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MRI for low back pain: Is it necessary?

MRI for low back pain: Is it necessary?

Dr. Michael Derry, DPT, PT, OCS Jacksonville, Florida
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Do I need an MRI for my low back pain?

That’s a billion-dollar question! Most people in your situation wonder what does an MRI for low back pain cost? What if my lower back pain MRI shows nothing? Or worse...what if it shows something very wrong? When should I get an MRI for low back pain or how long does an MRI of the low back take? With so many questions swirling around in your head as you're on your path to healing, lets dive in together.

Most likely, you don't need an MRI but you often want it. Okay, so if I don't need it, why did my Doctor recommend it? When we are in pain, we may want to know what is going on because we feel like that can help to fix the problem and feel better sooner. I can’t blame you for thinking that! We're human and it is in our nature to want to "fix" things. However, do you actually need a picture to do that? Let’s consider some points when contemplating an MRI. While this is focused on getting a MRI for low back pain, the premise holds true for other areas of the body as well.

When to get an MRI for back pain:

When contemplating your options, it is wise to think about what you want to do with the information you get. An MRI can warranted if you are considering a change in the pathway of care. One example would be transitioning to surgical options after failing conservative care such as physical therapy. However, low back pain imaging guidelines agree that imaging should NOT be considered early when you have lower back pain. In fact, low back pain imaging guidelines say that before imaging you should present with signs and symptoms such as...

  • Recent unexplained weight loss.
  • If you have a history of cancer.
  • Bowel or bladder changes.
  • Recent fever, chills, night sweats that are unrelated to anything else.
  • Abnormal reflexes, severe loss of strength, or loss of sensation in your legs.
  • You don't notice ANY improvement with about 4 weeks of conservative care.
  • Symptoms that remain constant despite change of positions, time of day or activity.
  • Trauma such as a high velocity car accident or a bad fall.

If you have these signs or symptoms then imaging can be useful and is recommended. With that said, if you don’t then the American College of Radiology, a governing body for radiologist, clearly states you don't need an image and one should not be ordered if you have pain for less than 6 weeks, no significant medical history, no nerve changes, and the physical exam is relativity normal.

"Early MRI is associated with increased disability in patients with acute Lower back pain without red flags."

Guidelines of emergency medicine, physical therapy, and family practice are clear that imaging should not be considered early for those with lower back pain.

Guidelines for when an MRI for low back pain may be necessary
Guidelines for when an MRI for low back pain may be necessary

What to expect with MRI for lower back pain:

In short, MRI means magnetic resonance imaging. Essentially a very fancy and sophisticated machine that can use magnets and great a deal of science to create a picture of your body. It’s not painful at all. Now, if you have a slight fear of small spaces then you may want to look for your local open MRI in Jacksonville, FL or discuss other options with your physician that may make the process more comfortable for you as an MRI of the lower back can take 30 to 60 minutes, or up to two hours. You will most likely be asked to take off all jewelry and change into provided scrubs.

When it comes to the results, expect incidental findings as they are almost always present. These are things that are discovered on images that we did not know were there prior. We have all heard of stories when doctors find something they were not looking for. It can be a real blessing, but in the lower back pain world, it can also be a curse. Most lower back pain is non-specific. Nearly 90% of all lower back pain, can not be explained by one particular tissue such as a joint, muscle, or even disc. However, the impression or report on the MRI commonly finds things such as degenerative disc disease, disc bulges, fact arthropathy, disc height loss, and more! These incidental findings are all very real but also unbelievably common.

This is good and bad at the same time. Some believe you need to properly identify the tissue in order to get better. On the other hand, trying to find one specific tissue issue can take a long time and is rather costly. This leads to more diagnostic testing and increases the chances of risky interventions such as lower back surgery. It can be re-assuring to know that what you may be feeling is relatively normal. This is where a detailed physical examination come into the picture and can merge what your body is telling us with what the image is telling us.

“Lumbar spine imaging in these settings is associated with a high risk of detecting incidental findings unrelated to the patient’s current symptoms and expose the patient to a surgical procedure with positive outcomes unlikely.”

MRI lumbar spine disc herniation L5-S1 with leg pain
MRI of lumbar spine L5-S1 disc herniation with leg pain

What if my lower back pain MRI shows nothing?

This is great! But, it can also be frustrating for you. When it comes to pain, knowing that you are normal is a good place to be. If your MRI shows nothing, we can rule out things such as cauda equina, cancer, or fractures (which accounts for less than 1% of low back pain). Also, MRIs cannot see pain. We have seen so many people with MRIs that show a laundry list of findings but have no pain, and people whose lower back pain MRI shows nothing and yet have chronic low pain pain. Taking the time to have someone, such as a physical therapist, understand what you are feeling and see how your body is moving is an excellent next step.

If we can’t see the problem, how do we treat it?

When it comes to lower back pain we are not great at specifically diagnosing tissues and that is okay. We don’t need to see it to treat it. It’s treated based on how it presents. If you have leg pain there are plenty of things we can do to treat it. If you have pain in your butt, that can be treated as well. Most of the time people have pain when they move. An MRI of you back is done when you are not moving. Lower back pain is often movement limiting so let someone take a look at you move and help you move better and with less pain. Check out this masterclass on hip and lower back pain. It can be a great place to start and it is free!  

How can I start feeling better?

Best evidence says try conservative care first such as physical therapy and exercise. If you are unsure what to do, this can be a great place to start! If you are the DIY type and you want to know more about lower back pain and pain that may radiate into your hip, check out this free webinar on hip and lower back pain. No decision is an easy decision but trust me, building your team that will find that perfect blend of best evidence with the best treatment options for you is a great place to start! 

In summary, an MRI for your lower back pain may be the best next step for you but please consider the above points. What we want and what we need can be two different things. This is why following imaging guidelines as stated above are important. They can help us make evidence informed decisions instead of emotionally informed decisions. If you do have an MRI make sure you spend time figuring if what they found on the image is actually what you are feeling. Imaging may be needed but make certain before you spend the time and money! Even if your insurance pays for it, an MRI for low back pain costs everyone money in the long term through increased utilization of health care leading to increased medical insurance premiums.

If you want to know more about improving hip and lower back pain check out this free webinar I completed. It covers differences between hip and back pain as well as common treatments for both as well as best evidence for recovery! 

Revision Health Services now offers telehealth for Florida residents as well as massage and physical therapy locally in Jacksonville, Nocatee, and St. Johns. To find out if our services could be the best fit for you, reach out and lets chat!

Until next time, stay healthy, keep moving, and take care of yourself.


Dr. Michael Derry is a Doctor of Physical Therapy and board certified in orthopedics. He is very passionate about treating lower back pain and helping people build their resiliency. He has spent time assisting at universities as well as managing large clinics before starting his own practice in Jacksonville, FL.

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