Jordan Loewenstein, D.C. | La Jolla Chiropractor
For most back pain the answer is no, and getting one early is linked to worse outcomes rather than better ones. Here is what the guidelines actually say, what scans find in people who have no pain at all, and the short list of situations where imaging genuinely matters.
For ordinary back pain with no warning signs, every major guideline says the same thing: do not image in the first six weeks. Not to save money. Because the scan almost never changes what you should be doing, and it frequently makes things worse.
The American College of Physicians, the American College of Radiology, the Choosing Wisely campaign and the UK's national guidelines all land in the same place. Those bodies rarely agree on anything. On this they do, and they have for well over a decade.
The reasoning is straightforward. Most back pain improves over a few weeks with movement, time and sensible loading. A scan taken in week one cannot tell you whether you will be one of the people who improves — and almost everyone is.
A large study followed 1,770 back injury claims and compared the people who had an MRI within the first month against those who did not.
The early-imaging group were off work a median of 174 days. The other group: 21 days. They had spinal injections at 11.4% versus 0.8%, surgery at 3.4% versus 0.1%, and around three times the medical costs.
Worth being straight about the limits of that: it is observational, not a randomised trial, and people whose backs look worse are more likely to get scanned in the first place. But the gap is enormous, it survives statistical adjustment, and it points the same way as everything else in this literature.
This is the part that actually matters to you.
A scan of a sore back will find something. It will find something on almost anybody, sore or not — which is the whole point of the next section.
Once that something has a name, a few things change. The back stops being sore and becomes damaged. People move less, lift less, and stop doing the things that were going to fix it. The report gets read at 11pm and the words in it are not reassuring words.
None of that means your pain is imaginary. It means a picture taken out of context is a poor guide to what to do next, and often a worse one than a good examination.
Researchers pooled 33 studies and looked at scans of 3,110 people with no back pain at all. At forty, 68% had disc degeneration and half had a disc bulge — with no symptoms whatsoever. The findings on your report mostly describe a spine that has been used, not a spine that is broken.
Here is the whole table. Every one of these people was pain free when they were scanned.
| Finding on the report | Age 20 | 30 | 40 | 50 | 60 | 70 | 80 |
|---|---|---|---|---|---|---|---|
| Disc degeneration“Degenerative disc disease” on a report | 37% | 52% | 68% | 80% | 88% | 93% | 96% |
| Disc signal lossA disc that has dried out | 17% | 33% | 54% | 73% | 86% | 94% | 97% |
| Loss of disc heightA disc that has flattened | 24% | 34% | 45% | 56% | 67% | 76% | 84% |
| Disc bulgeThe disc spreads past its normal edge | 30% | 40% | 50% | 60% | 69% | 77% | 84% |
| Disc protrusionA more focal bulge, often called a herniation | 29% | 31% | 33% | 36% | 38% | 40% | 43% |
| Annular fissureA small split in the outer ring of the disc | 19% | 20% | 22% | 23% | 25% | 27% | 29% |
| Facet joint wearArthritis in the small joints at the back | 4% | 9% | 18% | 32% | 50% | 69% | 83% |
| SpondylolisthesisOne vertebra sitting forward of the next | 3% | 5% | 8% | 14% | 23% | 35% | 50% |
On a phone, scroll the table sideways. Highlighted columns are ages 40 and 60.
These are the four phrases that send people home worried.
“Degenerative disc disease.” Not a disease, despite the name. Discs lose water content with age the same way hair goes grey. 96% of pain-free eighty-year-olds have it, and so do more than a third of pain-free twenty-year-olds.
“Disc bulge.” The disc spreads slightly past the edge of the bone. Half of pain-free fifty-year-olds have one. On its own it tells you very little about why your back hurts.
“Annular tear” or “annular fissure.” It sounds like something ripped. About one in five pain-free twenty-year-olds have one, and the number barely moves across a whole lifetime.
“Loss of disc height.” The gap between two vertebrae is a bit narrower than average. 45% of pain-free forty-year-olds.
No. An X-ray shows bone and nothing else. A disc is soft tissue, so it is simply not visible on a plain film. You can see the gap where a disc sits and infer that it has thinned, but that is an inference, not a picture of the disc.
Nobody can diagnose a herniated disc from an X-ray. If you want to see a disc, a nerve or the spinal cord, that is an MRI.
Terms like degeneration, bulge and impingement reliably raise fear and make people avoid movement, while the same situation described in plainer language does not. That effect is well documented enough that trials are now running on rewording radiology reports.
This is not a reason to dismiss what you feel. It is a good reason to have someone go through the report with you rather than reading it alone at eleven at night.
A good examination answers most of what you were hoping the scan would answer, and answers it the same day. If anything on that exam says you need imaging, I arrange it. And if you already have a report full of alarming words, going through it together is often the most useful ten minutes of the visit.
The question people actually want answered is not what does my spine look like. It is what is causing this, is it serious, and what do I do about it. A picture is surprisingly bad at the first two. An examination is quite good at all three.
What that looks like. I check how far your back moves and in which directions it runs out. I run orthopaedic tests to work out which structures are involved and which are not. If there is any question of a nerve, I test reflexes, strength and sensation, because that is the finding that actually changes the plan — not a bulge on a report.
Then, face down, I look at how the pelvis is sitting and work through the segments by hand to find where the movement stops. By the end of it there is usually a clear answer about what this is, and a clear answer about whether it needs a scan.
I do not have imaging in the office. When it is warranted I coordinate the referral out, which is the right way round — you get scanned because the exam raised a question, not because a scan was the first step.
The advice to hold off on scans comes with a short list of situations where it does not apply. These are uncommon, but they are the reason a proper history gets taken before anyone tells you to wait six weeks.
Numbness through the saddle area — the parts that would touch a bicycle seat. Losing control of your bladder or bowels, or being unable to start urinating. Weakness in both legs, particularly if it is getting worse over hours.
Together these can mean the nerves at the bottom of the spinal canal are being compressed. It is rare, and it is one of the few back problems where the number of hours matters. Do not wait for an appointment.
Worth saying what is not on that list. Being over fifty on its own. Tweaking your back lifting something. Pain that is severe. A back that has hurt before. None of those are red flags by themselves, and severity in particular is a poor guide — some of the most agonising backs are the ones that settle fastest.
They are not interchangeable. Each one is good at something the others are not.
Shows alignment, fractures, arthritis in the small joints, and a vertebra sitting forward of the one below it. It cannot show a disc, a nerve, the spinal cord or a muscle. Quick, cheap, and a small radiation dose.
Right for: suspected fracture, checking alignment, and looking at bone in an older or osteoporotic patient.
Shows discs, nerve roots, the spinal cord, infection and tumours. No radiation at all. The right scan when a nerve is genuinely involved and the answer will change what happens next.
The trade-off: it is also the scan that finds the most incidental things, which is exactly why it is worth ordering for a reason rather than out of curiosity.
The best look at complicated bone, and quick enough for an emergency department. It is also the fallback when an MRI is not possible — a pacemaker, certain metalwork, or severe claustrophobia.
The trade-off: a considerably higher radiation dose than a plain X-ray, so it is used deliberately rather than as a first look.
For ordinary back pain with no warning signs, no. Every major guideline recommends against imaging in the first six weeks, because the scan rarely changes what you should be doing and is linked to worse outcomes when it is done early.
An X-ray also only shows bone. If your concern is a disc or a nerve, an X-ray cannot answer it either way.
It is not a disease, despite the name. It describes discs that have lost water content, which happens to everyone with age. In people with no back pain at all it shows up in 37% at age twenty, 68% at forty and 96% at eighty.
So it is a description of a spine that has been lived in. Whether it has anything to do with your pain is a question for an examination, not for the report.
No. X-rays show bone. A disc is soft tissue and does not appear on a plain film at all. You can see that the gap between two vertebrae has narrowed and infer the disc has thinned, but that is an inference rather than a picture of the disc.
Seeing a disc, a nerve root or the spinal cord requires an MRI.
No. Plenty of genuinely painful problems are invisible on imaging — irritated joints, muscle and tendon problems, and sensitised nerves do not show up as a picture.
A clear scan is useful information. It rules out the things you were worried about and lets treatment get on with the actual problem.
Not routinely. The examination is what decides whether imaging is needed — range of motion, orthopaedic testing, and a neurological check if there is any question of a nerve.
If anything in that exam raises a flag, I arrange the referral then. That is the right order, because the exam gives the scan a question to answer.
Almost certainly not on the strength of a scan. Half of pain-free fifty-year-olds have a disc bulge and have no idea it is there.
Surgery is decided on symptoms, examination findings and how things respond over time — with the scan used to plan the operation rather than to justify it. Most disc-related symptoms improve substantially without surgery.
About six weeks of genuine treatment is the usual line, assuming there are no red flags. If you are meaningfully better in that time, the scan was never going to add anything.
Sooner if things are getting worse rather than better, if there is real weakness, or if any of the red flags on this page apply.
I do not have imaging in the office, so I coordinate referrals out when the examination warrants one. That is the sequence you want — the exam raises the question, the scan answers it.
If you already have a scan, bring the report and the images. Going through what it means for you specifically is often the most useful part of a first visit.
An examination answers most of what you were hoping a scan would answer, and it happens the same day. If it raises a question that needs imaging, I arrange it. If you already have a report, bring it and I can put it next to what your back is actually doing. Evening and Sunday appointments available.