Low back pain is one of the most common and most disabling of musculoskeletal conditions, costing a very large amount in personal and financial terms. Magnetic resonance imaging has given spinal surgeons an extremely useful tool for assessing the anatomical structures which might be responsible for back and leg pains. However, a recent review of six trials reported in an article on the BBC Health website has confirmed what many back pain professionals know, MRI scanning has little role in the management of most low back pain. Scanning should be reserved for serious back pain conditions and a comparison of a scanned group and a non-scanned group showed no differences in their outcomes either early on or in the longer term.
Doctors refer people for magnetic resonance imaging for a variety of reasons, one of which is the patient’s expectation that the scan will show what is wrong with their back and lead to a successful therapy. However, an obvious and treatable cause is rarely found on a scan and it more important to answer the patient’s many questions and clearly indicate the treatment strategy to them.
Because it is an easy technological intervention the rates of MRI scanning are increasing, leading to lots of misconceptions and awkward questions, let alone the communication errors which many medical professionals commit when explaining the findings to patients. Most patients would agree to have an x-ray or a scan if offered, illustrating the mismatch between what can realistically delivered by imaging and what patients want.
The examination and medical history of the patient should indicate whether there is a serious underlying cause for the back pain or whether it is mechanical. MRI scanning is not very useful in mechanical low back pain and should be reserved for cases where there are findings which indicate the necessity to do so and not just because the next step is not clear.
The management of low back pain includes patient education as to the likely underlying reasons for their pain (although they are often not clear), the absence of a need for imaging, manual therapy trial, acupuncture and a structured exercise programme. For people with severe and chronically disabling back pain or other pains then a pain management programme approach can be useful.
Reassurance is not an effective way of dealing with patients’ health anxiety and MRI scanning has been shown to be ineffective in accomplishing this goal. Abnormal findings are found in the spines of people without pain symptoms so it is difficult to decide which changes are relevant to the presenting symptoms and which are just incidental. It is vital to avoid creating unhelpful attitudes and images in the patients’ minds about what is occurring inside the spine. Sufficient time and communication skills are necessary to achieve a good understanding.
Explanations to patients are fraught with difficulties and many fall into what I call concepts without explanation, where the explanation is given to the patient with little or no care or checking as to what they take away from it. If we give them a concept to think about we have a responsibility to help them understand and fit it in to their attitudes and beliefs about their back pain in a realistic way. If we get this wrong by being careless with our communication this can have important and negative consequences.
Much of the explanation to patients comes under the category of what I call concepts without explanation. We give a concept, a way of seeing things, to patients but we don’t give them the accompanying information they need to make sense of it and incorporate it helpfully into their view of their back pain and its management. This is a very bad idea and has very unhelpful consequences as the patient’s interpretation of their condition informs their whole self-management.
Management of mechanical back pain is multi-faceted and health professionals need to take the time and make the effort to communicate clearly for successful treatment of low back pain and other pain conditions. Overall, MRI scanning has a very limited role here.