What a radiologist is doing, and what they are not

A radiologist describes what is visible on the images in front of them, thoroughly and without knowing your symptoms, your examination or your working life. That is the correct professional standard and it produces a complete inventory of everything present, normal for age or otherwise.

The inventory then reaches you as a list of alarming nouns. Degeneration. Desiccation. Bulging. Narrowing. Arthropathy. None of those words was chosen to describe your pain, because your pain was not in the room. The step that has usually been skipped is the one where a clinician reads that inventory against a physical examination and decides which line, if any, corresponds to what you feel.

The findings that are usually just age

• Disc desiccation — present in most adults past their thirties.
• Disc bulge — common and largely age-related; its prevalence rises decade by decade in people with no symptoms.
• Facet arthropathy — near-ubiquitous in later decades and, importantly, not the way facet pain is diagnosed. That requires a block.
• Mild foraminal or canal narrowing — only meaningful if it matches a symptom pattern and an examination.
• Schmorl’s nodes, endplate changes, mild scoliosis — usually incidental.
• Annular fissure — sometimes a genuine pain source, frequently not, and historically over-interpreted.

This is the central finding of decades of imaging research and it is not controversial: degenerative features on lumbar imaging are extremely common in people who have never had back pain, and they become more common with every decade. Which means that finding them in you establishes almost nothing on its own.

The findings that do change things

• A disc extrusion or sequestration that matches the symptomatic level and the examination.
• Compression of a nerve root on the side and at the level that corresponds to a real neurological deficit.
• Severe central canal stenosis in someone with the matching distance-limited walking pattern. Stenosis.
• Spondylolisthesis with demonstrable instability on flexion and extension views.
• Infection, fracture, or a lesion suspicious for malignancy — uncommon, and the reason imaging exists at all when a red flag is present.
• Inflammatory sacroiliitis, which points away from mechanical pain and toward rheumatology.

Notice the recurring word. Matches. A finding earns its significance from correspondence with the person, and nothing else on the report does.

The two errors that follow a scan

What the scan cannot see at all

It cannot see facet-mediated pain, sacroiliac pain, muscular and myofascial pain generators, central sensitization, or the metabolic state of the tissue it is picturing. Between them those account for a very large share of persistent low back pain, which is why a workup that begins and ends with imaging misses most of the field.

It also cannot see load. A disc photographed lying flat in a magnet is not the disc that fails at the end of a shift, and the whole clinical problem is behavior under load. That gap is not a flaw in the technology; it is a limit of what a still image of an unloaded spine can contain.

Why the terrain does not appear on the report either

The tissue in those images is being maintained by a metabolic system, and its state determines both why the structure degenerated and how it will respond to anything we do. Chronic hyperinsulinemia glycates and cross-links collagen, so the annulus and the facet capsule are stiffer and more prone to fissuring. Systemic inflammation holds the tissue in a degradative state, so ordinary microdamage does not clear. Endplate microvascular disease blocks the diffusion route that feeds the disc.

None of that is visible, and all of it is measurable in blood. It is the reason a back consultation here includes bloodwork alongside the imaging review — not to sell a metabolic program, but because a structural plan built on an inflamed terrain underperforms and it is better to know that before rather than after.

And there is a plain economic layer under it. The population that arrives with the worst imaging is disproportionately the population working the schedules and eating the food that produce the terrain, which is a fact about a food and labor system rather than about individual discipline. Treating the level and lecturing the patient is the wrong response to both halves.

Common questions

My MRI was normal. Does that mean it is in my head?

No, and that inference is one of the more damaging things done in this field. It means the cause is not one that MRI images. Facet joints, the sacroiliac joint and sensitization are all invisible on it and all common.

That is the subject of You have explained it four times. Nobody wrote it down..

Should I get a new scan?

Usually not, unless something has changed neurologically or a red flag has appeared. Repeating a scan rarely changes management and reliably finds another incidental abnormality to worry about. Re-scanning a known pattern finds the same changes it found last time.

My scan looks terrible. Am I heading for a wheelchair?

Almost certainly not. The correlation between how degenerate a lumbar spine looks and how a person functions is weak, and plenty of people with frightening reports walk, work and lift without difficulty. Function is the outcome that matters and it is more modifiable than the pictures.

It is not a disease and it is not progressive in the way the name implies. goes through it in detail.

What should I bring?

The actual images if you have them, not only the report — a disc on file or a portal login. Reading the images against an examination is the step that has usually been missed, and it needs the images. What happens at the first visit.

Related reading

• Lumbar facet syndrome
• Is it actually the disc?
• The diagnostic block, explained
• When back pain is an emergency
• Back pain doctor in St. Louis

Early imaging does not improve outcomes, and it reliably produces a culprit.