What Your MRI Can’t Tell You: The Hidden Truth About Back Pain
By: Brian Hoeflinger, MD
July 20, 2025 | #54
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Disclaimer: Opinions are my own. Not medical advice.
Medical Trivia of the Week
Which part of the spine is most commonly affected by herniated discs? (the correct answer is at the end of this email)
- A) Lumbar spine (lower back)
- B) Thoracic spine (mid-back)
- C) Cervical spine (neck)
- D) Sacral spine (pelvis)
The Hidden Truth About Back Pain
I’ve been a neurosurgeon for over 26 years. Every week, I meet patients who come in with a primary complaint of back pain and often the following question.
“My back hurts, can I get an MRI to find out what’s wrong?”
It’s a fair question. If something hurts, it must be broken, right? And if something’s broken, an MRI should find it.
But here’s the truth most people don’t realize:
Just because something shows up on an MRI doesn’t mean it’s the cause of your pain. And just because your MRI looks normal doesn’t mean the pain isn’t real.
Let me explain.
The Problem with Imaging
MRIs are powerful tools. They show detailed images of your spine, discs, nerves, and soft tissue. But they can also be misleading, especially when it comes to back pain.
In fact, studies show that:
- 60–80% of people over age 50 have disc bulges on MRI, even if they have zero back pain.
- People with severe back pain sometimes have perfectly normal scans.
- And others with alarming MRI results might feel perfectly fine.
So how can that be?
Because pain is more complicated than a picture.
What Your MRI Does Show
Let’s say your MRI shows:
- A bulging disc
- A herniated disc
- Degenerative disc disease
- Narrowing of the spinal canal (spinal stenosis)
- Facet hypertrophy
These are all common findings, especially as we age. They may or may not be the cause of your pain.
Here’s an analogy I like to use:
If you drive an older car, the tires may be worn, the paint may be dull, the body may be rusted, and the brakes may need changing. All of these things are to be expected as a car ages. But are any of these age-related findings causing your engine to stop working? Just like the aging car, there are expected changes that take place in our bodies as we grow old. Many of these changes can be seen on an MRI study but it doesn’t necessarily mean that there is anything wrong if we consider the person's actual age. The pain that the person is experiencing may be completely unrelated to the MRI findings.
What Your MRI Doesn’t Show
An MRI won’t show:
- Muscle strain
- Joint stiffness
- Inflammation or micro-tears
- Posture issues
- Or how your body moves in real time
It also doesn’t show your pain threshold, your stress levels, or the cumulative effects of poor sleep, sitting too long, or not exercising.
In other words, an MRI can’t always tell the full story. Pain is both physical and neurological. It’s influenced by your body, your brain, and your environment.
So What Should You Do When Your Back Hurts?
Here’s my thoughts as a neurosurgeon who's seen tens of thousands of back pain cases:
Start with conservative care
Most back pain gets better on its own within 6 weeks. Start with the following (always consult your primary care physician first):
- Gentle movement or walking
- Gentle stretching
- Warm baths or sitting in a hot tub
- Heat or ice
- Anti-inflammatory medications (ibuprofen, etc.)
- Physical therapy
Know when to worry
You should see a doctor if you have:
- Back pain that has not improved or gotten worse over 4 to 6 weeks
- Pain that shoots into your buttock or down your leg
- Numbness or weakness of the arms or legs
- Loss of bladder or bowel control
- Fever, night sweats, weight loss, or recent cancer diagnosis
- Significant trauma to your back
These could be signs of something more serious, such as a pinched nerve, a bone fracture in your back, infection, or possible cancer.
Move more, not less
The old advice of “bed rest” is outdated. Motion is lotion. Staying active (within reason) helps blood flow, prevents stiffness, and accelerates healing.
Strengthen your core
The spine is supported by muscles, especially your core and glutes. Weak or imbalanced muscles make back pain worse. Even 10 to 15 minutes of strengthening exercises a few times a week can help tremendously.
Don’t overlook your brain
Chronic back pain is influenced by the nervous system. Anxiety, depression, and stress all amplify pain signals in the brain. That doesn’t make the pain “all in your head," it means the brain is part of the pain experience.
Meditation, mindfulness, and managing stress can play a powerful role in recovery.
When Is an MRI Actually Useful?
MRIs are most helpful when:
- Your symptoms are severe and not improving
- You have neurological signs (like weakness or numbness in your arms or legs)
- You’re considering surgery or a specific intervention
- There’s concern for infection or tumor
In those cases, imaging can guide the next steps. But don’t jump to an MRI at the first sign of pain. You might end up chasing shadows.
Why This Matters
Back pain is one of the most common reasons people see a doctor. But too often, we rely on tests and scans instead of listening to the body and taking a whole-person approach.
My philosophy has always been treat the patient and not the picture. Some findings on an MRI can be misleading and potentially lead to unnecessary surgery. When treating a patient, I need to understand the patient’s presenting symptoms, duration of symptoms, clinical exam including a neurological exam, any testing and body scans which have been completed and what treatment measures thus far have been helpful or not helpful. By considering all this information and data as a whole package, I can then make the best and most appropriate decisions regarding my patient’s health and treatment plan.
Impactful Quote of the Week
"The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease."
- Thomas Edison
All my best,
Brian Hoeflinger
P.S. - if you enjoyed this newsletter, you may enjoy my book that details my life as neurosurgeon and the loss of my oldest son, Brian (see below a synopsis).
Check out My Book
Life and Death . . . Two words with such opposite meaning and which inflict such contradictory emotions and yet are so closely intertwined in our lives. As parents, we bring meaning and life into this world through our children. Our lives become defined as a result. We learn the joy, hardship, and responsibility of shaping an innocent life. But a day will come when that life will be taken. For some, death will come too soon. This is the story of my son, Brian Nicholas Hoeflinger, who died unexpectedly at age 18.
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Medical Trivia Answer:
The correct answer is A) Lumbar spine (lower back)
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