One of the most common challenges in pain medicine is the patient whose symptoms and imaging do not seem to match.

Sometimes the MRI report describes only mild degenerative change, yet the person in front of us is experiencing severe, disabling pain. At other times, imaging shows extensive degenerative disease in someone whose symptoms are relatively modest.

Neither situation should really surprise us.

Imaging is an important part of clinical assessment, but it is only one part. The relationship between structural abnormalities and the experience of pain is complex, and interpreting imaging well requires us to place it back into the context of the person.

Imaging findings are common in people without pain

Degenerative changes become increasingly common as we age.

Disc degeneration, disc bulges, facet joint osteoarthritis and other structural abnormalities can all be seen in people who have little or no pain. Their presence on an MRI therefore does not necessarily identify the source of a patient's symptoms.

Equally, describing imaging abnormalities as simply “wear and tear” can sometimes be unhelpful. Structural pathology may be clinically relevant; the challenge is determining whether it is relevant to this patient's presentation.

The scan provides anatomical information. The consultation provides the clinical context.

“Mild” imaging does not mean mild pain

The opposite problem is equally important.

A radiology report describing mild or moderate changes can inadvertently become a judgement about the legitimacy or expected severity of someone's pain.

But radiological severity and pain severity are not interchangeable.

A relatively modest structural abnormality may irritate a sensitive nerve root or painful joint and produce substantial symptoms. Conversely, apparently significant compression or degeneration may be remarkably well tolerated.

The words used in a radiology report describe appearances on a scan. They do not measure pain.

Start with the clinical phenotype

When reviewing imaging, I find it useful to return to a simple question:

What am I actually trying to explain?

For example, is the predominant problem:

• axial mechanical back pain?

• radicular pain?

• neurogenic claudication?

• focal neuropathic pain?

• widespread or multisite pain?

• pain associated with marked sensitivity or altered sensory processing?

• or a combination of several mechanisms?

The history and examination allow us to develop a clinical phenotype. Imaging can then be used to look for anatomical findings that might plausibly contribute to it.

This is subtly different from starting with an MRI abnormality and trying to make the patient's symptoms fit it.

Correlation matters more than the report in isolation

When imaging identifies a potential pain generator, several questions are useful.

Does the anatomical level correspond with the distribution of symptoms? Is there a plausible mechanism linking the finding to the pain? Are there supporting clinical signs? Does the time course make sense? And, importantly, are there other features of the presentation that the imaging does not explain?

This becomes particularly important in patients with multiple abnormalities.

A lumbar MRI may contain several disc bulges, areas of foraminal narrowing and degenerative facet joints. It is tempting to feel obliged to choose one of them as the diagnosis.

Sometimes that is possible.

Often it isn't.

More than one thing can be true

Pain medicine becomes much easier to understand when we allow several mechanisms to coexist.

A patient may have genuine nociceptive pain arising from osteoarthritis and increased nervous-system sensitivity.

Someone with lumbar radicular pain may also develop protective muscle guarding, poor sleep, reduced activity and fear of movement.

A person with longstanding widespread pain can still develop a new focal structural problem.

Recognising altered pain processing should not require us to disregard peripheral pathology. Equally, identifying structural pathology does not mean that every aspect of a complex pain presentation is explained by it.

The useful question is often not “Is this structural or sensitisation?”

It is:

“How much is each mechanism contributing, and what can we reasonably do about it?”

Diagnostic uncertainty is not therapeutic failure

There is understandable pressure in medicine to provide a precise anatomical diagnosis.

Sometimes we can.

Sometimes the most accurate conclusion is that there are several plausible contributors to the pain, without a single structural abnormality adequately explaining the whole presentation.

That uncertainty can be difficult for patients, particularly when they have already undergone multiple investigations and consultations.

But uncertainty does not mean that nothing is wrong, nor does it mean that nothing can be done.

A useful pain consultation can help establish what has been excluded, identify the most plausible contributing mechanisms, recognise potentially modifiable factors and develop a treatment or rehabilitation plan even when diagnostic certainty is incomplete.

Where do injections fit?

Interventional procedures can sometimes help when the clinical picture and imaging suggest a plausible target.

They may also occasionally provide useful diagnostic information.

But an abnormality on an MRI is not, by itself, an indication for an injection.

The decision should arise from the clinical presentation, examination, imaging and likely pain mechanism together, alongside a discussion about the limitations and realistic objectives of the procedure.

For some patients, an intervention may create a valuable window in which movement and rehabilitation become easier.

For others, the most useful intervention is helping them understand why further procedures are unlikely to change their overall pain.

Both can represent good pain medicine.

The importance of language

How we explain imaging matters.

Patients frequently arrive in pain clinics believing their spine is “crumbling,” “bone-on-bone,” “full of trapped nerves”or simply “worn out.”

Sometimes these beliefs have developed from entirely well-intentioned explanations of previous scans.

Language that implies fragility can understandably make people frightened of movement. Conversely, telling someone that their scan is “normal” when they are experiencing substantial pain can feel dismissive.

There is usually a better middle ground:

There are changes on the scan. We need to decide which of them are likely to matter, which may simply be part of normal ageing, and whether they explain the symptoms you are experiencing.

That conversation can itself be therapeutic.

Bringing the pieces together

MRI scans are extraordinarily useful. But they do not diagnose pain.

The most useful interpretation comes from bringing together the patient's story, examination, imaging, previous treatment responses and an understanding of the different biological and psychosocial factors that can influence pain.

Sometimes the scan gives us a clear target.

Sometimes it provides reassurance.

And sometimes its greatest value is helping us establish what isn't causing the problem.

The skill lies not simply in finding an abnormality, but in deciding what it means for the person sitting in front of us.

For clinicians

Wye Sanctuary welcomes referrals and self-referrals for patients where the cause of persistent pain remains uncertain, where symptoms appear disproportionate or discordant with imaging, or where advice is needed about whether an interventional approach may be appropriate.

We are also happy to work alongside a patient's existing physiotherapist or other treating clinicians where a joined-up approach would be helpful.

This article is intended for general professional education and does not replace individual clinical assessment or specialist advice.

I think this one is very Wye Sanctuary. It demonstrates that you understand interventions and anatomy while also avoiding the two extremes of “the MRI explains everything” and “it's all sensitisation.” That balance is particularly important for the complex patients you're increasingly being referred.