MRI

 "Doc, my back hurts.  I need an MRI."

The MRI seems to be the Holy Grail of diagnostic tests to many patients, especially for those with back pain.

Its utility?  Virtually zero.

As with most diagnostic testing, the question to ask is "What am I going to do with the information I get from the test?"  The answer, at least with MRIs order for back pain, is "Nothing."

First, a bit about back pain.  In generally, if one does absolutely nothing - no medication, no physical therapy, no MRI, X-ray, CT scan, no massage, no acupuncture - 90% of those presenting with back pain get better in 30 days.  There are exceptions, those that require more aggressive therapy, and more urgent diagnostic testing - the so-called "red flags of back pain" - but those are ascertained by a good history and physical examination.  The majority of cases, though, are not serious, medically speaking.  For sure, back pain can be life interfering, but for the most part acute onset low back pain will self resolve. 

The "good history and physical examination" is key.  One can tell, with fairly good certainty, the presence of a serious condition causing the back pain - a fracture, a herniated  disc causing spinal cord compression, cancer, an abscess, etc. - just be interacting with the patient.  Absent significant findings, an MRI is unlikely to uncover something that would alter the initial approach to therapy.  The MRI should be used to confirm  a diagnosis, not make a diagnosis.  

Unfortunately, many physicians default to the MRI; it is the easy way out, either because they are uncertain of their diagnostic skills or don't have time to explain to the patient why the MRI is not helpful.

But for the most part, it isn't. 

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