As a chiropractic physician and movement specialist a significant chunk of my practice consists of patients with lower back pain and sciatica. Often these patients present having already had a magnetic resonance imaging (MRI) scan performed, as this is the gold standard in diagnostic imaging when it comes to these types of conditions and therefore is overutilized by conventional medicine, especially in complex cases that are not responding well to treatment. A landmark study¹ that was published all the way back in April of 2001 (hard to believe that’s five months BEFORE 9/11!) looked to address whether the findings shown on an MRI correlated to the subjective pain symptoms reported by patients with lower back pain and sciatica. The conclusion was groundbreaking and 20 years later still holds weight when it comes to the dependence on imaging as a means to form a diagnosis and subsequent treatment plan.
The authors obtained MRI scans from 160 patients with one-sided sciatica and had the patients report their pain intensity and disability using a number of subjective measures followed by an examination. The authors then evaluated the MRI’s for degree of disc displacement and subsequent nerve root compression and attempted to correlate these imaging findings with the patients’ signs and symptoms. To their surprise they were not able to correlate any of the MRI findings to the patients’ symptoms, only to the examination findings. They then concluded that lower back and sciatic pain that is disc-related in its origins comes from some other mechanism than the pinched nerve that is shown on MRI and that therefore “The findings of this study indicate that magnetic resonance imaging is unable to distinguish sciatic patients in terms of the severity of their symptoms.”
Talk about revolutionary! And yet 20 years later here we are still dealing with the same conundrum. A common theme I hear when I first sit down with patients who present with lower back pain and sciatica for their initial consultation is, “Doctor, I brought an MRI that I had done recently and it shows that I have a disc that is pinching a nerve. Would you take a look?” My response is, “I will gladly take the time to review the MRI and radiology report but that I don’t form my diagnosis based on imaging, rather on a thorough history, examination, and well-informed clinical decision-making.” The results of this study confirm that this approach is the most prudent when it comes to treating lower back pain and sciatica. Conventional medicine has become over reliant on the use of advanced imaging tools like MRI as a means for diagnosis, usually due to time constraints and financial considerations (it’s easier to perform a brief and basic examination during a five-minute office visit and still get reimbursed handsomely and then just send a patient for an MRI). Imaging is just another piece of pertinent information and should never be used solely to come up with a diagnosis and treatment plan. This is why I don’t miss having x-rays on-site, something I chose to forgo when I opened my own clinic, HealthFit, in 2020. If a patient presents with a sign or symptom that is a “red flag”, such as incontinence in an individual with sciatica, then an MRI is in order as this constitutes surgical invention. Otherwise I prefer to take the necessary time to listen to the patient, perform a comprehensive examination, formulate a diagnosis, develop a treatment plan, write up a report of findings, and then sit down with the patient again to thoroughly go over everything. Sure it may take a couple of hours but I see it as time worth spent. Time that most patients relay to me they wish they got from other providers. Time that is often spent lying motionless in an MRI tube for no other reason than provider negligence.
¹Karppinen, Jaro MD*; Malmivaara, Antti MD, PhD∥;; Tervonen, Osmo MD, PhD†; Pääkkö, Eija MD, PhD†; Kurunlahti, Mauno MD†; Syrjälä, Pirjo MD‡; Vasari, Pekka MSc§ and; Vanharanta, Heikki MD, PhD; Spine: April 2001 - Volume 26 - Issue 7 - p E149-E154