Although a primary pain diagnosis rules out secondary causes like structural defects, a CT or MRI often will still show findings like small disc bulges and herniation. Our job as physicians is to interpret findings for our patients. To let them know that age-related changes on imaging can be associated with pain, but more often than not, they are mechanisms that contribute to pain - rather than the driving factor for pain. Explaining scans to patients, and making sure they understand what constitutes normal findings for their age, is very important and sets the stage for a positive recovery experience.
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Thus far, we have discussed primary pain as exclusionary for secondary causes, like structural defects. But oftentimes when we do scans, for example, a CT or MRI of the lumbar spine, we will undoubtedly find small disc bulges, herniations, but without scary features or red flags such as mass effect, spinal cord compression, high abnormal gadolinium signal findings that you'll have. How you explain this to patients is very important because if you just gave them the radiological findings, they could take that as the source or cause of their pain. More often than not, these are normal age-related findings. In the search for what the cause of a primary pain syndrome is, age-related changes on imaging could be associated with pain, but more often than not, those are mechanisms that contribute to pain and are not the driving factor for primary pain.

Our job, of course, is to filter information and interpret information. MRIs are good at finding tumors, fractures, abscesses, infections, things that are emergency situations that we have to treat. MRIs are also really good at finding normal findings. So when you look at the data from MRIs of the back in normal, healthy, and asymptomatic people, you find that 50% of 30-year-olds have disc degeneration on MRIs, who are asymptomatic. 80% of 50-year-olds have this, and 90% of 70-year-olds have disc degeneration. And so disc degeneration is not a cause of back pain. It's an incidental finding, and that's based on the data.

I often tell people, if we do an MRI, if you're over age 40, we're going to find something always. The question is, is that MRI finding the cause of the pain? I rely heavily on the physical exam. I think it's an important part when somebody has a complaint to examine this area, even if other doctors have done it.

I have had people up on the exam table and just asking them, "Does it hurt here where I push?" And I had one woman say to me, "You're the first doctor who's ever touched my back." She'd seen spine surgeons, she'd seen orthopedist, nobody had touched her back. They looked at her MRI, they walked in, they said, you need this or that. The hands on touching, doing an exam, super confidence building for the patient, super confidence building for me that I'm not missing something dangerous. I like the due diligence of imaging. I'm like, "Good. Oh, you did the imaging. The MRI shows us that you don't have bone cancer or you're not about to sever your spinal cord in half or something like that. And your exam's completely normal. This is good news. Everything's working here. Oh, I think this is great. We've got a treatment plan here. We can now start working on where the pain is coming from, coming from the nervous system."

What we can say to patients is, "We can carefully look together, we can explore the situation, we can look at the actual pain that you're having and determine if it actually is caused by these MRI findings or not. We can do that. And if you're interested in looking at that, let's do that together so that we don't over-interpret and scare you into thinking that there's something really wrong when maybe there isn't. That's the last thing that we would want to do. Sometimes doctors haven't been aware of this data that we just showed you. They haven't known about it, or physical therapists or people who may just say, 'Oh, well, because you have pain, this finding must be the cause.'"

In conclusion, we find that there are a lot of incidental or otherwise scary findings on neuroimaging and radiographical imaging, but those could be more so resembling the normal aging process like gray hair and like wrinkles that aren't directly attributable to the primary pain generation.