Appendix: Evidence of harm from back pain imaging

This is not a systematic review but a collection of the evidence on this topic.

For decades we have known that people with so-called degenerative changes on spinal imaging are somewhat more likely to report back pain—but the association is weak. Severe changes can occur in people without pain, while many people with disabling back pain have normal scans. Muscle spasm, for instance, can be profoundly painful but invisible on imaging. Conversely, “terrible” scans often belong to people with no symptoms at all.

Imaging remains essential when results will change management—for example, red flags, progressive neurological deficit, trauma, or surgical planning. The evidence above concerns routine or early imaging in non-specific low back pain, where studies consistently show harm without clinical benefit.

Importantly, imaging offers little help in deciding treatment, predicting work capacity, or explaining the lived experience of pain. The studies presented here highlight the problems that arise from routine or early imaging in non-specific low back pain. They are grouped together to show the weight of evidence that routine imaging does harm, and to underscore its significance for medical practice and for workers’ compensation schemes.

This appendix is included to complement the two articles on the harms of spinal radiology: the main text presents the argument and lived experience, while the appendix shows the breadth of underlying research evidence that links routine imaging to poorer recovery, more procedures, and higher costs.

How people interpret and respond to scan results

Patients reading their own reports become more worried and catastrophise
In a cross-sectional survey of 162 adults with low back pain who had recently undergone CT or MRI, 63% reported that reading their radiology reports improved their understanding. However, common terms such as “degeneration” or “disc bulge” provoked worry that exceeded spine specialists’ ratings, and this concern correlated with higher scores on the Pain Catastrophizing Scale. The study concluded that while access to reports can improve transparency, it can also provoke unnecessary anxiety in vulnerable patients.
Reference: Regev G, Treister R, Brill S, et al. Low back pain patients’ perceptions regarding their own radiology reports: pre-intervention survey. J Pain Res. 2023;16:933-941. PubMed: 36960465

Diagnostic labels shape expectations and demand for care
A large randomised scenario-based trial (n=1,375) tested the impact of different diagnostic labels on management expectations for low back pain. Participants given neutral terms such as “lumbar sprain” or “non-specific back pain” expected faster recovery and were less likely to believe they needed imaging, surgery, or second opinions. In contrast, those given pathologising terms such as “disc degeneration” or “arthritis” perceived the condition as more serious and expressed stronger preferences for medical intervention. The effect was consistent across those with and without previous back pain. This demonstrates how terminology alone can drive cascades of unnecessary care.
Reference: O’Keeffe M, Ferreira GE, Harris IA, et al. Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomised scenario-based experiment. Eur J Pain. 2022;26(7):1532-1545. PubMed: 35616226

Report wording can induce catastrophising and preference for invasive care
Rajasekaran and colleagues investigated the effects of standard radiology reporting on patient perceptions. Through a program of studies, they compared conventional reports with “clinical reporting” that described common findings as age-appropriate. In randomised and simulated settings, patients exposed to standard terminology were more likely to catastrophise and to prefer invasive treatments. When reports used contextual, reassuring wording, patients expressed less fear and were more accepting of conservative care.
Reference: Rajasekaran S, Tangavel C, Aiyer SN, et al. The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials. Eur Spine J. 2021;30(10):2069-2081. PubMed: 33748882

Being told about scan findings can worsen perceived health
A prospective randomised study of 246 patients with acute low back pain or radiculopathy compared disclosure versus non-disclosure of MRI/CT results. Clinicians were aware of all findings, but only half the patients were informed of their results. Those told their results reported significantly worse general health perceptions and more back-specific worry at follow-up, with effects persisting to one year. Clinical outcomes such as pain and function did not differ. The authors concluded that disclosure of benign findings can itself act as a nocebo, worsening perceived health without benefit.
Reference: Ash LM, Modic MT, Obuchowski NA, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008;29(6):1098-1103. PubMed: 18467522

Most scan “abnormalities” are normal age-related changes
A systematic review of 33 studies involving over 3,000 asymptomatic individuals analysed the prevalence of degenerative spinal changes across age groups. Findings traditionally labelled as abnormal, such as disc degeneration and disc bulges, were common in people without pain. Disc degeneration was present in 37% of healthy 20-year-olds and 96% of healthy 80-year-olds. Disc bulges were seen in 30% of 20-year-olds and 84% of 80-year-olds. The prevalence of these changes rose steadily with age, demonstrating that many “abnormalities” on imaging are normal features of ageing.
Reference: Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. PubMed: 25430861

Clinical harm: worse pain and delayed recovery

Early imaging makes pain persist longer and reduces recovery
An unblinded randomised controlled trial conducted across 52 UK general practices included 421 adults with persistent low back pain. Participants were randomised to receive immediate lumbar X-ray or usual care. Those who received imaging were more likely to have ongoing pain at 3 months, reported worse overall health, and consulted more often, despite no improvements in function. The imaging group was 26% more likely to report persistent pain compared with those managed without X-rays. The study concluded that routine radiography does not improve outcomes and may worsen patient perceptions of health.
Reference: Kendrick D, Fielding K, Bentley E, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ. 2001;322(7283):400-405. PubMed: 11179160

Workers with early scans stay off work far longer
In workers’ compensation cohorts, early MRI is associated with prolonged disability, more procedures, and substantially higher costs. A retrospective analysis of 1,770 claims found that workers imaged within 30 days had a median of 174 days off work, compared with just 21 days for those who did not undergo early imaging. Early MRI was also associated with greater psychological distress, more spinal injections (11.4% vs 0.8%) and surgeries (3.4% vs 0.1%), and nearly three-fold higher medical costs ($21,282 vs $7,198). These findings held even after adjusting for baseline severity, suggesting that early MRI itself contributes to worse outcomes.
Reference: Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine. 2013;38(22):1939-1946. PubMed: 23883826

Systematic evidence confirms early MRI prolongs disability
A systematic review and narrative synthesis examined multiple observational cohorts of workers with acute low back pain. Across all included studies, early MRI was consistently associated with longer disability duration and greater healthcare utilisation, without evidence of better clinical outcomes. The review concluded that early imaging acts as a driver of prolonged disability.
Reference: Shraim M, et al. The association between early MRI and length of disability in acute lower back pain: a systematic review and narrative synthesis. BMC Musculoskelet Disord. 2021;22:906. PubMed: 34819061

Medical consequences: unnecessary procedures and interventions

Early MRI leads to dramatically higher surgery rates
In a large retrospective matched cohort study using US Veterans Health Administration data (n≈57,293), patients with uncomplicated low back pain who underwent early MRI had markedly worse downstream outcomes. They were 12.7 times more likely to have lumbar surgery (1.48% vs 0.12%), 23% more likely to receive opioid prescriptions (35.1% vs 28.6%), and accrued significantly higher healthcare costs. Pain scores were also slightly worse in the early imaging group. The study demonstrates that early MRI can trigger a cascade of interventions without improving patient outcomes.
Reference: Jacobs JC, Jarvik JG, Chou R, et al. Observational study of the downstream consequences of inappropriate MRI of the lumbar spine. J Gen Intern Med. 2020;35(12):3605-3612. PubMed: 32989711

Workers’ compensation cases show more injections and surgery when MRI is early
The same retrospective cohort of 1,770 workers with acute disabling low back pain showed that those who underwent early MRI had far more procedures than those managed without. Spinal injections were performed in 11.4% of the early MRI group compared with 0.8% of the no-imaging group. Surgery was required in 3.4% vs 0.1%. These differences translated into almost three-fold higher medical costs, highlighting how early imaging drives invasive procedures and system costs.
Reference: Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine. 2013;38(22):1939-1946. PubMed: 23883826

Regional imaging rates predict surgery rates
A cross-sectional analysis of US hospital referral regions examined whether variation in imaging use was associated with variation in surgery. The study found a moderate positive correlation (r=0.46) between regional rates of advanced spinal imaging and rates of spine surgery (R²=0.22). This demonstrates that local supply and practice patterns, rather than patient need, strongly influence whether patients undergo surgery.
Reference: Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine. 2003;28(6):616-620. PubMed: 12642771

Economic impact: higher costs without better outcomes

Early imaging substantially increases costs
Analysis of the Veterans Health Administration cohort (n≈57,293) found that patients who underwent early MRI incurred significantly higher costs, even within the first episode of care. On average, costs were $8,082 compared with $5,560 for those who did not receive early imaging—a difference of $2,522. Costs continued to diverge over the following year as early imaging patients required more specialist consultations, procedures, and follow-up care. This confirms that the financial harms of early imaging emerge immediately and persist.
Reference: Jacobs JC, Jarvik JG, Chou R, et al. Observational study of the downstream consequences of inappropriate MRI of the lumbar spine. J Gen Intern Med. 2020;35(12):3605-3612. PubMed: 32989711

Workers’ compensation costs nearly triple with early MRI
In compensable care, early MRI is associated with strikingly higher system costs. In the 1,770-case workers’ compensation cohort, early MRI recipients accrued nearly three-fold higher medical costs: $21,282 compared with $7,198 for those who did not undergo early imaging. These costs reflect not just the price of the scan but the cascade of downstream care including injections, surgeries, prolonged disability and extended claim duration.
Reference: Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine. 2013;38(22):1939-1946. PubMed: 23883826

Cascade effects multiply initial costs
An economic evaluation of musculoskeletal MRI use in UK primary care found that each unnecessary scan generated downstream costs estimated at multiple times the price of the scan—on the order of five- to seven-fold in their estimates. These costs arose from follow-on referrals, further imaging, specialist consultations, procedures and prescriptions, all triggered by the initial investigation. The study demonstrates how seemingly minor overuse at the front end can cascade into substantial system burden.
Reference: Sajid IM, Parkunan A, Frost K. Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ Open Qual. 2021;10(3):e001287. PubMed: 34215659