Something which I have been looking thinking about a lot recently is how much time I spend discussing imaging with patients. Not so much their actual images (if they have any), but the possibility of getting them.

The process usually goes like this:

Patient: I have been thinking about having an x-ray/MRI for it
Me: Great! When you get it, there are two possibilities I want you to think about. What if the image shows something? And what if it shows nothing?

These outcomes are both interesting in their own right. Of course imaging can be fantastic and discover serious problems which are waaay outside the scope of my treatment, and can of course save lives. Hopefully the screening process that I perform will have some part to play in that as well. Outside of those cases, though…

If the imaging reveals nothing – what then? Is the problem all in your head (probably, or at least the pain is)? Does this mean that actually something else dreadful is going on which hasn’t been picked up on the local scan? Do we need more investigations? Will they feel like a fraud for having this pain with nothing to show for it?

These are all possibilities, but it is also possible to be reassured by finding nothing, and to feel better, of course!

On the other hand, what if something is found. You would be a pretty unusual adult if nothing was – these “kisses of time” (eloquently described on BIM here by Moseley) feature on everyone. They are responses to the actions you have taken, whether it be scarring, or thickening, or the terrifying “wear and tear”. But seeing them makes the course of action seem very clear! Lop off the disc bulge, flatten out the cartilage, smooth out the imperfections, and everything will be fine.

Unfortunately, this is not always the case. There is masses of evidence showing that there are essentially no links between imaging findings and (for example) low back pain. And so not good evidence to show that fixing them will lead to improvements. This is not to say that there is never a case for spinal surgery! Nor that people who have had beneficial effects after surgery are delusional, or were mistaken in their choice. But there may be a case for not performing invasive treatment in many situations. Certainly, many organisations recommend no routine imaging for low back pain.

All of which is to say, the conclusion of my talk is usually that I don’t recommend the further investigation, but would certainly not persuade them not to do it.

But if you are considering further imaging, make sure you think – what if something is wrong? What if nothing is?