At the beginning of every treatment stands the question of where the symptoms come from. It is not answered by a machine, but in the consultation and during the examination — and only afterwards, if necessary, by an image. This page describes how we proceed, which examinations exist, when they make sense and when they do not, and which of them take place at our practice and which elsewhere.
An image answers a question, it does not ask one. Anyone who examines without a question finds changes that almost everyone of that age has — and turns symptoms that would have passed into a diagnosis that stays.
When an assessment makes sense
Not every back pain needs a specialist examination. It becomes worthwhile when one of the following applies.
- The pain runs into the leg or into the arm — along a strip, often with tingling or numbness. This points to an irritated nerve root and can usually be assigned to a particular level by the examination.
- Strength or sensation has diminished — weakness when lifting the foot or the toes, an unsteady gait, a clumsy hand. That belongs examined promptly.
- The symptoms persist — if after several weeks of treatment they do not become clearly better, or if they keep returning.
- The walking distance is getting shorter — heavy, tired legs after a certain distance, which recover when sitting or bending forwards.
- A report raises questions — an MRI report that nobody has explained to you calmly, or a recommendation for surgery you are unsure about.
- Warning signs — fever, unintended weight loss, a cancer in your history, a fall with known osteoporosis, or pain at rest during the night. And immediately for numbness in the area between the legs, a new problem with bladder or bowel control, or increasing paralysis.
You do not need a referral. It is useful because it brings us your history. Do come even if you have no images and no previous reports.
What happens exactly?
- The consultationIt contributes most to the diagnosis. Since when have the symptoms been there, how did they begin, where exactly do they sit, do they radiate and how far? What makes them worse — sitting, standing, walking, bending forwards, bending backwards, coughing, the night? What relieves them? Is there tingling, numbness, weakness, trouble passing water? Along with previous illnesses, previous operations, medication, occupation and the question of what no longer works in everyday life.
- The examinationPosture, mobility, tenderness to tapping and pressure over the vertebrae. Then the neurological part: strength of individual muscle groups, reflexes, sensation in the typical skin areas, nerve stretch tests, gait pattern, standing on tiptoe and on the heels, coordination. If compression of the spinal cord is suspected, the signs that point to it as well. Loading tests for the sacroiliac joint, the facet joints and the hip mark off the neighbours. In the great majority of cases, the consultation and the examination give a clear direction before any image is available.
- Assessment and discussion of the findingsWe look at existing images ourselves, not only at the written report. What is decisive is whether the image fits the symptoms and the examination — the same level, the same side, the same nerve. If it does not fit together, the finding is not the explanation. At the end there is an understandable account of what we have found, what it means and what the options are.
When an image helps — and when it does harm
Imaging is not a first step but the answer to a specific question. For acute low back pain without warning signs, the German National Disease Management Guideline advises against X-ray, CT and MRI scans; they become useful where there are warning signs, where the nerve shows deficits, and if the symptoms persist after four to six weeks despite treatment.
The reason is not thrift but the frequency of incidental findings. A review of examinations in people with no back symptoms at all found signs of disc wear in 37 out of 100 of the 20-year-olds and in 96 out of 100 of the 80-year-olds. Bulges, loss of height and worn facet joints are therefore more a feature of age than a disease. Such a finding only explains symptoms if it fits them — and it can do harm if it is communicated without that context and turns a mobile person into a cautious one.
The individual methods
- X-ray — shows bone, alignment and the height of the disc spaces. Useful where a fracture is suspected, for malalignment and as a check after an operation. Soft tissue, nerves and disc tissue cannot be assessed.
- Flexion and extension views — X-rays taken in maximum forward and backward bending. They are the examination of choice where instability is suspected, for instance in spondylolisthesis: only the comparison of the two images shows whether a vertebra shifts during movement.
- MRI — the most important examination of the spine. It shows discs, nerve roots, the spinal cord, ligaments, inflammation and changes in the bone marrow, entirely without X-rays. A recent vertebral fracture can be told apart from an old one because the bone marrow oedema becomes visible.
- CT — the most precise depiction of bone. Useful for fractures, for assessing bony narrowing, for planning screws and when an MRI is not possible. It involves a dose of radiation.
- Bone density measurement — for a vertebral fracture without adequate force, for loss of height or after prolonged treatment with cortisone. It clarifies whether there is an osteoporosis that has to be treated independently of the fracture.
- Electrophysiology — measurement of nerve conduction velocity and recording of muscle activity. It comes into consideration when symptoms and image do not fit together, when several levels come into question, or when damage to the nerves outside the spine has to be marked off, such as a carpal tunnel syndrome or a polyneuropathy.
- Blood tests — where inflammation, a rheumatic condition or a tumour is suspected. In unremarkable back pain they yield nothing.
- Diagnostic injection — a local anaesthetic is placed precisely at one structure under image guidance: at a nerve root, at a facet joint or into the sacroiliac joint. If the pain clearly eases for as long as the drug acts, that speaks for this structure as the source. The test can mislead and is repeated before far-reaching decisions; it is one building block, not a proof.
What takes place at our practice — and what elsewhere
At our practice, what takes place is the detailed consultation, the physical and neurological examination, the review and discussion of your images and previous reports, and the assessment: which cause is likely, what that means for you and which treatment fits it. We provide periradicular therapy at the nerve root in a dedicated room at the practice; it also acts as a test, because its effect shows whether the treated root really is the source of the pain.
X-ray, CT and MRI scans as well as bone density measurement are carried out in radiology practices, and electrophysiological measurements in neurology practices. If one of these examinations is needed, we tell you which question it is meant to answer — and we then discuss the result with you. Please bring the images on a storage medium, not only the written report: the report does not replace the images.
Limits and risks
X-ray and CT involve a dose of radiation and are therefore only used where the question is clear. MRI involves no radiation, but it takes longer, is loud and is unpleasant for people with claustrophobia; pacemakers, certain implants and metal fragments have to be clarified beforehand. Contrast medium is only given for particular questions, for instance after an operation or where inflammation or a tumour is suspected, and it requires kidney values and the question of intolerances to be settled first. With an injection, the usual risks of an injection apply.
The greater limit is more fundamental in nature: in a considerable proportion of back pain, no single structure can be named that explains the pain. That is not a failure of diagnosis but the expected result — and good news, because the course is then usually favourable. More on this on the page back pain.
Before and after
Before the appointment: bring any existing images on CD or another storage medium, together with doctors’ letters, operation reports, reports on previous injections and their effect, and a complete list of your medication. Wear clothing in which you can be examined quickly. Notes on the course and on triggers are helpful — when it began, what makes it worse, what no longer works. If you like, bring someone with you; four ears remember more.
After the appointment: you should be able to take three things away with you — what we have found, what it means and how things go on, with an order of steps and a point in time for the next review. If an examination has been arranged, discussing the result is part of it. And you should know at which signs you should get in touch sooner: new or increasing weakness, new numbness in the area between the legs, trouble passing water, fever.
Frequently asked questions
Will I get an MRI at my first appointment?
Only if there is a question it can answer. Where there are warning signs, where the nerve shows deficits and where symptoms persist despite treatment, it makes sense. In recent back pain without such indications it does not as a rule change the treatment.
My report sounds dramatic. Is that bad?
Reports describe every deviation from an ideal state, including those that are typical for one’s age and harmless. What is decisive is whether the finding fits your symptoms. We go through it with you; a translation of the most common terms can be found on the page understanding your MRI report.
Is the written report enough, or do you need the images?
We need the images. The report is a description; for assigning it to your symptoms, what counts is what can be seen at which level and on which side. Ask the radiology practice for a storage medium.
How old may an image be?
That depends on whether the symptoms have changed since. An image that fits today’s picture of symptoms remains usable; if the site, character or radiation of the pain has changed, or if new deficits have been added, a new image is worth considering. Bring older images along all the same — the comparison over time is often more informative than a single image.
Can you see in the image whether an operation is necessary?
No. What is operated on is symptoms, not images. A marked narrowing without matching symptoms is not operated on, and conversely a small finding in the right place can cause considerable deficits. The decision arises from looking at everything together.
Why does the consultation take so long?
Because it is the part of the diagnostic process with the greatest yield. Timing, course, triggers and accompanying symptoms narrow down the possible causes more than any single examination — and they decide which examination is worthwhile at all.
If you have been advised elsewhere to have an operation, you can obtain a second opinion from us. We look at your images, examine you and tell you frankly whether we share the recommendation — and what happens if you wait for the time being. What you should bring is on the page Your first appointment.