Do Imaging Findings Like Disc Herniation Really Correlate With Pain?

The scenario is familiar to every physician: A patient presents with back pain. You order an MRI. The radiology report reads, “L4-L5 disc herniation with nerve root impingement.” The patient clutches the printout like a verdict, convinced they’ve found the source of their agony. But have they?

In modern medicine, there’s a growing paradox: We have more imaging data than ever, yet we understand less about what it actually means—especially when it comes to chronic pain. This is particularly true with spinal imaging.

So the core question emerges: Do findings like disc herniation actually correlate with clinical pain? Or are we treating MRIs instead of patients?

A Glut of Imaging — And a Lack of Context

With the advent of high-resolution MRI, disc abnormalities are more detectable than ever. But the clinical relevance of these findings is often misunderstood. Studies have shown that a significant percentage of asymptomatic individuals have spinal abnormalities on imaging:

Degenerative disc disease is seen in more than 90% of adults over the age of 60.

disc herniation is found in nearly 30% of people who report no back pain at all.

Spinal stenosis is commonly detected in older adults, even when they’re entirely pain-free.

These figures force us to confront a difficult reality: A visible abnormality on imaging doesn’t necessarily indicate the root cause of a patient’s symptoms. In fact, the correlation is often weak, and yet decisions are still being made based on these snapshots of anatomy.

Understanding Pain: A Multidimensional Experience

Pain is not merely a result of structural changes in the body. It’s an intricate and multidimensional phenomenon, influenced by multiple overlapping factors. These include:

Nociceptive input, which relates to tissue damage or mechanical pressure on nerves.

Central nervous system processing, where the brain interprets incoming sensory signals and assigns meaning or intensity to them.

Psychosocial components, such as a person’s mood, history of trauma, levels of anxiety, and their beliefs about movement or disability.

Therefore, the presence of a disc herniation on MRI, though visually compelling, may or may not have anything to do with a patient’s actual experience of pain. The broader context always matters.

What the Research Says

Several key studies have reinforced the disconnect between imaging findings and clinical symptoms. These studies are frequently cited in both radiological and pain literature and are instrumental in reshaping how we interpret MRI results in spine pain.

The Jensen Study (NEJM, 1994)
In a landmark paper, MRIs were performed on 98 asymptomatic individuals:

• 52% had a disc bulge
  
  
• 27% had a disc protrusion
  
  
• 1% had a disc extrusion

None of these individuals had back pain, suggesting that anatomical changes in the spine are often incidental findings rather than pathologic markers.

Brinjikji Meta-Analysis (AJNR, 2015)
This extensive meta-analysis examined 3,110 asymptomatic individuals and found:

• disc degeneration in 37% of 20-year-olds and up to 96% in 80-year-olds
  
  
• Disc bulges in 30% of 20-year-olds and 84% of 80-year-olds

The authors concluded that “spine MRI findings must be interpreted in the context of age and symptoms,” reminding clinicians not to over-attribute symptoms to imaging abnormalities.

Red Flags and True Correlation

Imaging is not without value. In specific clinical contexts—especially when red flags are present—MRI findings do carry diagnostic and therapeutic weight. These situations include:

• Radiculopathy that matches a dermatomal distribution
  
  
• Objective neurological deficits like motor weakness or loss of reflexes
  
  
• Red flags such as cauda equina syndrome, infection, or malignancy
  
  
• Rapidly progressive neurological impairment

Even in these situations, however, the presence of radiological abnormalities does not automatically explain the symptomatology. It’s entirely possible for nerve impingement to appear on imaging with no clinical consequence—or for symptoms to arise with no corresponding radiological abnormality.

Why We Over-Treat Based on Imaging

Despite all evidence, spine imaging continues to be over-utilized and over-interpreted. This is due to several interconnected forces:

• Defensive medicine, where clinicians fear litigation if something is “missed”
  
  
• Patient expectations, with many individuals equating MRIs with answers and legitimacy
  
  
• Insurance requirements, where imaging is necessary before authorizing referrals to physiotherapy or surgery
  
  
• Specialist-driven decisions, where orthopedic or neurosurgical consultations heavily depend on imaging results

The result is a cascade effect:
MRI leads to a diagnosis → the diagnosis drives intervention → the intervention may not work → the patient remains in pain.

This spiral can lead to unnecessary procedures and prolonged suffering—not because the system failed to act, but because it acted on the wrong information.

What Happens When We Treat the Image, Not the Patient

Clinical decision-making that’s overly reliant on imaging leads to significant consequences. These include:

• Unwarranted surgeries, such as spinal fusions for degenerative changes that are part of normal aging
  
  
• Long-term opioid therapy based on anatomical findings, even when those findings are incidental
  
  
• Entrenched chronic pain behaviors due to misdirected treatment and persistent symptoms

Many of these patients become trapped in a cycle where their pain is never adequately addressed, largely because the initial assumptions were incorrect. We must remember: A disc on an MRI is not a diagnosis—it’s a detail in a much larger story.

disc herniation and Pain: When It Matters

That being said, not all imaging findings are irrelevant. In certain acute presentations, disc herniation does indeed correlate well with symptoms:

• Sudden-onset radicular pain following heavy lifting
  
  
• A positive straight leg raise test on physical exam
  
  
• MRI demonstrating a disc impinging on the corresponding nerve root

In these cases, appropriate non-operative management—including physical therapy, NSAIDs, and corticosteroid injections—can provide significant relief. And for patients with persistent symptoms and confirmed imaging-clinical correlation, surgical intervention such as microdiscectomy can be effective.

The key, as always, is not the image itself but its correlation with the clinical picture.

Teaching Medical Students and Patients the Nuance

There’s an urgent need to reshape both medical education and patient communication. We must teach future clinicians—and remind ourselves—that:

• MRI findings are incidental until proven clinically relevant
  
  
• Pain is a subjective, biopsychosocial phenomenon—not simply a structural problem
  
  
• Imaging should support a diagnosis, not serve as the primary discovery tool

Equally important is managing patient expectations. When discussing MRI results, it’s critical to say:

“Just because something appears on the scan doesn’t mean it’s what’s causing your pain.”

These words can reframe the entire clinical encounter and prevent the cascade of unnecessary interventions.

The Psychological Impact of an MRI Report

One of the most underestimated aspects of modern imaging is its psychological effect on patients. Diagnostic labels carry emotional weight. When patients are told they have “degenerative disc disease,” it often leads to:

• Avoidance of activity and movement
  
  
• Fear of worsening the problem
  
  
• A self-perception of being “damaged” or fragile

Despite the fact that degenerative disc disease is a common feature of normal aging, the term “disease” can foster anxiety, dependency, and maladaptive behaviors. Clinicians must communicate imaging results with context and care to avoid iatrogenic harm.

So, Should We Still Order MRIs for back pain?

Yes—but judiciously. Most evidence-based guidelines agree that imaging should be performed only when:

• There are signs of serious pathology (e.g., cancer, infection, fracture, or cauda equina)
  
  
• Neurological deficits are severe or worsening
  
  
• Symptoms persist beyond six weeks despite conservative therapy

Imaging should not be ordered for:

• Acute nonspecific low back pain of less than six weeks’ duration
  
  
• Pain without any red flags
  
  
• Patients whose symptoms are well-controlled and improving

Following these principles helps ensure imaging enhances care rather than misleads it.

Conclusion: Imaging Is a Tool, Not a Truth

Disc herniations are common. back pain is complex. The two often coexist, but not always causally. As clinicians, we need to shift our mindset:

• Not every disc herniation is painful
  
  
• Not every case of back pain has an identifiable structural cause
  
  
• Not all imaging findings require treatment

The real clinical art lies in aligning the patient’s story with the imaging—not the other way around. An MRI should never dictate the plan. Instead, it should serve as a supporting character in the broader clinical narrative.