The Language We Use to Describe Back Issues and its Impact on Outcomes

Who has more back pain? The person with the back imaged with the MRI in Figure 1 or Figure 2 below?

• Figure 1

• Figure 2

Even to an untrained eye the image in figure 2 looks a lot worse.  However, studies have shown (see below) that there is no way to know based on just the image.  What is more, neither of these individuals may have any pain even though the MRIs are “abnormal.”

As physicians, we often toss around terms like degenerative disc disease, arthritis, disc herniation, etc. with little consideration for the consequences that flow from use of these words.

When I read a radiology report that says lumbar degenerative disc it likely means something very different to me than it might to a lay person reading the same report.  The unthinking use of these words can significantly affect the course and prognosis for a person dealing personally with these issues.

Before diving in and looking at the meaning/interpretation of some of these terms, let us set the stage by considering a study done with MRI and back pain called the LAIDBack Study (2001).

This study looked at the prevalence of MRI findings in persons without current low back pain.  Of these 148 people studied, 46% had never experienced low back pain, 83% had moderate to severe desiccation of one or more discs, 64% had one or more bulging discs, 32% had at least one disc protrusion, 6% had one or more disc extrusion. (SPINE. 2001 May 15;26(10):1158-66.)

The significance of these findings cannot be underestimated.  83% of these people without any current back pain have MRI findings fall into a category of what might be called “degenerative disc disease.”  64% of these “normal” people without any back pain have disc protrusions or what might be called a “herniated disc.” 

The authors conclude that “imaging findings must be interpreted carefully and considered in the context of the clinical situation.”  What is more, the question of what is disease and what is normal is hard to define.

Often times a patient comes into my office and has been told at one point in time or another that they have “degenerative disc disease.”  While they may have some wear and tear in disc(s) of the spine, one of my primary goals for the encounter is to remind people that these disc changes are common (even normal) and most of the time issues related to discs, for example, improve with nonsurgical means in the vast majority of cases.  It is hard, though, sometimes to undue the damage done by having a person told that they have a degenerative condition that in their mind is something progressive and “abnormal.”

Studies have shown that people with a history of prior low back symptoms that resolved have “a better set of beliefs.” (Spine 26 (23): 2535-2542.  2001)  That is, these individuals have palpable experience with the fact that most back pain resolves probably regardless of intervention.  On this note, there is “convincing evidence that psychosocial factors [including attitudes and beliefs], more than biomedical or biomechanical factors, are strongly linked to the transition from acute to chronic back pain disability.” (Spine 26 (23): 2535-2542.  2001)

Simple advice to stay active in the context of back pain can make a difference.  “Education on positive messages about back pain can successfully improve outcomes and decrease disability.”  (BMJ Volume 322. 23 June 2001.) 

That is a lesson patients and physicians alike can learn together.