Words matter in radiology reporting. Consider 2 ways of reporting the same lumbar MRI findings:

Standard report: ‘Moderate disc degeneration at L4-5 with posterior disc bulge. Mild facet joint arthropathy L4-5 bilaterally’.

Contextualised report: ‘Disc degeneration at L4-5 with posterior disc bulge (present in 60% of asymptomatic individuals this age). Mild facet joint changes L4-5 (present in 69% of asymptomatic individuals this age). These are normal age-appropriate findings’.

The second report provides crucial context: these findings are normal for the patient's age. This simple addition — including epidemiological prevalence data — can fundamentally change how findings are interpreted.

Building and maintaining confidence in back movement is fundamental to recovery from back pain. Fear-avoidance beliefs are among the predictors of poor outcomes, and standard radiology terminology creates alarm about findings that are normal age-related changes. Including normative data in reports supports evidence-based care by normalising common findings and providing reassurance.

Importantly, many general practitioners and specialists also need education about normal imaging findings. With limited musculoskeletal medicine training during undergraduate and postgraduate years, clinicians may share patients' concerns about ‘degeneration’ and ‘abnormalities’. 

In workers' compensation settings — where imaging findings drive decisions about work capacity and treatment — contextualised reporting becomes even more critical. While there is limited research on this intervention in work injury settings, research on the general population with back pain indicates that contextualised reporting is worthwhile.  

The evidence — promising results in need of specific workers’ comp trials

Large trial shows modest but measurable benefits

The Lumbar Imaging with Reporting of Epidemiology (LIRE) trial involved 238,886 patients across 98 US primary care clinics. Radiologists inserted age-specific prevalence statements like ‘disc degeneration is seen in [X]% of individuals [patient's age] years old’ into reports. 

This simple intervention produced a 5% reduction in opioid prescribing (OR 0.95, P=0.04). CT imaging showed particularly strong results with 29.3% reduction in healthcare utilisation. The intervention was inexpensive (~$5,000 per health system) and showed no adverse effects.(1)

An earlier pilot study suggested stronger effects

A pilot study of 237 lumbar MRI reports found a 71% reduction in narcotic prescribing (OR 0.29, P=0.01) when reports included epidemiological statements.(2) The substantial difference between this and the LIRE trial suggests that how prevalence information is presented may matter as much as whether it is included.

Including epidemiological information reduces subsequent imaging costs

A controlled study found that integrating epidemiological information into MRI reports reduced ensuing radiologic testing costs among patients with low back pain.(3) This demonstrates potential economic benefits alongside clinical outcomes.

Communication approach matters — report wording and patient education

Research on how imaging findings are communicated reveals important insights. Studies examining report wording show that choosing words carefully influences patient perceptions and engagement with best-practice care.(4) When patients receive epidemiological information about findings, they demonstrate more positive back-related perceptions.(5) 

Psychoeducational interventions that help patients interpret imaging results in reassuring ways show feasibility and potential benefit.(6, 7) This suggests that how findings are discussed — with active reassurance and normalising language—profoundly affects outcomes.

The foundation — imaging findings are normal

A systematic review of 3,110 asymptomatic individuals found disc degeneration in 37% at age 20, increasing to 96% by age 80 and disc bulges in 30% at age 20 to 84% by age 80.(8) Findings labelled ‘abnormalities’ are normal age-related changes in pain-free individuals.

A systematic review confirms promise and need for further research

A systematic review of interventions targeting imaging reporting, communication or clinical interpretation found moderate certainty evidence for reduced opioid prescribing and consistent direction of benefit.(9) The review concluded that while effects are modest, further research to refine and optimise these interventions is warranted.

Workers' compensation — where the need is greatest

As detailed in our previous articles on imaging harm, workers' compensation populations experience particularly severe iatrogenic effects from early imaging. 

Australian data shows workers receiving multiple imaging have median disability of 49 weeks versus 6.1 weeks for those with no imaging. 

US data demonstrates $13,000+ higher costs with early MRI despite worse outcomes. Fear-avoidance beliefs predict early imaging utilisation in injured workers. Yet no studies have tested contextualised reporting in workers' compensation settings — the population most likely to benefit.

What might assist

Australian workers' compensation research

A randomised controlled trial testing optimised contextualised reporting—combining prevalence data with reassuring language—in Australian workers' compensation would make a meaningful contribution. With disability differences of 6 weeks versus 49 weeks, the potential for meaningful impact is substantial.

Radiologists — consider including normative data now

While awaiting definitive evidence, radiologists could begin including age-appropriate prevalence information for common findings. Example: ‘Disc degeneration at L4-5 (present in approximately 60% of asymptomatic individuals aged 50-59) or ‘These findings are commonly seen in pain-free individuals and represent normal age-related changes.’ This requires minimal effort and existing evidence demonstrates safety with consistent direction of benefit.

Educate referring clinicians

GPs, physiotherapists and specialists need accessible education about the prevalence of imaging findings in asymptomatic populations. Professional education programs and clinical guidelines should emphasise that most findings do not correlate with symptoms or predict outcomes.

System-level changes in schemes

Workers' compensation schemes have, for decades, tried to discourage early imaging without clinical indication. Working with radiology departments to implement standardised contextualised reporting for work injury claims may reduce the harm from over diagnosis and overtreatment.  

Evidence demonstrates that including normative data in radiology reports is feasible, inexpensive, safe and produces measurable benefits. The effects have been modest, suggesting the approach may benefit from refinement — particularly combining prevalence data with explicitly reassuring language. 

Workers' compensation represents the setting where potential benefits are greatest. Australian research could demonstrate whether optimised contextualised reporting meaningfully improves return-to-work outcomes. In the meantime, radiologists can begin including normative data in routine practice, knowing that even modest population-level effects prevent substantial harm.

Words matter. Context matters. How we report imaging findings can either contribute to harm or support recovery.

References

1. Jarvik JG, Meier EN, James KT, et al. The effect of including benchmark prevalence data of common imaging findings in spine image reports on health care utilization among adults undergoing spine imaging: a stepped-wedge randomized clinical trial. JAMA Netw Open. 2020;3(9):e2015713. 

2. McCullough BJ, Johnson GR, Martin BI, Jarvik JG. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology. 2012;262(3):941-946.

3. Weeks WB, Pike J, Schaeffer CJ, et al. Integrating epidemiological information into MRI reports reduces ensuing radiologic testing costs among patients with low back pain: a controlled study. Jt Comm J Qual Patient Saf. 2020;46(6):365-368. 

4. Karran EL, Medalian Y, Hillier SL, Moseley GL. The impact of choosing words carefully: an online investigation into imaging reporting strategies and best practice care for low back pain. PeerJ. 2017;5:e4151.

5. Medalian Y, Moseley GL, Karran EL. An online investigation into the impact of adding epidemiological information to imaging reports for low back pain. Scand J Pain. 2019;19(3):629-633. 

6. Karran EL, Hillier SL, Yau Y-H, McAuley JH, Moseley GL. A quasi-randomised, controlled, feasibility trial of GLITtER (Green Light Imaging Interpretation to Enhance Recovery)—a psychoeducational intervention for adults with low back pain attending secondary care. PeerJ. 2018;6:e4301. 

7. Karran EL, Yau Y-H, Hillier SL, Moseley GL. The reassuring potential of spinal imaging results: development and testing of a brief, psycho-education intervention for patients attending secondary care. Eur Spine J. 2018;27(1):101-108. 

8. 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. 

9. Witherow MJ, Lawton R, Rees P, et al. Characteristics and effectiveness of interventions that target the reporting, communication, or clinical interpretation of lumbar imaging findings: a systematic review. AJNR Am J Neuroradiol. 2022;43(3):493-500.