The Back Pain Disc-onnect: It’s Not Just About the Disc!

May 08, 2015

If you have not experienced back pain, then you likely know someone who has endured a short bout of low back pain or perhaps is still suffering from the affliction. The most common assumption by many patients is that they have “slipped a disc.” Worst of all, there is a tendency for limited histories and physical exams to be done and MRI studies ordered hastily. Unfortunately, this can lead to an overutilization of unnecessary imaging technology, which leads to many dreadful-sounding descriptions of the patient’s back. The patient’s concerns that a single event happened, such as a slipped disc, may be reaffirmed. This could lead to a patient becoming diagnocentric (see my blog, Diagnocentricity).

But let me just blow some assumptions out of the water here. Does the presence of bulging discs really mean PAIN? Take a look at the graph below to see where your age fits among the various groups:


ALL of these individuals are people who DO have disc bulges, but DO NOT have PAIN. I will repeat for the sake of clarity…many of these PAIN-FREE individuals have disc bulges! 

So what do you do with this information? It is important to know, that in most cases if you have a significant disc bulge impinging or compressing on a nerve root, then a history and physical exam should support a true radiculopathy. Radiculopathy from a low back disc bulge is a pattern that typically follows a certain pain pathway down the leg with resulting shooting pain, numbness, and/or weakness. You should have a good evaluation that strongly suggests that a radiculopathy exists before any MRI is ordered unless there are other concerning red flags (e.g. significant weight loss, etc.).

It is astounding how much our society believes that all back pain is related to the disc. This is where the disc-onnect happens. Sure, the disc is one of those structures that is inherently part of the spine. But not all low back pain problems are disc problems. You may be easily mislead by MRIs. If you do not have any red flags, then consideration must be given to some other potential issues. Some of those other reasons for low back pain are discussed in my book, PAINDEMIC (


Graph modified from: W. Brinjikji et al, “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations,” Am J Neuroradiol 2014 Nov 27: 1-6. [Epub ahead of print] 2014© by American Society of Neuroradiology.

Other images purchased from Shutterstock.