biggest reason imaging is useful for a good practitioner to help you with your back pain.

It gives context, it eliminates the inevitable inaccuracies of physical examination. Far too often, those that condemn images, have little to no experience with it, they also often go way too far with what they can infer from their examination process. 

Simply put, these practitioners lack the experience with images to help them understand the patient. This results in dodgy “diagnosis”, things like short legs, twisted pelvis, hyper-lordosis, shortened muscles that need stretching, anterior pelvic tilt, the list goes on. Unaware that these diagnoses carry weight in the minds of a patient, they band them about the place with such vigour and certainly, completely unaware of the reality that their examinations are so woefully inadequate they cannot possibly make such proclamations with accuracy. 

A great example of this in action occurred way back in university. As an undergraduate Osteopath you spend a significant majority of your time being looked at by your peers and tutors in your underwear. Tutors being qualified osteopaths with much experience in most cases. The amount of qualified eyes cast over Lara’s posture over the years, students, and tutors alike, yet no one identified a significant scoliosis present in her spine. It was only later in the clinic that we had X-rays done on her spine and we discovered this significant issue. 

Understanding that in the education process you’re looking incredibly critically to pick up anything to talk about for education purposes, it is just one case of physical examination inaccuracy. Granted, you can see a shoulder might be higher than the other but you have no clue specifically why without a frame of reference, is the spine tilted, is the shoulder hitched, who knows without the complete picture. 

Moving on, the amount of times clinically we would see patients being told that they have hyperlordosis or anterior pelvic tilt, when the truth was the opposite, only to realise they’ve been vigorously doing pelvic tucks when they need not for months or more.

The diagnostic process and the above false observations are often acted upon, with special exercises or stretches that focus on rectifying an issue that simply isn’t there!

If the practitioner had more experience with imaging two benefits would occur. Firstly, they would take a large fist full of salt when it came to the physical examination’s conclusions. Secondarily, they’d become much more competent, knowing the limitations of what they can know in the absence of imaging, they’d work towards principles in their rehabilitation or treatment recommendations. Principles that apply to the load bearing spine, and spine health. This would result in more success and a less confused or even paranoia for the patient!

So what’s the verdict on imaging for back pain

Ultimately imaging is only as helpful as the person that is walking you through it. Sheets of paper are fundamentally useless, perhaps even detrimental in some ways. In our opinion, imaging can be a great tool to help you understand your own body and in some cases guide the remodelling work, but the delay for imaging of weeks or even months should not put you off making forward movements with your rehabilitation work. This is the big mistake that too many make. A good program will include education from the outset and this in of itself can be transformative, offering you much needed pointers on daily activities, and how to do things in ways that do not strain your injured low back while you are waiting for any imaging that might be in the pipeline. You do of course know where such a program might be found…

(hint: click the image below)

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