02/20/2025
This is an article from the New York Times, 1994, which questions the causes of most back pain. Very interesting; worth the read:
A study that examined the spines of people without back pain is casting serious doubt on the
methods used to diagnose and treat people whose backs ache.
The study, led by Dr. Michael N. Brant-Zawadzki, a radiologist at Hoag Memorial Hospital in
Newport Beach, Calif., used magnetic resonance imaging, or M.R.I., to examine the spines of
98 men and women who had no back pain. The researchers found that nearly two-thirds of
the subjects had spinal abnormalities, including bulging or protruding disks, herniated disks
and degenerated disks. A third had more than one abnormal disk.
The investigators concluded that in many cases it may be sheer coincidence -- not cause and
effect -- when a person with back pain is found to have an abnormal disk. Nevertheless,
experts say, the use of M.R.I., a popular and sensitive imaging method, often leads to
unnecessary surgery.
The study is being published today in The New England Journal of Medicine, accompanied
by an editorial by Dr. Richard Deyo, a specialist in internal medicine at the University of
Washington in Seattle.
"I hope this study is very influential," said Dr. Deyo, whose research focuses on the outcome
of treatment for back pain. Many doctors routinely use M.R.I.'s to diagnose back pain, he
said. Misuse of the results this imaging method "is a bigger problem than physicians or
patients realize," he said, adding, "The opportunity to be misled is substantial."
Dr. Robert Boyd, an orthopedic surgeon at Massachusetts General Hospital in Boston, said
researchers did not understand why most people with back pain had symptoms of
abnormalities. Cost Put at $8 Billion
The new study follows others that showed that no matter what methods doctors used to
diagnose disk problems, there seemed to be no correlation between back abnormalities and
back pain. X-rays, CT scans and, in some other studies, M.R.I. scans all showed disk
abnormalities in a large percentage of people with no back pain.
"Most back pain is never explained," Dr. Boyd said. But he added that most back pain also
went away by itself. "If you take 100 people with back pain and look at them again three
months later, 98 of them will be better," he said. "Anything you do to treat them in those
three months will be given credit for healing. Treaters begin to believe that what they are
doing is the reason for the improvement. And patients believe it, too."
Back pain is second only to the common cold as a reason Americans visit their doctors, Dr.
Brant-Zawadzki said. As many as 80 percent of the nation's citizens complain of aching
backs at some time in their lives, and nearly a third have back pain at any given moment.
The annual cost of medical care for people with back pain is more than $8 billion, he said.
Since M.R.I. scans cost about $1,000 each, their overuse and misuse wastes health care
dollars, medical researchers said.
"Too often, people try to use the M.R.I to make a diagnosis," said Dr. John Froymeyer,
director of the McClure Musculoskeletal Research Center at the University of Vermont. "It
misleads you often enough that you perform unnecessary surgery, and the results are not
very good." 'Temptation' for Doctors
Moreover, Dr. Froymeyer said, Americans have almost 10 times more spinal disk operations
than people in other Western countries. Perhaps not coincidentally, there also are far more
neurosurgeons and orthopedic surgeons in the United States, and many times more M.R.I.
machines. For example, he said, there are more M.R.I. machines in Boston than in all of
Canada.
Dr. Boyd attributed overuse of M.R.I.'s to "insecurity, threat of lawsuits, inexperience and
the potential for economic gain."
Dr. Brant-Zawadzki said: "Certain physicians like to be able to explain to their patients why
they're feeling what they're feeling. The temptation is there for doctors who are not
sophisticated to be glib about disk abnormalities and patients' symptoms."
In all the years that doctors have been operating on people with back pain, there has been
only one randomized controlled clinical trial comparing surgery to conservative treatment
like bed rest and exercises, and that was done 20 years ago in Norway.
The study included patients with ruptured disks, Dr. Boyd said, and found that a year after
the patients' problems were diagnosed, about 80 percent of those who had surgery were
better, compared with half of those who did not have surgery. But four years after the study
began, the patients who had had surgery were no different from those who were treated
without it -- about 80 percent of both groups were better.
"Surgery doesn't put new backs in and it doesn't give better long-term results," Dr. Boyd
said. "It is indicated when pain doesn't respond to conservative treatment and is clearly
associated with nerve root compression. Then the results of surgery are excellent. Instead
of waiting a year or two or three to get better, you can wake up from the operation and that
bad leg pain is gone or much better."
But he added that only about 5 percent of people with back pain fell into this category. Tests
Often Unnecessary
Dr. Froymeyer said M.R.I. scans could not even tell a surgeon where to operate. "These
tests are to confirm clinical judgment, not to make a diagnosis," he said. "People need to
understand that most of the time these tests do not need to be done unless there is some
definite reason."
Asked if more M.R.I.'s are done than are needed, Dr. Boyd said his answer was "an
unqualified yes." He said that although he would recommend M.R.I. scans for very few of
the patients referred to him, "I don't see many patients who haven't already had two or
three M.R.I.'s."
He added: "Some physicians won't even see a patient without getting an M.R.I. They will
say, 'Get an M.R.I., send it to me, and I'll tell you if I want to see you.' "
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