Do I need an MRI for my back pain? What the evidence says

When your back hurts, it’s natural to want to “see what’s going on.” But an MRI doesn’t always answer that question. The American College of Physicians (ACP) puts it this way: in this area, more testing does not equate to better care.^[1] That doesn’t mean imaging is useless: it is very valuable when it is indicated.

When imaging is indicated

According to the ACP, imaging is indicated for low back pain only if there are severe progressive neurologic deficits, or signs or symptoms that suggest a serious or specific underlying condition.^[1] A summary published in American Family Physician details these cases:^[4]

Sources: ACP, Annals of Internal Medicine (2011)^[1]; American Family Physician (2012).^[4] Your doctor makes the decision based on your case.

Why it isn’t recommended routinely

According to the same evidence summary, in people without an underlying condition, routine imaging:^[4]

• Doesn’t improve pain, function or quality of life.
• Doesn’t reduce anxiety about back pain.
• Is associated with higher costs, poorer reported health and a greater risk of surgery.

The ACP concludes that routine imaging has no clinically meaningful benefits and can lead to harms.^[1]

Many findings also show up without pain

A review of 33 studies with 3,110 people with no symptoms found that degenerative changes are very common, and more so with age:^[2]

Spine imaging findings in people with no back pain

At age 20At age 80

Disc degeneration

37%96%

Disc bulge

30%84%

The authors conclude that many of these changes are likely part of normal aging and unassociated with pain, and that they must be interpreted in the context of each patient’s clinical condition.^[2]

An important nuance

That doesn’t mean these findings never matter. A meta-analysis by the same lead author, in adults 50 or younger, found that some of them, such as disc bulge and degeneration, were more common in people with low back pain than in people without it.^[3] The key point is that imaging doesn’t explain pain on its own: it has to be combined with your history and a physical exam.

When to see a doctor without waiting

NIAMS recommends seeing a doctor if the pain doesn’t improve after a few weeks, is severe and not helped by medication, started after a fall or injury, or comes with trouble urinating, leg weakness or numbness, fever, or unexplained weight loss.^[5]

If you already have an MRI

If your report says “herniation,” “protrusion” or “disc degeneration,” don’t panic yet. Ask your doctor:

1. Does this finding explain my symptoms?
2. Does it change the treatment you recommend?
3. What are my options before considering surgery?

An assessment combines your history, a physical exam and, when needed, imaging to understand where your pain is coming from.