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MRI scans: where abnormal findings are normal

Magnetic Resonance Imaging (MRI) is a tool that is used to visualize the inner workings of the human body.  The widespread availability of MRI scanners has turned them into “answer machines”: What’s wrong with the patient?  Don’t know?  Get an MRI scan!  MRI uses a very powerful magnetic field to magnetize the atoms in the human body and then a special computer detector is able to reconstruct an 3-dimensional image of the anatomic structures anywhere in the body with incredible clarity, focus, and contrast.  This allows us to visualize the human body in ways that were completely unimaginable a generation ago.

The crux of the MRI scan is the interpretation.  The images produced by the MRI scan are interpreted by a radiologist.  In the process of determining what’s normal and what’s abnormal the images are compared in the mind’s eye of the radiologist to a theoretically normal “young” human with no wear and tear.  Here is an analogy that I use often.  Look at these two pictures of human skin.  If the skin of the person in the second picture was biopsied and viewed under a microscope, the pathologist would probably find evidence of advanced solar elastosis, pre-malignant cells, severe degenerative changes, and a long list of terrible medical conditions which would be described as VERY ABNORMAL.  But this is only because this skin is seen in the context of the first picture which is being used to define the NORMAL state.   Looked at another way, the skin of the second person is perfectly normal as a function of age.  It may not be as appealing, but similar changes are going to happen to all of us.

normal skin  aged skin

Now lets examine the images from MRI scans of the lumbar spine.  This first image is called a sagittal slice of the lumbar spine.  It allows us to clearly see the bones of the spinal column (the vertebral bodies), the intervertebral disks, the spinal cord, and the nerve roots.  The lumbar spine is composed of 5 vertebral bodies: L1, L2, L3, L4, and L5.  There are 5 intervertebral disks which are named according to the vertebral bodies that they separate.  These five disks are called: L1/2, L2/3, L3/4, L4/5, and L5/S1.  The center of the intervertebral disk is a soft squishy gel-like substance made of proteins that is surrounded by a tough ligamentous wrap called the annulus fibrosis.

saggital MRI of the spine  axial MRI scan  annotated axial MRI scan L5.S1  axial MRI facet neuroforamen

This is a normal MRI scan from a healthy 19 year old patient.  The first image is of a “sagittal slice” of the lumbar spine which shows the spine as if we used a laser beam cut the spine in half lengthwise.  In this image the head is to the top, the back to the right, and the feet to the bottom of the image.  It is oriented as if the patient were standing up, facing to the our left.  On this image, the spine is normally aligned, the center of the disks show up as bright white because they are well hydrated and have a high water content, and there is no evidence of compression of the nerve roots.  On the second image we see an “axial slice” which is a horizontal cut through the spine at the level of the horizontal reference line seen on the first image.  In the 3rd and 4th images, I have annotated the anatomic landmarks so that you can see where the spinal canal, neuroforamen, and facet joints are located.

annular tear L4.5

This is an MRI scan from a 22 year old woman with low back pain.  In this image, we see a tiny white dot in the midst of the fibers of the annulus fibrosis at the back of the intervertebral disk.  This is called a “High Intensity Posterior Zone Lesion” and it is often described by the radiologist as an “annular tear”.  The finding is a tiny white dot seen in the posterior fibers of the disk just underneath the yellow reference line.

mildy spondylosis of the lumbar spine

This MRI scan is from a 50 year old male patient with moderate back pain.  The most noticeable change in this image is the change in color of the center of the disks — from white to dark.  This is a normal part of aging that occurs because the proteins in the center of the disks lose their water content, become brittle and stiff, and the blood supply to the center of the disk naturally shuts down relatively early in life.  While this is a change that will occur to every human spine, it is described as an abnormal finding by the radiologist as “disc desiccation” and “degenerative disk disease.”

L4.5 and L5.S1 disk extrusions  L4.5 and L5.S1 disk extrusions

This is an MRI scan from a 26 year old patient.  In these two images of the L4.5 and L5.S1 disks, the disks are bulging slightly into the spinal canal.  While this is basically a normal finding, this is described by the radiologist as “multi-level degenerative disk disease with broad based disk bulging and focal disk extrusions at L4.5 and L5.S1″

Recently, it has become much more common to give the patient a copy of the MRI and report from the radiologist before it is interpreted for them by someone who is knowledgeable about the natural history of low back pain and MRI findings.  Unfortunately, this often creates a lot of confusion that can be difficult to rectify.  By the time that a patient sees me, they usually have had the opportunity to read their own MRI report which typically sounds something like: “disc dessication is prominent at L5/S1.  There is broad based disk bulging at L4/5 and L5/S1 and degenerative disk disease at these two levels.”  This patient arrives in my office CONVINCED that there is something dramatically wrong with their back.

I begin by explaining that these findings are normal and that they frequently occur in patients without back pain or sciatica.  For example, in a study published in a medical journal called Radiology, 36 volunteers with no history of recent back pain had MRI scans of the lumbar spine.  In this group of “NORMAL” patients, bulging disks were seen 81% of the time, annular tears were seen 56% of the time, and small disk herniations were seen 33% of the time.  Click here for this reference.

Unfortunately, after I have reviewed the scan with the patient and explained that the MRI scan could be described as normal for the patient’s age, the patient is usually unconvinced.  An MRI scan is high-tech piece of equipment, the process of being scanned is frequently quite an experience for the patient, and the ability to see inside the human body with this tool is dramatic.  I believe that the patient remains unconvinced because they just had an expensive high-tech test, the radiologist who looked at the MRI scan found lots of abnormal findings, and they certainly have back pain.  Now they have a spine surgeon telling them that their MRI scan is normal!

 

While there is a healthy debate about what constitutes an abnormal versus a normal MRI scan of the spine, there are a few key findings that reveal a problem that we know will require surgery.  For example, here are some images of problems in the spine that are more likely to require surgical treatment….

Large disk herniations with nerve root pain

Large L4.5 herniated nucleus pulposus  L4.5 herniated disc

These are the images of a large disk herniation at the L4/5 level that is causing severe low back and leg pain, numbness in the L5 distribution, and weakness in the calf.  This patient has had pain for several months, is unable to work, sit, or ride in a car, and ultimately she underwent a microscopic discectomy with excellent relief.  In the following image I have outlined a similarly large disk herniation at the L5/S1 level that also required a microscopic discectomy.  The herniation is outlined in white dots and is completely filling the neuroforamen, putting severe pressure on the nerve root.

L5.S1 disc hernation microdiscectomy

 

Spondylolisthesis:

These images are of someone with an instability of the lumbar spine called a spondylolisthesis.  In the following images there is a slippage between the L4 and L5 vertebral bodies which results in a narrow of the spinal canal and severe pressure on the nerve roots.  This causes severe low back pain, bilateral leg pain, and typically the patient is not able to stand for long periods without feeling like their legs are going to collapse.  Ultimately, this patient underwent an operation in which the spine was stabilized and fused at this level.  In the first two images we can see the amount of narrowing at the L4/5 level is severe compared to the space available for the nerve roots just above the level of the slip.  I have outlined the limited amount of space available for the nerve roots with white dots and also the misalignment between L4 and L5 by drawing a series of dots along the posterior aspect of L4/5 and L3/4.

L4/5 spondylolisthesis with stenosis  L4/5 spondylolisthesis surgical decompression

These images are of someone with severe stenosis of the lumbar spine.  This is caused by severe arthritis and degeneration of the spine and this patient has low back and bilateral leg pain and can walk less than 100 feet without having to find a place to sit down and flex forward.  This patient experienced profound improvement in their symptoms after a microscopic lumbar laminectomy done via a minimally invasive approach.   On the first image we can see the severe narrowing of the spinal canal and neuroforamen at the L4/5 level and on the second image we can see how much space should be available for the nerve roots.

severe stenosis microscopic decompression  severe stenosis surgical treatment

Take home message #1: If your MRI scan does not show evidence of severe stenosis, spondylolisthesis, neuroforaminal narrowing, or a large extruded disk hernation, chances are you will not be a candidate for surgical treatment.

next topic: Narcotic pain medications are not a great idea for an open-ended diagnosis like back pain

17 comments

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  1. Scott Ledbury

    Hi there

    I am so glad that I have read the above article as I have only yesterday had a consultation following an MRI Scan and came away feeling very dissalusioned and confused / feeling quite low.

    My scan and pain is pretty much exactly as you describe above of the 26 year old patient with bulging disks or should I say, your disecription is pretty much the same as explained to me by my consultant.

    I have one major concern though, I play golf to quite a high standard and I have reached the stage where my pain whilst playing is pretty much unbareble. It also hurts quite a lot while doing any strenuous activity including walking………….the golf is the most important thing though as its pretty much my life and has been for 25 years or more. I am 42 but still consider myself very agile……….. It was mentioned by my consultant, almost to mobile and flexible which may be adding to my back problem.

    My worrying thing is that I was told to stop playing golf or take pain killers (I have them before I play anyway). I was told to do lots of core exercise and strengthening, stop stretching all the time as it compounds my flexibility issue as I need to become stiffer.

    My question would be, if I made my living from golf would the answer have been the same or is there anything else that can be done in your opinion? ………… If Tiger Woods came in with the equivelant MRI to the 26 year old and was in severe pain when he hit balls, would you tell him to stop playing or would you be able to help and fix him?

    What is the odds of core strengthening actually making me become pain free? Is it possible to become pain free again?

    Best regards
    Scott

  2. Caroline Myers

    Very interesting article.My 14 year old daughter who is studying Ballet had an MRI that concluded Disc Lesion at L4-5 and L5-S1 slightly more marked at L5-S1. Reading your article this presents as normal, she is now 16years and experiencing some lower back pain,while training to be a Ballerina,is this seroius or just requires rest,
    Also would the previous MRI results have changed now or repaired itself with age.

    Thankyou
    Kind Regards.

  3. Dominic Ninivaggi

    Hello,
    I hope that you can provide some guidance for me and please let me know if I would be a candidate for surgery. I live in Ontario Canada, presently I am looking for private out of country surgery. Here are the Radiologist Report…
    X-RAY of the Lumbar Spine
    -end plate entophytes are present at multiple levels in the Lumbar and lower Thoracic Spine

    C.T of the Lumbar Spine

    T12-L1-there are small end-plate entophytes and there is mild bilateral facet osteoarthritis
    L1-L2-there are end-plate entophytes and there is mild bilateral osteoarthritis. There is a slight bulging of the disc
    L2-L3-there is a far right disc protrusion, disc material extending into the intervertebral foramen along the exciting L2 nerve root. There are end plate entophytes. There is mild narrowing of the interverterbral foramen bilaterally
    L3-L4-there are end plate entophytes and there is bilateral facet osteoarthritis. There is mild narrowing of the intervertebral foramina bilaterally. There is a bulging of the disc and there is mild bilateral ligament flavum hypertrophy. There is mild central spinal stenosis.
    L4-L5-there are end plate entophytes and there is bilateral facet osteoarthritis. There is a mild narrowing of the intervertebral foramina bilaterally. There is bulging of the disc, and there seems to be a left sided disc protrusion. There is borderline central spinal stenosis.
    L5-S1-there are end plate entophytes and there is bilateral facet osteoarthritis. There is mild narrowing of the intervertebral foramina bilaterally and there is a mild bulging of the disc.

    MRI Of the Lumbar Spine

    L2-L3-There is a right far lateral disc extrusion with some extension into the inferior foramen bilaterally. More so on the right with possible impingement upon the exiting L2 nerve root.
    L3-L4-There is decreased signal intensity and disc height with a broad based protrusion measuring several millimetres flattening the ventral thecal sac. This extends into the far lateral region bilaterally and there is a mild degree of bilateral foramina stenosis. I suspect possible impingement on the exiting L3 nerve root.
    L4-L5-There is a decreased signal intensity and disc height with a broad based disc extrusion flattening the ventral thecal sac. There is a focus of increased signal intensity in the dorsal disc margin which may represent a fissure in the annulus. The broad based bulge does abut the L5 nerve roots in the lateral recesses , more so on the left with likely impingement upon the descending L5 nerve root against the posterior bony canal wall.
    L5-S1- There is a decreased disc in height and signal intensity.
    A broad based disc extrusion is noted posteriorly near the mid line flattening the ventral thecal sac causing a mild degree of left sided foramina stenosis. There is likely impingement upon the exiting L5 nerve root.

    MRI of the Thoracic Spine

    Findings

    A disc bulge is noted at the T8-T9. This appears to be causing spinal cord compression.

    A further disc bulge is noted at the T11-T12. This also appears to be causing spinal cord compression.
    I am in alot of pain, please help.

  4. Mal Read

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    Good Afternoon
    Iam 64 years old and have been holding out in pain for many years by not having surgery. Iam told it is time to carry out what is called major surgery, and have bilateral L4/5 invasive decompression & fusion/fixation with dynamic stabilization procedure done. I have sought second and third opinions and all concur the need for surgery with my preferred surgeon being highly respected in such operations.
    My problem is Iam unable to locate someone who has had successful or failed operations like the above mentioned. Could you please put me in contact with any legitimate persons who are prepared to tell it the way it is after such a procedure.
    I reside at Perth Western Australia if that is of any interest.
    I have been retired for 4 years and consider this time to be a most unpleasant duration due to my poor quality of life which obviously affects others of my family.
    Please give thought to my plight and reply via this email address.

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    1. admin

      Dear Mal,
      If you haven’t already received attention for your problem, please send a summary of your medical history and copies of your MRI scan and xrays to:
      Monterey Spine and Joint
      attention: Jennifer
      12 Upper Ragsdale
      Suite A
      Monterey, CA 93940

  5. William

    Have L1-2 & L2-3 & L3-4 & L4-5 & L5-S1 Discs all buldging with stenosis.Can these be fixed so severe pain will go away.I can’t walk without a walker and pain is so severe I can’t sleep at night.My doctor has given every kind of medication available and none of it has stopped this pain.I think I need a surgeon.Am I right in your opinion? Please send me your opinion.I’ll check in the am to see if you answered.Iam in Georgia and it is 11;40 pm where I am. Thanks for any imfo.

    1. admin

      William,
      It sounds like to you need to see someone promptly and there are certainly many surgeons in Georgia. If you would like us to review your MRI scans and Xrays, please send them to:
      Monterey Spine and Joint
      Attention: Jennifer
      12 Upper Ragsdale
      Suite A
      Monterey, CA 93940

  6. Jennifer

    Hi,

    My mom had MRI and in the report it is marked as “Annular tear noted in l2 l3 and l3-l4 intervertebral disc”

    Is it curable ?

  7. Len Griffiths

    My MRI scan reports,”Large disc extrusion at L4/L5 which in combination with facet joint and ligamentum flavum hypertrophy is causing severe spinal canal stenosis and PRESUMED compression of the transitting nerve roots in cauda equina”. I do not see a specialist for two weeks my questionsa are;
    1.Is he likely to say surgery is neccessary .
    2. Which surgery is it likely to be- microdiscetomy ? Laminectomy? Fusion?
    3.Are there any other alternatives.

    My pain is in right hip,buttock and outside of lower shin/ankle; I can walk normal and have no incontinence;
    I am a 70 year old and have been a bodybuilder for years; the pain arrived 3 months ago;and was a 9 out of ten it is now 6 out of ten; I take Tramadol 50 mg 3×1 per day, diclofenac 2x50ng morning;
    I am worreid in casespecialist says I need MAJOR INVASIVE SURGERY; PLEASE CAN I HAVE YOUR OPINION,

  8. Karen

    What an absolutely wonderful site! You have reduced my anxiety level immensely and I now understand what the doctors are saying – somewhat. I was so lost not understanding anything – + the Dr.’s weren’t helping. You have helped. Thank you.

    Karen

  9. Len Griffiths

    HELLO; your opinion/advice would be welcomed; I am 71 ,and a bodybuilder; early July 2013 I had been the gym and after,felt a severe pain from my buttock to my ankle; the visit to my doctor resulted in diagnosis of sciatica,and I was given Diclofenac tabs,and Tramadol caps; (both 50mg); after no improvement I had an MRI scan; the findings referred to a large disc extrusion which extends superiorly adjacent to the L4. Causing severe spinal canal stenosis in combination to facet joint and ligamentum flaum hypertrophy.There is bunching and presumed compression of the nerve roots in the cauda equina.
    This scan was done at end of August 2013; I do not experience any loss of bowel or bladder control at this moment; and as at 13th October 2013,the pain has lessened; but is bad whene i get out of bed; my questions for your opinion are;
    1.Will I need a discetomy?
    2.Are there any other alternatives?
    3 If the part that is bulged is removed will I not need a Fusion for stability?
    4. Would a Laminectomy be neccessary as well?
    5.If I dont agree to surgery,will my condition worsen,and what would be the possible outcome?

    The pain at first was,on a scale of 1-10, a ten!
    The pain now (14 weeks later) is a 5.

    Your valued opinion or comments would be appreciated.

    Len Griffiths

  10. Julie Karrick

    I recently had my second MRI, I slipped on ice in a parking lot 5 years ago and have had back problems ever since. My recent MRI from 10/22/13 states mild disk space narrowing and mild loss of signal, small broad-based disk protrusion in midline causing pressure effect. Impression was Mild degenerative disk disease. and small disk protrusion at L5-S1, I am only 33 years old, what does this all mean?

  11. billly

    I have been having lower back pain for years and it has become unbearable. I am a 57 year old male and did manual labor in the oil fields for years and have had upper back surgeries. I had a MRI last week that showed, Conus ends at L1. Epidural scarring at L4-L5 and L5-S1. There is a disc protrusion at L5-S1. There is a disc bulge at L4-L5. There is lateral recess stenosis at L4-L5 on the right side. There is foraminal stenosis at L5-S1 bilaterally. There is a Tarlov cyst at L2. Facet arthritis noted in the lower spine as well. What would you recommend? I can get down on my back for two and three weeks without being able to raise up and have severe left leg pain when lying down. What do you recommend? Thanks,Billy.

  12. anthony

    I just had an appointment with my GP about back pain ive been having for a couple months now. He said there was unusual wear found between the L4 and L5 or the L5 and S1 on the MRI. I was told that I need to walk an hour a day but I can barely walk 50 feet without needing to sit down or turn back. the pain medications I was given over that period of time does not help ease the pain. My question is “If there is unusual wear how would walking help? Would it not make the problem worse. Ive been off work now for almost 1 1/2 months. Please help thank you for your time.

  13. Dragan

    I have l5 s1 ddd and spinal stinosis … I’m 27 years and I can’t walk long and can’t stand long what to do this problem is from September this year .

  14. Dragan

    And. From September I have that Ingury on l5 s1 how much time need to pass to start exserase or somting to cure ?

  15. David

    Hello,
    I’m 23 years-old and have had a disectomy and and fusion on at c-5 /c6 as a result of a right lateral protrusion causing severe pain and atrophy caused by nerve irritation. I had be surgery three years ago and still experience burning, and muscle tightness and constant pain on the right side of my neck and trap exclusively, although my muscles in neck do not actually tighten up. After several MRIs, epidurald and radio frequency procedures, nothing has helped. The MRI did not show anything to abnormal in my context. Several disc buldges, degenerative disc disease, disc shortness in legnth etc. In addition, EMG tests revealed nothing significantly abnormal. However since the pain still severely exists, I am still looking for the cause. One think I noticed was that the disc I had the operation on was substantially brighter and extremely whiter the the others. What does this mean? I’m assuming it’s inflammation that still exists three years later. If so, can that be the reason for the chronic pain that had and still lasts only on the right side of my neck/ trap? Thank you.

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