One of the most common questions patients ask when they come in with back pain is whether they need an X-ray or MRI. The honest answer is: most of the time, no. Imaging for acute low back pain is frequently ordered, frequently unhelpful, and sometimes actively misleading.
Studies consistently show that structural findings on spinal imaging — disc bulges, degenerative changes, mild foraminal narrowing — are present in large percentages of people with no pain at all. A 2015 systematic review found that disc degeneration is present in 37% of asymptomatic 20-year-olds and over 90% of 60-year-olds. These are not pathological findings. They are normal age-related changes. Imaging them doesn’t change that.
When imaging is not indicated
For most acute and subacute low back pain without red flags, imaging is not clinically indicated in the first four to six weeks. This is the consensus position of virtually every major clinical guideline — including those from the American College of Physicians, the AMA, and the Choosing Wisely initiative. Early imaging in uncomplicated back pain increases cost, increases radiation exposure, and frequently leads to unnecessary intervention on incidental findings.
When imaging is indicated
Red flags change the calculus. These include: significant trauma (fall from height, motor vehicle accident), suspicion of fracture, history of osteoporosis, unexplained weight loss, fever or signs of infection, history of cancer, bowel or bladder dysfunction, progressive neurological deficit, or pain that is constant, severe, and unrelenting regardless of position.
Radiculopathy — nerve root pain with associated neurological signs — is also an indication for imaging if conservative care is not producing improvement, or if surgical consultation is being considered. The decision is based on the clinical picture, not the pain level alone.
What imaging tells you — and doesn’t
Imaging shows structure. It does not show function. A normal MRI does not mean nothing is wrong — joint restriction, muscle dysfunction, and movement pattern problems don’t show up on imaging. An abnormal MRI doesn’t mean surgery is necessary, or even that the finding is responsible for the pain.
When we see patients with existing imaging, we review it as one input among many — alongside the clinical exam, history, and functional assessment. If you don’t have imaging and don’t meet criteria for it, we’ll tell you that directly. If you do meet criteria, we’ll refer you for it before proceeding.
Written by Dr. Arthur Chakrian, DC — Spine Bar Chiropractic, Toluca Lake