My Back Hurts! Do I need X-rays or an MRI?

I see a lot of spine X-rays and MRIs every day. We all get pain in our back if we are fortunate to live long enough. So when should you get it evaluated by your healthcare provider. Should they be ordering X-rays or an MRI of your back? Most of the time, the answer is no. Back pain is so common that up to one in every four patients seen by their primary care provider is for back pain.

If you hurt your back doing exercise more than usual, then it probably doesn’t need to be looked at by anyone. We all push it too hard now and then (gardening, snow shoveling, weekend warriors, etc.). When the pain is dull and achy it is almost always musculoskeletal (i.e. you “pulled” your muscles and worked them too hard). For early/acute pain I always suggest RICE (recommended to a patient just today in fact): Rest, Ice, Compression, and Elevation. Sure that might not work for all your body parts, but you get the idea. Take it easy for several weeks or maybe even a couple months. Use ice early and after 48 hours you might switch to a heat pad. It’s hard to compress your back, but if you know a great person to provide a little massage therapy that will suffice nicely. Lastly elevation can decrease the gravitational pressure and weight, so put your feet up and rest on the couch some. The last piece of advice I obtained from a friend who is now the Section Chief of Musculoskeletal Imaging at Mount Sinai Hospital in NYC. I occasionally utilize standard Aleve when the pain is too much to bear. I always take it on a full stomach and never more than twice a day with at least four hours between my dose for size (I’m 200 lbs. so I usually take 3). I resort to something like that at most up to half a dozen times a year, depending on how much I exert myself, or let myself get out of shape.

So what if I want to see my doctor? Awesome, go for it! Most primary healthcare society  recommendations suggest, that for the dull achy pain I mention above, to not image for SIX WEEKS. They should tell you to do at least some of what I just suggested above. If it is chronic pain, which is pain for more than six weeks, then X-rays are recommended as a starting point. Even then your provider may not order an MRI. When is an MRI indicated?

An MRI should be ordered if you have what we call RED FLAGS. These are objective findings, not the subjective findings of pain and tingling. Back pain is often caused from nerve root compression/impingement.

Neurogenic back pain, commonly called sciatica, comes from irritation of a nerve root. This often happens from mechanical compression that can occur from degenerative reactive bone production called osteophytes. These osteophytes/bone spurs can develop in response to increased stress and pressure. They commonly occur at the ends of the lowest fourth and fifth lumbar vertebral bodies and the joints in the back of the vertebrae that allow us to stretch, bend and move. These osteophytes form little bone spurs/spikes that narrow the small channels that the nerve roots have to exit from your spinal canal to innervate your body. Cushions between the vertebrae called discs get smashed throughout  life and can collapse and herniate where a part may go into the canal where your spinal cord and lower back nerve roots live. A herniated disc is like when you squeeze down on a balloon or ball that when placed under pressure causes a small bubble to come out of the balloon or ball you are compressing because of a focal weakening in the wall of the structure. That’s what happens to your disc. Human biomechanics are such that the bulge or herniation tends to occur backwards into the canal narrowing it.

So, if you have a severe enough mechanical compression, then you can develop neurogenic symptoms, which if left untreated could result in permanent nerve damage. These are the RED FLAGS: severe or progressive neurologic impairment. Say what? How about foot drop where your foot doesn’t come off the ground like your other one when your walking, dragging along with you. If you ever have bowel or bladder incontinence, you should have it investigated by a specialist. I shit you not, pun intended, people put off some things way, way too long.

So, before I overstate my welcome, please let me know what you think so far in the comments below. I’m open to topics and suggestions.



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I am an American Board of Radiology certified Diagnostic Radiologist with a certificate of additional qualification in Neuroradiology. I absolutely love my job. I have learned a tremendous amount about the human body, including its’ expected complications given our extraordinary complexity, and get to use that knowledge to help people. I personally have experienced emotional devastation and loss, which has made me compassionate and empathetic. I really care about people, and I hope I can use this site to help you. I graduated medical school in 2004 from New York Medical College. My wife and I had our first son in NY where we bought our 900 sf two bedroom one bath starter home. I stayed at Westchester Medical Center for radiology residency, where we had our second son. I obtained a neuroradiology fellowship position at Yale New Haven Medical Center commuting about an hour and a half each way for a year while we had our third boy. Upon graduation I was fortunate to return to Westchester Medical Center to work in Neuroradiology, Body Imaging, and Women’s Imaging departments, a rarity in academic medicine. Almost a decade later and I am living in a larger home in Reno working in a private practice community based outpatient radiology group which contracts with a rural hospital in Elko, Nevada. My wife and I now have four boys and gave up on the girl. We also have a male Bernese mountain Dog named Helmut and female Newfoundland named Lucy. Despite all its hardships and tremendous struggles, I have an absolutely amazing life, which is a gift I cherish. It’s down to my philosophy. I am a firm believer in teamwork. So much comes down to communication. When healthcare providers talk to each other one-on-one, the patient care is always improved, every time! We might not find an answer to your problem, but our collective knowledge sure can help improve your chances. At Yale the best conference I ever regularly attended was a head and neck tumor board. The head and neck surgeon (otolaryngologist = ENT) presented the patient’s clinical history, the radiologist showed the images, the oncologist discussed the tumor and chemotherapy options, and the patient came to the conference and we all did a physical exam looking into their mouth to directly visualize a tumor. It was incredible! Patients came from far and wide to see this highly trained, world-renowned, humble, Japanese, gentleman surgeon. It was also an epiphany. I found that when I see the patient, talk to them, listen to their story, examine them and discuss the patient with my colleagues, the patient felt better and I had a lot of fun. It’s weird but reminds me of seeing a comedy where it is always funnier in a packed theater with everyone laughing. Knowledge and compassion are both infectious and contagious. My greatest days are helping patients deal with some of their most difficult days, and I am good at it.

2 thoughts on “My Back Hurts! Do I need X-rays or an MRI?

  1. Thanks Ron for stressing that imaging is overutulized in common back pain. I would like to add that early intervention with physical therapy has shown to significantly reduce the need for additional healthcare services down the line. Too much avoidance of activity can create reduced mobility in the spine which makes the person more likely to have repeat episodes of back pain. People also become fearful of certain movements or activity without education. Sorry, I just had to add my plug, and take advantage of an educational opportunity!

    Liked by 1 person

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