Resolve Low Back Issues Part 5: You Are Not Your Image. (Red Flags & Imaging Considerations)

In part 4 of our Fix Your Low Back series, we discussed some of the most common myths and misunderstandings around low back pain, care of low back pain, as well as updating some of the old-fashioned thoughts. Today, we are going to discuss imaging and red flags as it pertains to low back pain and a couple of VERY IMPORTANT things you need to know.


Imaging is a excellent diagnostic tool, when appropriate, to help ASSURE PROPER care.

Not-so-long ago, a patient would walk into a chiropractic office and get a standard set of x-rays; or they would schedule an appointment with an orthopedic physician and would be required to obtain an MRI before they can be seen.

This standard practice has fortunately been labeled as inappropriate, and national organizations such as the American Chiropractic Association and American College of Physicians have recently taken a strong stance against these practices.


  1. Do not obtain spinal imaging for patients with acute low-back pain during the initial 6 weeks after onset in the absence of red flags.

  2. Imaging should not be utilized to monitor a patients progress.


There are two extremely important things to know concerning imaging…

  1. Imaging can be harmful. Radiation aside. Unnecessary x-rays and MRIs can bring to light ‘normal variances’ that are NOT the generator of pain, but are easy to blame. This causes what is being referred to as the ‘medicalization’ of low back pain.

    Example: Someone presents with low back pain, an image is immediately ordered, it shows a bulging disc or some other skeletal irregularity, and the blame for the complaint is placed on this without further discussion. This patient goes on to think that they are doomed to low back pain forever, that their ‘bad back’ will keep them from enjoying their normal activities, and unfortunately, they end up with a regular dose of over-the-counter and prescription drugs.

    Now, this is not always the case, but once or twice each month, a patient with low back pain presents to our office stating that they had a bulging disc in their low back over 10 years ago and have been in constant pain ever since. These cases have more to them than just pain, the overutilization and misuse of imaging leads to fear avoidance and catastrophizing. Both are always present in chronic low back pain!

  2. Through recent studies, we know that to a certain degree, lower spine degeneration and pathology are normal, AND NON-PAIN GENERATING, at almost all ages.

What is so important about this chart? Well….

These numbers represent the percent of specific age groups that had degeneration and disc pathology of the lower back in patients who had NO SYMPTOMS OR COMPLAINTS whatsoever.

Also, this was no small review….this study included over 3100 people!

In review, If we took a pain-free 40 y/o person with NO history of low back pain…

Almost 70% would demonstrate degeneration on x-ray.

50% would show a bulging disc on MRI.

Our take-a-way here… YOU ARE NOT YOUR IMAGE! They can play tricks on your thinking and make your back pain much worse just by you believing that what your image is showing is the end all be all of your pain.

With that aside, we do need imaging. WHEN INDICATED THROUGH A PROPER EXAM! Imaging is great for ruling out serious pathology.



Red flags are indicators that let physicians know there might be something more serious going on. This can come from a simple history and exam and they demand attention and should be considered before care of any kind is provided. With that said, here is a small list of ‘Red Flags’ common with low back pain complaints.

  • History of Cancer.

  • Night Pain.

  • Progressive Neurological Symptoms & Weakness.

  • Pain Following Trauma (Fall, Auto Accident, etc.)

  • Sudden Loss of Bowel or Bladder Function.

  • Recent Weight Loss.

  • New Back Pain With Fever.

  • Failure of 4-6 Weeks of Conservative Care.

  • History of Recent Fracture of Suspected Fracture.

  • Family History & Signs of Osteopenia & Osteoporosis.

In summary, and I hate to keep harping on this, but your imaging results may not be as important as they are made out to be in regards to uncomplicated, and even chronic, low back pain.

  • Spinal degeneration, disc bulge, and other pathologies are often normal findings as we age and have not been proven to be pain generators.

  • Imaging early in the care process in the absence of red flags is NOT in line with current ‘best practice’ suggestions and guidelines.

  • Studies have shown that a thorough history and exam with your provider can provide information to determine the actual cause of your low back pain.

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.