An MRI report of a lumbar spine (and to a similar extent, the entire spine) is one of the more alarming documents a person can read about themselves. There is a scene most spine surgeons will recognise. A new patient sits down in the consulting room, clearly in a huff, and slaps a large envelope from a radiology practice on the desk. Asked what I can do for them, the answer comes back tersely - "It's in there. It's the L4, just read the bloody report." What has happened, almost always, is that they have been stewing on the revelations contained in their radiology report, sometimes for a week or more, and the consultation opens as the recipient of all that accumulated anxiety. It can take some doing to steer things back towards a more productive tone, and to de-escalate an amped up interpretation of their spinal "pathology".

So, as you can see, the recent trend towards this kind of unrestrained patient autonomy cuts both ways, and whilst I do advocate for people being informed of their own results it's important to understand that just because patients are rightly entitled to this information, unfortunately it does not necessarily equate to greater understanding in every instance.

And here's the key point that patients may not appreciate - a radiology report is written by a radiologist, for a referring doctor - not the patient themselves. It is written in a technical register, and it lists everything visible whether or not any of it is causing trouble. Radiologists are specialist doctors who are experts at interpreting medical images, from any part of the body. Some are sub-specialists in particular areas, but on the whole a radiologist report is to provide guidance for whoever requested the scan. For GPs, who can't be expected to be experts in all the areas in which patients seek their care, a report is used to help them make a provisional diagnosis, and guide referral to a specialist if necessary. Generally speaking, most specialists don't really require the radiology report at all, as we tend to be as good, if not better at interpreting imaging relating to our own field of expertise, than most generalist radiologists (no disrespect to my radiology colleagues). This is for two reasons - firstly, it's all we look at. A radiologist might look at more scans in a day than a spine surgeon, but it's unlikely they look at more spine scans in a day. Second, and more importantly, for clinicians who actually treat the patient in front of them - surgically or otherwise - we are viewing the scans through the eyes of someone who is able to transform those static images into living human tissue, with the hope of relieving symptoms. Occasionally a specialist will seek the expert opinion of a sub-specialist radiologist if something is unusual or indeed outside their own area of expertise (I still read the report regarding parts of the body I am not an expert in myself), but more often than not we would sooner show the images to a colleague instead.

With this in mind, when read cold, by the person whose spine it describes, it can sound like a catalogue of disintegration.

Usually it is not. Usually it is a description of a spine that has been in use for several decades and looks like it. But how are they to know that?

Therefore, this is a guide to reading one without frightening yourself, and to recognising the smaller number of findings that genuinely need attention. There is a short list at the end, of symptoms that need an emergency department today rather than an appointment in a few weeks, and if you are reading this because something is wrong right now, skip to that.

The most useful thing to understand

A scan shows structure. It is a poor guide to pain, which in the end is experienced in a patient's brain. That's not to imply that your pain is "in your head", I say it to remind people that pain is a sensation experienced on an emotional level, which is exactly why the sterile description of your anatomy can only form part of an explanation.

Those two things overlap far less than people assume. I feel like I say this to almost every patient I see - take a large group of adults with no back pain at all, scan every one of them, and you find a great deal. The figures below come from a systematic review of imaging in people who had no low back pain at the time, and they are reproduced in Australia's national clinical care standard for low back pain. Percentages are the proportion of pain-free people with each finding.

Finding on MRI Age 20 Age 40 Age 60 Age 80
Disc degeneration 37% 68% 88% 96%
Disc height loss 24% 45% 67% 84%
Disc bulge 30% 50% 69% 84%
Disc protrusion 29% 33% 38% 43%
Annular fissure 19% 22% 25% 29%
Facet joint degeneration 4% 18% 50% 83%

Read the disc degeneration row again. At sixty, without any back pain, there is an 88% chance an MRI would describe your discs as degenerate.

I want to be careful not to overstate this in the other direction, because the honest position is that the correlation is weak, not absent. In the same body of work, some findings are modestly commoner in people who do have pain - a disc bulge, a disc extrusion, a protrusion, disc degeneration. The associations are real but they are loose, and the confidence intervals around several of them are very wide. So, the accurate statement is not "these findings mean nothing." It is that they are common in people with no symptoms, and finding one does not establish that it is causing yours.

Two consequences follow, and they run in opposite directions. A frightening-looking scan can belong to someone who feels fine. And, more importantly, the worst-looking level on a scan may not be the level generating the pain. It's my job to work out the significance of the imaging findings as they relate to your individual problem.

There is also a longer-term version of this. In one study, twenty-one people who were pain-free at the outset went on to develop back pain over the following seven years - and twelve of them had entirely normal scans at baseline. The imaging did not predict who would end up in trouble.

Findings that are common in people with no symptoms

A note on the section heading. I have not written "findings that are normal ageing", even though that is how these are often explained, including by me. The international nomenclature for reporting disc pathology deliberately declines to say whether a given change is ageing or disease - it treats "degenerated disc" as a description that "does not infer knowledge of cause, relationship to aging, presence of symptoms, or need for treatment", and expressly flags the ageing gloss as non-standard usage. It may seem like they are trying to avoid sounding "ageist", however there is a common sense reason - you can't say something is caused by ageing when some young patients have it, and some older people don't. I tend to call the changes "wear and tear", as it's my experience that these changes are far more common in people who have used their spine to the fullest (male tradies and female nurses are the commonest I see); however in the obverse I will often describe wear and tear as "age-appropriate". So, the take home is that these findings are common in people without pain. And whilst you are more likely to see these changes - symptomatic or not - in older patients, the same changes can be seen at any age - symptomatic or not.

Disc degeneration, or degenerative disc disease. An unhelpful name, because "disease" implies pathology. In the simplest terms it describes a disc that has undergone structural changes that ultimately lead to reduced water content and, consequently, "height". On a cellular level it is more complicated of course, but from a purely structural point of view, this is basically what the MRI is telling us. Think about one of those cheap inflatable pools you would have seen during summer - when you first fill it with water the rubber is springy and smooth. If you don't replace the water, over time it evaporates, and the walls of the pool get saggy. Eventually some leaves get in the pool, and occasionally too many kids get in and the rubber bursts. On a scan the disc looks darker and flatter than a normal one.

Disc desiccation. The same thing, described differently. The disc has dried out somewhat. You might come across the term "black disc", which is when the "colour" of the disc changes from completely white to completely black. This occurs when there is essentially no water left in the disc. Although it may be a cause of pain, similarly it may not.

Disc bulge. The disc's outer wall extends beyond where it ideally would, generally around most of its circumference. Near-universal with age. Common in people without symptoms and somewhat commoner in people with them.

Disc protrusion or herniation. Worth distinguishing from a bulge. A herniation is localised - involving less than a quarter of the disc's circumference - whereas anything broader is a bulge. A focal herniation is more likely, though still not certain, to be pressing on something like a nerve root.

Spondylosis. A general term for wear-related change across the discs, joints and bone. Not a diagnosis so much as a description. It's literally Ancient Greek for abnormal spine - spondylos: vertebra, and -osis: disease state.

Ligamentum flavum hypertrophy. Normally a thin band of tissue that joins the back of the bones between each spinal segment. Unfortunately, this tissue can thicken significantly to the point that it can eventually, over a long period of time, start to compress the nerve roots in that area. Because it takes so long to develop, you're likely to see it well before it's become symptomatic.

Facet arthropathy/hypertrophy. Arthritis of the small paired joints at the back of each spinal segment. These joints also have a sneaky tendency to enlarge over time too, which may gradually contribute to narrowing of the spaces where nerve roots would normally travel. Note from the table that this one is genuinely age-dependent rather than universal: 4% at twenty, 18% at forty, 83% at eighty. Often silent - but not reliably so. Studies that simply ask "is there facet arthritis, yes or no" find no association with back pain; studies that grade its severity in older adults do find a modest one, and find that it increases with each additional badly affected joint. So mild facet change on a report is weak evidence of anything. Severe, multi-level facet change in an older person is worth a conversation - if you have symptoms.

Annular fissure, or annular tear. "Tear" sounds acute and traumatic. In practice these are usually gradual and are seen in about a fifth to a quarter of pain-free people at any age. One exception worth knowing: if the report specifically describes a high-intensity zone, that is a more meaningful finding, and its association with pain on provocation testing (ie on examination) is considerably stronger.

Anterior and lateral vertebral osteophytes - small (though sometimes larger - which doesn't necessarily imply worse) bone spurs at the front and sides of the vertebral bodies. These are the one finding I am comfortable calling a consequence of normal ageing, because they have been found in effectively everyone over forty.

Mild canal or foraminal narrowing. The word doing the work is "mild".

Spondylolisthesis - one vertebra slipped forward on the one below. Sounds dramatic, and can be a cause of symptoms, but in and of itself does not necessarily require treatment unless this is the case. More Greek - olisthesis: slip.

Modic changes. Signal changes in the bone immediately next to a disc. They are much commoner in people with back pain than without - one large study found them in 43% of a clinical back pain population against 6% without - and in a general-population study of adults all aged exactly forty, Modic changes were among the least common findings but had among the strongest associations with low back pain. Type 1 changes also carry prognostic weight: in one cohort of people off work with back pain, type 1 Modic change predicted a lower chance of improvement in pain and function, and of returning to work. The evidence is not unanimous, and prevalence figures across studies vary wildly. Take home - Modic I: Possibly significant. Modic II & III: Extremely unlikely.

None of that list means nothing can be done about your pain. It means the above alone cannot identify the cause. Because by far and away what is more important than what you will read are your symptoms, and how they correlate with the imaging findings. Without you they are just pictures.

Findings that are common in people with symptoms

Moderate to severe canal or foraminal stenosis with symptoms. Narrowing of the central canal (where the whole bunch of nerve roots go) - when severe enough - can cause compression of the cauda equina that may result in patients developing something called spinal claudication. This is usually experienced as pain that travels down both legs, and comes on in a predictable pattern - when someone stands for a certain period of time, or walks a certain distance, and goes away when they sit.

When one or more neural foramen (the spaces where a single nerve root on one side travels as it exits the spine altogether) is significantly narrowed, or where the report describes that a specific nerve root might be compressed (they will have a whole thesaurus of words to describe the same thing), patients may describe leg (or arm for cervical spine) pain (sciatica), and/or weakness, and/or sensory changes and numbness.

But remember - the changes on your MRI are almost certainly ones that have developed over months, if not years. It is unlikely that there is anything on that scan that wasn't there last month. Which begs the question - why do I have symptoms now? Firstly, as much as what I've just said is the truth, it is of course possible that in your particular case something has changed. But in my experience, more often than not, people's spines - wear and tear changes and all - very frequently look identical on repeat imaging. The best analogy I can give is one a colleague shared with me many years ago - she said that she thought of an MRI like Google Earth: it's amazing, we can see "everything", we can even zoom into our neighbour's backyard. But we still can't see inside their house, and that's where the interesting stuff is occurring.

And to labour the point - that is why your symptoms are what makes the MRI finding meaningful, and worth an assessment by a specialist. For context: around one in five people over sixty have imaging evidence of lumbar canal stenosis, yet more than 80% of them have no symptoms from it. This imaging finding alone is not the diagnosis, and asymptomatic stenosis is not treated. Note the word treated, that doesn't mean it will necessarily be dismissed or ignored entirely. The point is we don't want to go doing a whole bunch of unnecessary surgery on people. However, when the compressed root corresponds to the distribution of the symptoms, the scan and the story are telling one story. Slam dunk.

Cervical cord compression with symptoms. In the neck and thoracic spine, abnormalities can lead to compression of the spinal cord itself, in addition to individual nerve roots. Cervical nerve root compression is common in its own right, and its presence alongside cord compression is one of the strongest predictors that cord compression will progress. Combined with clumsy hands, numbness in the feet and/or hands, deteriorating balance or loss of fine motor control - this needs assessment without much delay. For context again: incidental cord compression appears on a majority of cervical MRIs in older adults, rising from about a third of people in their forties to two-thirds in their seventies, and only a small minority ever develop symptoms.

A lesion, mass or unexplained fracture. Uncommon, and the reason we scan at all.

Symptoms that need action, whatever the scan says

This section is about symptoms, not images, and it overrides everything above. Individual warning signs perform poorly on their own - but several appearing together raises the concern sharply, and that is the pattern to watch for.

Go to an emergency department today

These point to pressure on the bundle of nerves at the bottom of the spinal canal. The window in which this can be reversed is short, and the early signs are the ones most easily dismissed. Get going if any of these are new:

  • Difficulty starting to pass urine, a weaker stream, needing to strain, or no longer feeling when your bladder is full. These come before losing control, and they are the ones that matter. Do not wait for incontinence - by the time that is literally true, the chance of full recovery has usually gone.
  • Leaking urine, or losing control of your bowels.
  • Numbness or altered sensation in the saddle area - between the legs, around the back passage, or noticed when wiping.
  • New numbness in the genitals, or sexual function that has changed suddenly.
  • Sciatica that has become bilateral (both legs), when previously it had just been on one side.
  • Weakness in a leg getting worse over hours or days, a foot that catches or drops, or a change in how you walk.

Do not pass Go, do not collect $200 - go straight to the emergency department, and do not delay by arranging imaging first. Where this is suspected the standard of care is an urgent MRI within hours, which will likely be done in the ED if you have this constellation of symptoms.

Be seen within days, regardless of how bad the pain is

Note that pain severity is not the guide for any of these. Mild, steadily worsening pain in the wrong context matters more than severe pain in the right one.

  • A history of cancer. This is the single most informative warning sign in the whole list, and it does not require the pain to be severe.
  • Unexplained weight loss, fevers or sweats.
  • Significant recent trauma - or minor trauma if you are over about fifty, have osteoporosis, or take steroids (prolonged steroid use can weaken your bones, which people often don't think to mention).
  • A weakened immune system, intravenous drug use, a recent spinal injection or procedure, or a recent blood stream infection. Fever is not a reliable marker of spinal infection on its own - the classic combination of fever, pain and neurological signs is present in only a minority of cases - so these risk factors matter in their own right.
  • Weakness or numbness that is progressing, even slowly over weeks. It does not have to be rapid to be worth assessing.
  • Being over seventy with new back pain, which raises the chance of a fracture considerably.

Worth raising if you are under forty-five

Back pain with morning stiffness lasting over half an hour, pain in the second half of the night, alternating buttock pain, and symptoms that improve with exercise rather than rest. This pattern suggests the possibility of inflammatory back pain rather than mechanical, it is treated completely differently, and it is typically diagnosed years later than it should be. It is not an emergency. But if you are young, the reassurance in the first half of this article is the least applicable to you, and this is the diagnosis most often missed.

Why the words are frightening

Radiologists are not writing to reassure. They are writing a complete description for a clinician who will combine it with the examination and the history. Completeness is the point, and a report that omitted incidental findings would be a worse report.

The difficulty is that patients now routinely receive these documents directly, often before anyone has explained them, typically on a Friday afternoon so they have the whole weekend to fret about the impending doom they've just read about themselves. The vocabulary of radiology - degeneration, tear, deformity, compromise - is ordinary technical language that reads, to anyone else, like a prognosis.

It is worth knowing that this is a recognised problem with measurable consequences. When radiologists add a note about how common these findings are in people without symptoms, downstream prescribing of strong painkillers falls. The numbers in the table above are not just reassurance - the evidence shows that putting things into context actually impacts how you manage your symptoms. My hope is that something you've read today has helped allay at least some of your anxiety.

What to do with a worrying report

Do not conclude anything from the report alone. Its meaning depends on whether the findings line up with your symptoms and examination.

Write down what you actually experience before your appointment: where the pain is, where it travels, what brings it on, what relieves it, whether anything is numb or weak, and how it has changed. That account carries more diagnostic weight than the report does.

Ask which finding is thought to be responsible, and why. A good answer explains how a specific finding accounts for your specific symptoms. If no finding explains them, that is worth knowing too, and it is a legitimate answer.

Be cautious about treating a picture rather than a person. An intervention aimed at an abnormality that is not producing your symptoms will not help, and every intervention carries risk. That applies with particular force to surgery.

Do not look up each term in isolation. Every phrase in a spinal report has a worst-case version attached to it somewhere, and reading them in sequence produces a picture that bears no relation to your own.

The short version

A scan is one piece of the puzzle - not the puzzle itself. Modern imaging is remarkably detailed, which is exactly why it finds so much that does not matter. Most of what a spinal imaging report describes in a person over forty is also present in people the same age with no pain at all - and now you have the numbers.

The findings worth acting on are the ones that explain what you are actually feeling. Working out which do is what really matters, and a report cannot do it on its own. A good surgeon knows this and will help put this into perspective for you.

This article is general information about reading imaging reports. It is not advice about your own scan or symptoms, which need your history, your examination and your own doctor. If any of the symptoms in the "emergency department today" list above are new, go now - do not wait for an appointment, and do not wait to arrange a scan first.

Principal sources: Brinjikji et al., American Journal of Neuroradiology 2015 (two papers - asymptomatic prevalence, and imaging findings in symptomatic versus asymptomatic populations); Fardon et al., The Spine Journal 2014 (lumbar disc nomenclature v2.0); Australian Commission on Safety and Quality in Health Care, Low Back Pain Clinical Care Standard 2022; RACGP, First do no harm, 2022; Downie et al., BMJ 2013 and Han et al., Cochrane 2023 (warning signs for fracture and malignancy); Verhagen et al., Pain 2017; Katz et al., JAMA 2022 (lumbar stenosis); Davies et al., BMJ 2018 (cervical cord compression); Jensen et al., European Spine Journal 2008 and Kjaer et al., Spine 2005 (Modic changes); Borenstein et al., Journal of Bone and Joint Surgery 2001; McCullough et al., Radiology 2012.