Do you need images: x-rays, CT scan and MRI?

Understandably, with ongoing pain you’re anxious to find out exactly what’s causing it. It seems reasonable that images such as an X-ray or even better an MRI, which shows intricate anatomical details, will reveal the cause of your problem. But, images are often not as promising as they seem and in fact can lead you down an unhelpful path.

Images are not a good indicator of the cause of symptoms

A mountain of studies have shown that people with imaging “abnormalities” are little to no more likely to suffer pain than people who have “normal” images. Such "abnormalities" include cartilage wear and tear, abnormal bone formations (irregular joint contour, cysts and spurs), osteoarthritis, disc herniation, disc prolapse, slipped vertebra (spondylolisthesis) and nerve compression

In fact, by the time you reach 50 years of age almost everybody’s spine starts to look pretty ugly. For example, one study found that ninety percent of seniors without back pain had substantial spinal “abnormalities” that showed up on MRI. The same goes for images of other parts of your body such as your knee joint; worn and torn cartilage, calcified tendons, bone spurs and cysts are commonly found in pain-free knees.

The bottom line is imaging examinations is by no means a sure indicator of the cause of symptoms, add little to becoming pain free and in fact can be worse than useless.

Imaging is used excessively and often unnecessarily

Professor of Radiology, Tim Maus of the Mayo Medical School warns against using imaging excessively and unnecessarily. Maus says: “the primary role of imaging is to identify a systemic disease (such as cancers and infections) and bone fractures as a cause of the pain. Alongside the benefit in a small number of cases, imaging carries risks, such as labeling the patient as suffering from a degenerative disease, increased financial cost, unnecessary radiation exposure, and potentially provoking unwarranted minimally invasive or surgical intervention”.

Imaging often lead to unnecessary costly treatment

Diagnostic labels based on incidental findings can cause needless worry and unnecessary follow-up tests that carry risks, such as biopsies and lumbar punctures, ongoing “maintenance” treatment or even risky treatments such as long-term medication, spinal injections, and/or surgery which can have their own complications.

Images are often the first step down many number of treatment pathways but do they help? According to research on treatment outcomes the answer is at best, only in the short-term and at worst, costly and harmful. For example, one study found that back-pain sufferers who had an MRI in the first month were eight times more likely to have surgery and medical expenses were five times more than those who didn’t have an MRI—but they didn’t recover faster. They are more likely to be on long-term opioid medication, suffer complications from surgery and on average take three times longer to return to work. Furthermore, many studies show that more than 60% of low back surgery results in no improvement or worsening long-term pain, called failed back surgery syndrome, while the degree of improvements in positive outcomes is modest.

Images of other joints showing abnormalities also often lead to needless surgery. For example, a common surgical procedure for an arthritic knee is keyhole surgery to trim the torn meniscus cartilage and “shave” any untidy cartilage (arthroscopic meniscectomy). It seems like a very reasonable, straightforward procedure to do in the circumstances. In fact, around 160,000 are being done in Australia every year.

Professor Rachelle Buchbinder, Director of the Department of Epidemiology & Preventive Medicine at Monash University, Melbourne, Joint Coordinating Editor of the Cochrane Musculoskeletal Group and chair of the Australian Rheumatology Association Database (ARAD) Management Committee, states that ‘ Persuasive evidence from randomised, controlled trials indicates that arthroscopic knee surgery is no more effective than sham surgery and non-operative alternatives for symptomatic knee osteoarthritis.’

Dr Graham Mercer, president of the Australian Orthopaedic Association, said although there were some indications for doing arthroscopy for arthritis in some patients, most surgeons “would say it doesn't do a great deal and there is a chance you can actually make patients worse”.

Indeed, recent studies have found that knee arthroscopy often leads to long-term damage of the cartilage and further ongoing procedures. These studies reveal that the amount of removed meniscus is the most important predictor for the development of further knee osteoarthritis. In yet another recently published study, after repair of a meniscus tear surgeons went back at a later time to look at the meniscus under arthroscopy to find almost none of the “repaired” tears healed.

Image findings instil fear

Professor Richard Deyo, from the departments of Family Medicine, Medicine, and Public Health and Preventive Medicine at Oregon Health and Science University in Portland, suggested that in order to reduce anxiety radiologists should add information to imaging reports regarding the frequency of “abnormal” findings among normal patients.

Fear is fuelled by diagnoses such as a “collapsed or bulging disc”, “bone on bone”, degenerative disease, a “pinched” or compressed nerve and other diagnoses based on images.  They tend to affirm any thoughts you might have that you’re “falling apart” and that you should be extra careful to avoid the use of the painful part of your body for fear of further pain, injury and/or “degeneration”. Fear avoidance in itself is a well established major risk factor for the recurrence of further painful episodes.

Given such a diagnosis, naturally you will avoid activities you believe might risk further damage and pain in future. You’re likely to give up doing exercise such as playing sport, jogging, walking and swimming, avoid your work duties or avoid even carrying out your routine daily activities especially when it exacerbates your pain. But your body thrives on being active and fear avoidance makes your muscles weaker and stiffer further increasing your likelihood of ongoing pain.