Back pain: what an MRI shows and what the findings mean

A systematic review in the American Journal of Neuroradiology combined 33 studies involving 3,110 people without back pain. All underwent CT or MRI. The results by age were:

• Disc degeneration: 37 percent of 20-year-olds and 96 percent of 80-year-olds
• Disc bulge: 30 percent of 20-year-olds and 84 percent of 80-year-olds
• Disc protrusion: 29 percent of 20-year-olds and 43 percent of 80-year-olds
• Annular fissure: 19 percent of 20-year-olds and 29 percent of 80-year-olds

The authors conclude that many imaging features form part of normal ageing and are not reliably associated with pain. A finding becomes meaningful only when interpreted with the clinical picture.

In short: a disc bulge in a 45-year-old is common. It explains pain only when the examination and symptom pattern fit.

The three papers in the 2018 Lancet low back pain series describe the consequences. Most low back pain cannot be assigned to one specific structural cause. Imaging without a clinical indication can lead to more tests, more procedures, greater concern, and less movement.

Believing that the spine is damaged often changes how a person moves. Reduced load can lower strength and coordination, which may amplify the symptoms under investigation. The explanation attached to the image can therefore affect recovery.

The German National Disease Management Guideline for non-specific low back pain provides a clear framework. Imaging is not recommended at the first presentation of low back pain without warning signs. If symptoms persist despite guideline-based treatment, the diagnosis is reviewed after four to six weeks without improvement. Repeat imaging is not required when the symptom pattern remains unchanged.

Warning signs require prompt assessment:

• loss of strength or progressive neurological deficits in the leg
• numbness in the saddle area or changes in bladder or bowel function
• fever, unintentional weight loss, or a history of cancer
• significant trauma, osteoporosis, or prolonged corticosteroid treatment
• night pain at rest that does not change with position

These situations need timely medical assessment. The clinical examination comes first because it identifies which pathway is appropriate.

An MRI shows structure at rest, while lying down and without load. Pain commonly occurs during movement and daily activity. The examination connects these two perspectives.

We assess:

• Movement. Mobility of the hips and thoracic spine, and how load is distributed through the lumbar spine.
• Strength and control. Trunk stability, gluteal function, and side-to-side activation. Patterns often become visible during single-leg stance or a simple squat.
• Provocation and relief. Which movement reproduces the pain and which reduces it. This helps identify the structures and loads involved.
• Context. Sleep, stress, training history, workstation, and previous episodes. These factors are associated with persistent pain and belong in the initial assessment.

The findings lead to a working diagnosis and a plan with measurable goals for load, mobility, and everyday pain. We assess the same measures again at follow-up.

In short: imaging describes anatomy. Examination describes function, which provides concrete targets for treatment.

An existing scan remains valuable when interpreted correctly. Bring the images and written report. During the appointment, we consider three questions:

1. Does the finding match the location, side, and distribution of your symptoms?
2. Are there warning signs that require further assessment?
3. What does the functional examination show beyond the image?

This conversation often makes an alarming report understandable and gives it an appropriate clinical weight.

Spinal MRI findings are common in people without symptoms, and their prevalence increases with age. A sound assessment begins with medical history and examination, checks warning signs, and uses imaging when it can change a decision. Treatment targets function, and progress is measured over time.