Can We Image Low Back Pain with MRI?

Written by: James Demetrious, DC, DABCO

Diplomate, American Board of Chiropractic Orthopedists

Can We Visualize the Painful Spine?

How meaningful are degenerative changes on MRI?

Imaging appropriateness criteria based upon exhaustive systematic reviews often negate the utilization of MRI without substantial risk factors. In the absence of higher-order clinical indications, why should physicians order MRI assessments of the spine if research reveals substantial degenerative changes in asymptomatic populations?

Arthrosis vs Artrhitis?

In a recent article, Harvard researchers offer some insight into the ability to image painful conditions with favorable inter-and intra-clinician reliability. Acosta et al. offer a scoping review of grading systems of lumbar facet joint inflammatory changes on MRI. The authors reflect upon concordant signs of facet joint and per-articular edema on MRI with associated back pain. [1]

Many papers have concluded, with high rates of probability, the relationship of Modic 1 changes associated with lower back pain.


In their article, Mayo Clinic neuroradiologists Czervionke and Fenton offer a means to improve the conspicuity of facet synovitis utilizing fat-saturated MRI sequences. The authors report,

“Facet synovitis is a common condition and appears to correlate with the patient’s pain.” [2]

Fat-saturated imaging sequences uniquely provide the ability to visualize painful edematous changes. The following images offered by Czervionke and Fenton provides remarkable insight into the severity and scope of inflammatory facet arthropathy. [2]

The authors provide the following grading system for facet synovitis. [2]

Clinical Utility

In clinical practice, the information gained by utilizing proper fat-saturated MRI sequences provides insight with regard to pain generation and therapeutic interventions. Certainly, the approach and therapeutic dosing for patients exhibiting Czervionke Grade 1 synovitis should differ from a Grade 4 synovitis.

When ordering spinal MRI studies, it is vitally important to minimally request additional STIR sequences in sagittal and axial planes.


  1. Acosta et al. SPINE. 2023; 48(9) 636-644.
  2. Czervionke and Fenton. PAIN MEDICINE. 2008; 9(4):400-406.


The views and opinions expressed in this presentation are solely those of the author. The information is not offered as a standard of care, as research and care evolve. We offer this only to educate and inform. Patients should seek the care of their doctors regarding their conditions.

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