Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Technology Insight: imaging of low back pain

Nature Clinical Practice Rheumatology volume 2, pages 554–561 (2006)Cite this article

Abstract

Chronic low back pain is a common condition that has significant economic consequences for affected patients and their communities. Despite the prevailing view that an anatomic diagnosis is often impossible, an origin for the pain can frequently be found if current diagnostic techniques are fully used. Such techniques include a mixture of noninvasive and invasive imaging. Prevalence data suggest that the intervertebral disc is one of the most common sources of back pain, accounting for around 40% of cases. The pathologic basis for discogenic low back pain might be full-thickness radial tears of the annulus fibrosus. Unfortunately, only MRI can image the internal morphology of the disc, and both CT and MRI lack the necessary specificity to validate this hypothesis. Many so-called radiographic abnormalities seen on CT and MRI are commonly encountered in asymptomatic individuals. Invasive techniques such as joint injections, nerve blocks and provocative discography can show the connection between an abnormal image and the source of low back pain, but do have notable related risks. The development of a noninvasive, low-risk technique that can show this connection is desirable.

Key Points

  • The anatomic diagnosis of low back pain is possible in approximately half of the patients with chronic low back pain

  • Currently available imaging techniques have diagnostic limitations

  • The use of both noninvasive and invasive imaging is necessary to diagnose chronic low back pain

  • MRI and provocative discography are the most valuable imaging techniques

  • Discography and joint injections are currently the only means of determining whether abnormal structures are the origin of low back pain

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Use of joint injection and nerve block to assess facet joint and sacroiliac joint pain.
Figure 2: Plain lateral radiograph of the lumbar spine demonstrating degenerative changes in the disc.
Figure 3: Single-photon emission CT of the lumbar spine demonstrating increased metabolic activity in the L5 facet joints.
Figure 4: Reconstructed sagittal CT view of the lumbar spine demonstrating an L5/S1 foraminal spur, visible despite the presence of metal instrumentation.
Figure 5: Identification of degenerative changes on MRI of the lumbar spine.
Figure 6: Lumbar discograms showing annular fissures.

Similar content being viewed by others

References

  1. Deyo RA (1993) Back pain revisited: newer thinking on diagnosis and therapy. Consultant 33: 88–100

    Google Scholar 

  2. Waddell G (1987) A new clinical model for the treatment of low-back pain: 1987 Volvo award in clinical sciences. Spine 12: 632–644

    Article  CAS  Google Scholar 

  3. Lawrence RC et al. (1998) Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 41: 778–799

    Article  CAS  Google Scholar 

  4. Hourcade S and Treves R (2002) Computed tomography in low back pain and sciatica: a retrospective study of 132 patients in the Haute-Vienne district of France. Joint Bone Spine 69: 589–596

    Article  Google Scholar 

  5. Kuslich SD et al. (1991) The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop Clin North Am 22: 181–187

    CAS  PubMed  Google Scholar 

  6. Bogduk N and McGuirk B (2002) Causes and sources of chronic low back pain. In Medical Management of Acute and Chronic Low Back Pain. An Evidence-Based Approach, 115–126 (Eds Bogduk N and McGuirk B) Amsterdam: Elsevier. [Pain Research and Clinical Management, vol 13.]

    Google Scholar 

  7. Jensen MC et al. (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. N Eng J Med 331: 69–73

    Article  CAS  Google Scholar 

  8. Benneker LM et al. (2005) Correlation of radiographic and MRI parameters to morphological and biochemical assessment of intervertebral disc degeneration. Eur Spine J 14: 27–35

    Article  Google Scholar 

  9. Mixter WJ and Bar JS (1934) Rupture of the intervertebral disc with involvement of the spinal canal. N Eng J Med 211: 210–215

    Article  Google Scholar 

  10. Crock HV (1970) A reappraisal of intervertebral disc lesions. Med J Aust 16: 983–989

    Google Scholar 

  11. Lee KS et al. (2003) Diagnostic criteria for the clinical syndrome of internal disc disruption: are they reliable? Br J Neurosurg 17: 19–23

    CAS  PubMed  Google Scholar 

  12. Beattie PF and Meyers SP (1998) Magnetic resonance imaging in low back pain: general principles and clinical issues. Phys Ther 78: 738–753

    Article  CAS  Google Scholar 

  13. Buckwalter JA (1995) Aging and degeneration of the human intervertebral disc. Spine 20: 1307–1314

    Article  CAS  Google Scholar 

  14. Adams MA et al. (1996) 'Stress' distributions inside intervertebral discs: the effects of age and degeneration. J Bone Joint Surg 78: 965–972

    Article  CAS  Google Scholar 

  15. Jarvik JG and Deyo RA (2000) Imaging of lumbar intervertebral disk degeneration and aging, excluding disk herniations. Radiol Clin N Am 38: 1255–1266

    Article  CAS  Google Scholar 

  16. Peng B et al. (2005) The pathogenesis of discogenic low back pain. J Bone Joint Surg 87: 62–67

    Article  CAS  Google Scholar 

  17. Schwarzer AC et al. (1994) Clinical features of patients with pain stemming from the lumbar zygapophysial joints: is the lumbar facet syndrome a clinical entity? Spine 19: 1132–1137

    Article  CAS  Google Scholar 

  18. Schwarzer AC et al. (1995) The prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis 54: 100–106

    Article  CAS  Google Scholar 

  19. Maigne J-Y et al. (1996) Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 21: 1889–1892

    Article  CAS  Google Scholar 

  20. Manchikanti L et al. (2001) Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 4: 308–316

    CAS  PubMed  Google Scholar 

  21. Cohen SP et al. (2002) Does needle insertion site affect diskography results? A retrospective analysis. Spine 27: 2279–2283

    Article  Google Scholar 

  22. Schwarzer AC (1995) The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 20: 1878–1883

    Article  CAS  Google Scholar 

  23. Yukawa Y et al. (1997) Groin pain associated with lower lumbar disc herniation. Spine 22: 1736–1739

    Article  CAS  Google Scholar 

  24. Mann NH et al. (1992) Expert performance in low-back disorder recognition using patient pain drawings. J Spinal Disord 5: 254–259

    Article  Google Scholar 

  25. Ohnmeiss DD et al. (1999) Relation between pain location and disc pathology: a study of pain drawings and CT/discography. Clin J Pain 15: 210–217

    Article  CAS  Google Scholar 

  26. Frobin W et al. (2001) Height of lumbar discs measured from radiographs compared with degeneration and height classified from MR images. Eur Radiol 11: 263–269

    Article  CAS  Google Scholar 

  27. Naish C et al. (2003) Ultrasound imaging of the intervertebral disc. Spine 28: 107–113

    Article  Google Scholar 

  28. Kakitsubata Y et al. (2005) Sonographic characterization of the lumbar intervertebral disk with anatomic correlation and histopathologic findings. J Ultrasound Med 24: 489–499

    Article  Google Scholar 

  29. Tervonen O et al. (1991) Ultrasound diagnosis of lumbar disc degeneration. Comparison with computed tomography/discography. Spine 16: 951–954

    Article  CAS  Google Scholar 

  30. Murray IP and Dixon J (1989) The role of single proton emission computed tomography in bone scintigraphy. Skeletal Radiol 18: 493–505

    Article  CAS  Google Scholar 

  31. Gates GF (1988) SPECT imaging of the lumbrosacral spine and pelvis. Clin Nucl Med 13: 907–914

    Article  CAS  Google Scholar 

  32. Dolan AL et al. (1996) The value of SPECT scans in identifying back pain likely to benefit from facet joint injection. Br J Rheumatol 35: 1269–1273

    Article  CAS  Google Scholar 

  33. Haughton V (2004) Medical imaging of intervertebral disc degeneration: current status of imaging. Spine 29: 2751–2756

    Article  Google Scholar 

  34. Liem LA and van Dongen VC (1997) Magnetic resonance imaging and spinal cord stimulation systems. Pain 70: 95–97

    Article  CAS  Google Scholar 

  35. Haughton VM et al. (2002) Measuring the axial rotation of lumbar vertebrae in vivo with MR imaging. AJNR 23: 1110–1116

    PubMed  Google Scholar 

  36. Masui T et al. (2005) Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. J Spinal Disord Tech 18: 121–126

    Article  Google Scholar 

  37. Kjaer P et al. (2005) Magnetic resonance imaging and low back pain in adults: a diagnostic imaging study of 40-year-old men and women. Spine 30: 1173–1180

    Article  Google Scholar 

  38. Ito M et al. (1998) Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine 23: 1252–1260

    Article  CAS  Google Scholar 

  39. Aprill C and Bogduk N (1992) High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol 65: 361–369

    Article  CAS  Google Scholar 

  40. Lam KS et al. (2001) Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the diagnostic pain source. Eur Spine J 9: 36–41

    Article  Google Scholar 

  41. Carragee EJ and Alamin TF (2001) Discography: a review. Spine J 1: 364–372

    Article  CAS  Google Scholar 

  42. Schellhas KP et al. (1996) Lumbar disc high-intensity zone: correlation of magnetic resonance imaging and discography. Spine 21: 79–86

    Article  CAS  Google Scholar 

  43. Horton WC and Daftari TK (1992) Which disc as visualized by magnetic resonance imaging is actually a source of pain? Spine 17: S164–S171

    Article  CAS  Google Scholar 

  44. Brightbill TC et al. (1994) Normal magnetic resonance imaging and abnormal discography in lumbar disc disruption. Spine 18: 1075–1077

    Article  Google Scholar 

  45. Modic MT et al. (1998) Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 166: 195–199

    Google Scholar 

  46. Braithwaite I et al. (1998) Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur Spine J 7: 363–368

    Article  CAS  Google Scholar 

  47. Sandhu HS et al. (2000) Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI. J Spinal Disord 13: 438–443

    Article  CAS  Google Scholar 

  48. Bydder GM (2002) New approaches to magnetic resonance imaging of intervertebral discs, tendons, ligaments and menisci. Spine 27: 1264–1268

    Article  Google Scholar 

  49. Siddiqui M et al. (2005) The positional magnetic resonance imaging changes in the lumbar spine following insertion of a novel interspinous process distraction device. Spine 30: 2677–2682

    Article  Google Scholar 

  50. Osti OL et al. (1990) Discitis after discography: the role of prophylactic antibiotics. J Bone Joint Surg 72: 271–274

    Article  CAS  Google Scholar 

  51. Lindblom K (1948) Diagnostic puncture of intervertebral disks in sciatica. Acta Orthop Scand 17: 231–259

    Article  CAS  Google Scholar 

  52. Holt EP (1968) The question of lumbar discography. J Bone Joint Surg 50A: 720–726

    Article  Google Scholar 

  53. Walsh TR et al. (1990) Lumbar discography in normal subjects. J Bone Joint Surg 72A: 1081–1088

    Article  Google Scholar 

  54. Carragee EJ et al. (2000) Lumbar high-intensity zone and discography in subjects without low back problems: 2000 Volvo Award winner in clinical studies. Spine 25: 2987–2992

    Article  CAS  Google Scholar 

  55. Carragee EJ et al. (2005) Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J 5: 24–35

    Article  Google Scholar 

  56. Carragee EJ et al. (1999) False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. Spine 24: 2542–2547

    Article  CAS  Google Scholar 

  57. Derby R et al. (1999) The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Spine 24: 364–371

    Article  CAS  Google Scholar 

  58. Moneta GB et al. (1994) Reported pain during lumbar discography as a function of anular ruptures and disc degeneration. A re-analysis of 833 discograms. Spine 19: 1968–1974

    Article  CAS  Google Scholar 

  59. Derby R et al. (2005) The relation between annular disruption on computed tomography scan and pressure-controlled discography. Arch Phys Med Rehabil 86: 1534–1538

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Director of the Perth Pain Management Center, South Perth, Western Australia

    Philip Finch

Authors
  1. Philip Finch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Philip Finch.

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Finch, P. Technology Insight: imaging of low back pain. Nat Rev Rheumatol 2, 554–561 (2006). https://doi.org/10.1038/ncprheum0293

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncprheum0293

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing