MRI Scans: Where Abnormal Findings Are Normal

An Introduction to MRI scans

The very first MRI scan of the human body was performed in 1977. Prior to this, we were basically making educated guesses about what was wrong with the spine. Today, the modern practice of spine surgery relies heavily on the interpretation of MRI scans.

MRI scans slice the human body into thin sections

Magnetic Resonance Imaging creates thin section images of the inside of the human body. This technique allows us to visualize anatomic structures from any angle and direction. The two most common slices that we look at on MRI scans of the spine are the sagittal and coronal slices. The saggital plane sections the human body lengthwise. The axial plane creates a cross section of the human body.

MRI axial planeMRI sagittal plane

An MRI image looks like a photograph, but it is actually a computerized image of the nuclear magnetic resonance of molecules inside the human body. These images are superior to CT scans and X-rays. The resolution and clarity of the images is better, we can see more fine detail, and this test uses harmless radio waves instead of ionizing radiation.

MRI scans as a medical tool

Magnetic Resonance Imaging is an amazing tool that allows us to see deep inside the human body with a degree of clarity that is absolutely amazing. We can visualize the tiny details of normal and abnormal human anatomy. We can clearly see the intervertebral discs, spinal cord and nerve roots. In addition to normal anatomy, we have also learned to identify a number of findings that may cause neck and arm pain or back and leg pain. The list of abnormal findings that we can see on an MRI scan include the following:

disc desiccation

disc degeneration

disc bulging

disc herniations

annular tears

spinal stenosis

neuroforaminal narrowing

We are going to look at examples of each of these conditions. However, before we do, it is important that you understand that after the age of 30, essentially every MRI scan of the human body is abnormal.

Every MRI scan after the age of 30 is “abnormal”

These two pictures explain why. The natural aging process causes changes to every structure of the human body. The spine is no different. If we were to look at the skin of the gentlemen on the right with a microscope, we would see evidence of degeneration, loss of elasticity (which is called elastosis), noncancerous skin growths (called keratoacanthomas), pigment changes such as liver spots, and thickening of the skin. These findings would all be described as “abnormal”.

MRI scans reveal a natural aging process

However, we could describe the skin on the right as “normal for age”. We only describe it as abnormal when we compare it to the image of the baby on the left.  Most people, even if they don’t have any back pain, will still have evidence of abnormalities on MRI scans.  Disc degeneration, bulging disks, and herniated discs occur very commonly and they may not be causing symptoms of pain. For example, in a paper published in the journal radiology, the researches found that approximately 90% of people WITHOUT any history of back pain in the last 6 months still have evidence of annular tears, disc degeneration, and disc bulging at one or multiple levels.

Therefore, the critical task when it comes to interpreting MRI scan is CORRELATING the findings on the MRI scan with the patient’s complaints and with the physical exam.

What a normal MRI scan looks like.

This is an MRI scan of a 40 year old male. There are 5 intervertebral discs in the lumbar spine. We are going to start with a normal level which has a normal intervertebral disc. Each disc separates two bones called vertebrae in the spine. In this case, this is the L3-4 disc. Above the disc is the L3 vertebral body and below the disc is the L4 vertebral body. The center of the disc, the annulus pulpous is relatively white. The front and back of the disc, the annulus fibrosis is dark black, thick, and is not bulging into the spinal canal. The spinal canal is filled with white fluid, called cerebrospinal fluid (CSF).  Inside the CSF is the spinal cord and the nerve root that go down to the legs.

normal saggital MRI scan lumbar spine

On the axial image, the neuroforamen are wide open and there is plenty of space available for the nerve roots.

normal axial slice MRI lumbar spine

Disc dessication

Using the same MRI scan, let’s look at a dessicated disc. Desiccation is the state of dryness, or the process of drying. The theory here is that when we are young, and our discs are young, our discs have a high water content.

MRI scan lumbar disc dessicationWhen we are young, the center of the disc, called the annulus fibrosis, has an electrical charge that holds onto water very well. The disc is viscous, elastic, and is a good shock absorber. With time, the center of the disk loses water content and the disk starts to “dry out”. I tell patients that all of our intervertebral discs start out as fat plump grapes and eventually end up like raisins. Just like us.

MRI reveals disc dessicationDisc Degeneration

Disc degeneration is a more advanced form of disc dessication. In addition to the nucleus pulposus drying out, the disc starts to collapse.  Bone spurs form around the edges of the intervertebral disc. Disc degeneration is the same thing as degenerative arthritis. This condition is inevitable. It’s just as certain as death and taxes, and it will happen to everyone if they live long enough. The one thing that predicts whether or not you will have degeneration of your discs is the number of birthdays you have had. The more birthdays, the more evidence you are certain to have of disc degeneration.

MRI scan shows disc space degeneration

Disc bulging and herniations

Disc bulges and herniations come in all sorts of sizes and shapes. As the disc starts to degenerate, it can bulge out towards the spinal canal and the nerve roots. This first example is described by the radiologist as a “herniation”.  This herniation is still contained by the annulus.  As such, it is probably more accurate to describe this as a disc bulge.

MRI scans focal disk herniation

In contrast, this example shows a really large disc herniation.  In this case, the nucleus pulposus has herniated completely through the annulus and there is a large free fragment of disc material filling the neural foramen and completely obstructing the normal path for the exiting and traversing nerve roots.

 MRI scan large disc herniationAnnular tears on MRI scan

Annular tears are a particularly interesting finding on MRI scans. They represent a partial disc herniation where only a few of the fibers of the annulus fibrosis remain. Here is a short video illustrating the typical findings in an annular tear.

 

Spinal Stenosis and neuroforaminal narrowing: what that looks like on the MRI scan

The end result of all of these changes is spinal stenosis. Stenosis mean “narrowing”.  The process of disc bulging, degenerative disc disease, and the development of arthritis of the spine all cause narrowing of the space available for the nerve roots. Here is a short video where I review the MRI scan of someone with two level severe spinal stenosis and illustrates this process.

Making Sense of your MRI scan

Recently, it has become much more common to give the patient a copy of the MRI and report from the radiologist.  Unfortunately, this often creates a lot of confusion and concern.

I have been practicing spine surgery in Monterey, California for more than 12 years.  About 4 or 5 years ago, ObamaCare mandated that patients be given a health care summary document when they finished seeing the doctor.  This applied to MRI scanners as well.  Now, it is very common for the patient to see the radiologists report, usually before they see the doctor who ordered the scan.

By the time that a patient sees me, they usually have had the opportunity to read their own MRI report which typically sounds something like:

  • “disc dessication is prominent at L5/S1.”
  • “There is broad based disk bulging at L4/5 and L5/S1 and degenerative disk disease at these two levels.”
  • “Complete disc space collapse with prominent osteophytosis is noted at L5-S1”

Patients love Google.  After an hour or two of typing the words they don’t recognize on their MRI report into the Google search bar they are scared.  They arrive in my office CONVINCED that there is something dramatically wrong with their back.

I begin by explaining that these findings can be considered a normal part of aging and that they frequently occur in patients without back pain or sciatica.

While there is a healthy debate about what constitutes an abnormal versus a normal MRI scan of the spine, there are a few key findings that reveal a problem that we know will require surgery.

If your MRI scan does not show evidence of severe stenosis, spondylolisthesis, neuroforaminal narrowing, or a large extruded disk hernation, chances are that you can probably get better without surgical treatment.

However, the opposite is also true.  If you MRI scan shows that you have a large disk herniation, a free fragment, severe neuroforaminal narrowing, severe spinal stenosis, or a severe spondylolisthesis, chances are, you may need to have an operation after all.  The important thing to do is make sure that you have the right operation.

I specialize in non-fusion, outpatient, microscopic surgery for herniated disks, spinal stenosis, spondylolisthesis, and sciatica. If you think you may be a candidate, I will review your MRI scan to see if we can help you.

If you are interested in having me review your MRI scan, you can follow this link:

[button url=”https://sohrabgolloglymd.com/upload-mri/” target=”_blank” color=”blue” size=”large” border=”true” icon=”MRI review”]MRI review[/button]

I have also prepared a short video explaining some of your options so that you can make the right decision about spine surgery.

Leave a comment



Scott Ledbury

5 years ago

Hi there

I am so glad that I have read the above article as I have only yesterday had a consultation following an MRI Scan and came away feeling very dissalusioned and confused / feeling quite low.

My scan and pain is pretty much exactly as you describe above of the 26 year old patient with bulging disks or should I say, your disecription is pretty much the same as explained to me by my consultant.

I have one major concern though, I play golf to quite a high standard and I have reached the stage where my pain whilst playing is pretty much unbareble. It also hurts quite a lot while doing any strenuous activity including walking………….the golf is the most important thing though as its pretty much my life and has been for 25 years or more. I am 42 but still consider myself very agile……….. It was mentioned by my consultant, almost to mobile and flexible which may be adding to my back problem.

My worrying thing is that I was told to stop playing golf or take pain killers (I have them before I play anyway). I was told to do lots of core exercise and strengthening, stop stretching all the time as it compounds my flexibility issue as I need to become stiffer.

My question would be, if I made my living from golf would the answer have been the same or is there anything else that can be done in your opinion? ………… If Tiger Woods came in with the equivelant MRI to the 26 year old and was in severe pain when he hit balls, would you tell him to stop playing or would you be able to help and fix him?

What is the odds of core strengthening actually making me become pain free? Is it possible to become pain free again?

Best regards
Scott

Caroline Myers

5 years ago

Very interesting article.My 14 year old daughter who is studying Ballet had an MRI that concluded Disc Lesion at L4-5 and L5-S1 slightly more marked at L5-S1. Reading your article this presents as normal, she is now 16years and experiencing some lower back pain,while training to be a Ballerina,is this seroius or just requires rest,
Also would the previous MRI results have changed now or repaired itself with age.

Thankyou
Kind Regards.

Dominic Ninivaggi

4 years ago

Hello,
I hope that you can provide some guidance for me and please let me know if I would be a candidate for surgery. I live in Ontario Canada, presently I am looking for private out of country surgery. Here are the Radiologist Report…
X-RAY of the Lumbar Spine
-end plate entophytes are present at multiple levels in the Lumbar and lower Thoracic Spine

C.T of the Lumbar Spine

T12-L1-there are small end-plate entophytes and there is mild bilateral facet osteoarthritis
L1-L2-there are end-plate entophytes and there is mild bilateral osteoarthritis. There is a slight bulging of the disc
L2-L3-there is a far right disc protrusion, disc material extending into the intervertebral foramen along the exciting L2 nerve root. There are end plate entophytes. There is mild narrowing of the interverterbral foramen bilaterally
L3-L4-there are end plate entophytes and there is bilateral facet osteoarthritis. There is mild narrowing of the intervertebral foramina bilaterally. There is a bulging of the disc and there is mild bilateral ligament flavum hypertrophy. There is mild central spinal stenosis.
L4-L5-there are end plate entophytes and there is bilateral facet osteoarthritis. There is a mild narrowing of the intervertebral foramina bilaterally. There is bulging of the disc, and there seems to be a left sided disc protrusion. There is borderline central spinal stenosis.
L5-S1-there are end plate entophytes and there is bilateral facet osteoarthritis. There is mild narrowing of the intervertebral foramina bilaterally and there is a mild bulging of the disc.

MRI Of the Lumbar Spine

L2-L3-There is a right far lateral disc extrusion with some extension into the inferior foramen bilaterally. More so on the right with possible impingement upon the exiting L2 nerve root.
L3-L4-There is decreased signal intensity and disc height with a broad based protrusion measuring several millimetres flattening the ventral thecal sac. This extends into the far lateral region bilaterally and there is a mild degree of bilateral foramina stenosis. I suspect possible impingement on the exiting L3 nerve root.
L4-L5-There is a decreased signal intensity and disc height with a broad based disc extrusion flattening the ventral thecal sac. There is a focus of increased signal intensity in the dorsal disc margin which may represent a fissure in the annulus. The broad based bulge does abut the L5 nerve roots in the lateral recesses , more so on the left with likely impingement upon the descending L5 nerve root against the posterior bony canal wall.
L5-S1- There is a decreased disc in height and signal intensity.
A broad based disc extrusion is noted posteriorly near the mid line flattening the ventral thecal sac causing a mild degree of left sided foramina stenosis. There is likely impingement upon the exiting L5 nerve root.

MRI of the Thoracic Spine

Findings

A disc bulge is noted at the T8-T9. This appears to be causing spinal cord compression.

A further disc bulge is noted at the T11-T12. This also appears to be causing spinal cord compression.
I am in alot of pain, please help.

Mal Read

4 years ago

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Good Afternoon
Iam 64 years old and have been holding out in pain for many years by not having surgery. Iam told it is time to carry out what is called major surgery, and have bilateral L4/5 invasive decompression & fusion/fixation with dynamic stabilization procedure done. I have sought second and third opinions and all concur the need for surgery with my preferred surgeon being highly respected in such operations.
My problem is Iam unable to locate someone who has had successful or failed operations like the above mentioned. Could you please put me in contact with any legitimate persons who are prepared to tell it the way it is after such a procedure.
I reside at Perth Western Australia if that is of any interest.
I have been retired for 4 years and consider this time to be a most unpleasant duration due to my poor quality of life which obviously affects others of my family.
Please give thought to my plight and reply via this email address.

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admin

4 years ago

Dear Mal,
If you haven’t already received attention for your problem, please send a summary of your medical history and copies of your MRI scan and xrays to:
Monterey Spine and Joint
attention: Jennifer
12 Upper Ragsdale
Suite A
Monterey, CA 93940

William

4 years ago

Have L1-2 & L2-3 & L3-4 & L4-5 & L5-S1 Discs all buldging with stenosis.Can these be fixed so severe pain will go away.I can’t walk without a walker and pain is so severe I can’t sleep at night.My doctor has given every kind of medication available and none of it has stopped this pain.I think I need a surgeon.Am I right in your opinion? Please send me your opinion.I’ll check in the am to see if you answered.Iam in Georgia and it is 11;40 pm where I am. Thanks for any imfo.

admin

4 years ago

William,
It sounds like to you need to see someone promptly and there are certainly many surgeons in Georgia. If you would like us to review your MRI scans and Xrays, please send them to:
Monterey Spine and Joint
Attention: Jennifer
12 Upper Ragsdale
Suite A
Monterey, CA 93940

Jennifer

4 years ago

Hi,

My mom had MRI and in the report it is marked as “Annular tear noted in l2 l3 and l3-l4 intervertebral disc”

Is it curable ?

Len Griffiths

4 years ago

My MRI scan reports,”Large disc extrusion at L4/L5 which in combination with facet joint and ligamentum flavum hypertrophy is causing severe spinal canal stenosis and PRESUMED compression of the transitting nerve roots in cauda equina”. I do not see a specialist for two weeks my questionsa are;
1.Is he likely to say surgery is neccessary .
2. Which surgery is it likely to be- microdiscetomy ? Laminectomy? Fusion?
3.Are there any other alternatives.

My pain is in right hip,buttock and outside of lower shin/ankle; I can walk normal and have no incontinence;
I am a 70 year old and have been a bodybuilder for years; the pain arrived 3 months ago;and was a 9 out of ten it is now 6 out of ten; I take Tramadol 50 mg 3×1 per day, diclofenac 2x50ng morning;
I am worreid in casespecialist says I need MAJOR INVASIVE SURGERY; PLEASE CAN I HAVE YOUR OPINION,

Karen

4 years ago

What an absolutely wonderful site! You have reduced my anxiety level immensely and I now understand what the doctors are saying – somewhat. I was so lost not understanding anything – + the Dr.’s weren’t helping. You have helped. Thank you.

Karen

Len Griffiths

4 years ago

HELLO; your opinion/advice would be welcomed; I am 71 ,and a bodybuilder; early July 2013 I had been the gym and after,felt a severe pain from my buttock to my ankle; the visit to my doctor resulted in diagnosis of sciatica,and I was given Diclofenac tabs,and Tramadol caps; (both 50mg); after no improvement I had an MRI scan; the findings referred to a large disc extrusion which extends superiorly adjacent to the L4. Causing severe spinal canal stenosis in combination to facet joint and ligamentum flaum hypertrophy.There is bunching and presumed compression of the nerve roots in the cauda equina.
This scan was done at end of August 2013; I do not experience any loss of bowel or bladder control at this moment; and as at 13th October 2013,the pain has lessened; but is bad whene i get out of bed; my questions for your opinion are;
1.Will I need a discetomy?
2.Are there any other alternatives?
3 If the part that is bulged is removed will I not need a Fusion for stability?
4. Would a Laminectomy be neccessary as well?
5.If I dont agree to surgery,will my condition worsen,and what would be the possible outcome?

The pain at first was,on a scale of 1-10, a ten!
The pain now (14 weeks later) is a 5.

Your valued opinion or comments would be appreciated.

Len Griffiths

Julie Karrick

4 years ago

I recently had my second MRI, I slipped on ice in a parking lot 5 years ago and have had back problems ever since. My recent MRI from 10/22/13 states mild disk space narrowing and mild loss of signal, small broad-based disk protrusion in midline causing pressure effect. Impression was Mild degenerative disk disease. and small disk protrusion at L5-S1, I am only 33 years old, what does this all mean?

billly

4 years ago

I have been having lower back pain for years and it has become unbearable. I am a 57 year old male and did manual labor in the oil fields for years and have had upper back surgeries. I had a MRI last week that showed, Conus ends at L1. Epidural scarring at L4-L5 and L5-S1. There is a disc protrusion at L5-S1. There is a disc bulge at L4-L5. There is lateral recess stenosis at L4-L5 on the right side. There is foraminal stenosis at L5-S1 bilaterally. There is a Tarlov cyst at L2. Facet arthritis noted in the lower spine as well. What would you recommend? I can get down on my back for two and three weeks without being able to raise up and have severe left leg pain when lying down. What do you recommend? Thanks,Billy.

anthony

4 years ago

I just had an appointment with my GP about back pain ive been having for a couple months now. He said there was unusual wear found between the L4 and L5 or the L5 and S1 on the MRI. I was told that I need to walk an hour a day but I can barely walk 50 feet without needing to sit down or turn back. the pain medications I was given over that period of time does not help ease the pain. My question is “If there is unusual wear how would walking help? Would it not make the problem worse. Ive been off work now for almost 1 1/2 months. Please help thank you for your time.

Dragan

4 years ago

I have l5 s1 ddd and spinal stinosis … I’m 27 years and I can’t walk long and can’t stand long what to do this problem is from September this year .

Dragan

4 years ago

And. From September I have that Ingury on l5 s1 how much time need to pass to start exserase or somting to cure ?

Dean

1 year ago

A cure? Read about L4/5 S1. No cure just good management practices. Sorry but I have heard no one ever recovering from degenerative disk disease – just a slow and bumpy decline. Exercise, keep moving and never give up but do yourself a favour and forget CURE. Learn MANAGEMENT. Any surgeon will tell you the knife “cures” very few but can remobilise severe spine problems….broken, badly impinged nerves ect. Diskeptomy only if impingement is severe. So learn, learn. learn and manage best you can. (that is the best advice I can muster and applies to all but a few on this page, and those few unfortunately can be operated on but success long term is fickle to say the least but it will enable them some degree of life. We (not severe) must manage our pain and live our lives because believe me 20 years I have been searching for a cure and my life is gone…I have to start all over at 40 because I wasted so much time and effort trying to get better. I am sorry but I dont want to see anyone else end up like me…alone, in pain, not working and wasting away slowely. Live your life and accept it (the pains) before it consumes you and all those around you.

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David

4 years ago

Hello,
I’m 23 years-old and have had a disectomy and and fusion on at c-5 /c6 as a result of a right lateral protrusion causing severe pain and atrophy caused by nerve irritation. I had be surgery three years ago and still experience burning, and muscle tightness and constant pain on the right side of my neck and trap exclusively, although my muscles in neck do not actually tighten up. After several MRIs, epidurald and radio frequency procedures, nothing has helped. The MRI did not show anything to abnormal in my context. Several disc buldges, degenerative disc disease, disc shortness in legnth etc. In addition, EMG tests revealed nothing significantly abnormal. However since the pain still severely exists, I am still looking for the cause. One think I noticed was that the disc I had the operation on was substantially brighter and extremely whiter the the others. What does this mean? I’m assuming it’s inflammation that still exists three years later. If so, can that be the reason for the chronic pain that had and still lasts only on the right side of my neck/ trap? Thank you.

Dean

1 year ago

The message for us all is – Surgeons cannot cure pain. They can repair some structures and easily remove others but as for reducing pain no surgeon will sign off on that in fact most surgeons know most procedures are ineffective if you still have some mobility. A scalpel is not the correct implement for persistent back pain especially if it is at multiple levels. Radiographic studies on spines is great – but as it relates to recovery, diagnosis of a physical condition and treatment modality Radiography is quite useless in gauging nerve pain (unless enhanced elecrtography/pet I think thats what it is called) where in depth study of the nerves and the signal they send recieve ect. (expensive very very expensive) to prove what —-your in pain. The key here is unless you are basically immobilised or in acute severe distress (like impossible to get to or goto the toilet) at all than you would be better off staying well away from the surgeons. I have witnessed during my 20 year battle with back pain the many many individuals in pursuit of improvement only to see them 5 years later taking twice as many opiods and suffering severe suicidal depression…We all want to be better but believe me leave the surgeons well enough alone…If you need chopping up it will be done, if not you will be like I was for years – searching everywhere for some type of cure or relief. It may not exist but do not resort to surgeons or for that matter giving up. The medical industry no longer supplies diagnosis for spines as the legalities override patient concern or care. You will have degenerative disease (no insurance complication for the specialist) rather than a “slip disk” or “Buldging Disk ” it will now be a Bulding /dissected disk due to degeneration….insarance companies are to blame as are patients looking for a silver bullet for the compo claim…those of us who suffer in the middle must seek help from Chiropractors, Oesteopaths, Massage Therapy,Chinese Medicine and of course stay right away from narcotics – the effect wanes and long term you will have no means of pain relief due to resistance to the oxycodone that builds with regular use and you will simply end up a morphiene addict with a sore back…..STAY STRONG and seek your relief from anywhere you can provided it is not from Big Pharma or at the end of a surgeons scalpel…..Experienced warning from someone who knows — hurt at 24 and suffering ever since now 40. (drug free now)

Kate

1 year ago

Hello, Base on my MRI I have L5 S1. It has been last year that I have been feeling pain on my lower body, from my legs to my feet. I have checked with my ortho doctor before and he said I just had plantar fascitiis. This January I checked with another doctor and my MRI showed L5 S1 – there is disc desiccation associated with a central and bilateral parecentral disc protrusion.
I am already having my PT sessions but the nurses informed me that it will not go back and the PT sessions will just help alleviate the pain.
What I need to know is will I ever get back to my athletic form? I travel, bike, hike and do a lot of sports and wish to know if there is a chance for me to get back. Thank you!

SG-sliderSS1

Sohrab Gollogly, MD is a board-certified orthopedic surgeon and Fellowship-trained spine surgeon who also performs scientific research and participates in several volunteer surgical organizations.

Dr. Gollogly completed his undergraduate education in biology at Reed College in Portland, Ore. He earned his medical degree from the University of Washington School of Medicine.

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