One of the most common musculoskeletal disorders in the world, low backache (LBA) poses a serious public health burden because of its socioeconomic ramifications, disability, and medical expenses. Over 80% of people worldwide are predicted to suffer from low back pain at some time in their life, making it the primary cause of years lived with disability (YLDs) in the majority of nations. In 2020, Buchbinder R. et al.^[1]. Low back pain is a major cause of absenteeism, lost productivity, and a decline in quality of life in both developed and developing countries.

Depending on how long it lasts, low back pain can be categorised as acute (less than six weeks), subacute (6–12 weeks), or chronic (more than twelve weeks). (2010) Koes BW et al.^[2]. Low back discomfort has a complex aetiology that can include more serious conditions such infections, cancers, and fractures as well as benign mechanical reasons. A thorough clinical examination backed by the right imaging methods is necessary for the diagnostic evaluation of patients with LBA. Due to its capacity to provide detailed images of both soft tissues and bone without exposing users to ionising radiation, magnetic resonance imaging, or MRI, has become the gold standard for assessing spinal disorders. In 2020, Lancaster B. et al.^[3].

According to Donnally III CJ et al. (2023), MRI provides highly accurate identification of neural compression, spinal canal stenosis, vertebral body alterations, and intervertebral disc diseases^[4]. Compared to standard radiography or CT scans, it offers better visualisation of the spinal cord, nerve roots, intervertebral discs, and vertebral marrow. Belavy DL et al. (2022)^[5] state that it is very helpful in the diagnosis of degenerative disc disease, herniated discs, modulic alterations, annular tears, and infections such as spondylodiscitis. However, it is important to use caution when interpreting MRI results since many asymptomatic people may have degenerative changes, which are frequently age-related and incidental. Brinjikji W et al. (2015)^[6]

Poor ergonomics, a lack of knowledge about spinal health, and occupational dangers all contribute to the prevalence of LBA in India. Jobs involving hard lifting, repetitive motions, or extended sitting are especially linked to higher risk. In 2024, Vasireddi N et al.^[7]. The chronicity of symptoms and heightened reliance on imaging modalities for diagnosis and treatment planning are caused by inadequate rehabilitation and a lack of early intervention. Even though MRI is becoming more and more common, there is still a disconnect between imaging results and clinical connection, which might result in misuse of MRI in some situations. Jenkins, H.J., and others (2018)^[8].

More than 50% of asymptomatic persons exhibited discernible spinal abnormalities on MRI, according to a research by Chadha M et al. (2022), indicating that not all radiological results match clinical complaints ^[9]. This disparity emphasises how crucial it is to combine MRI results with patient history and clinical judgement. According to Allegri M et al. (2016)^[10], MRI is still very helpful in situations of suspected radiculopathy, spinal infections, tumours, or when conservative therapy is ineffective.

A tertiary care hospital in India conducted this study to assess the range of MRI results in individuals who had mild back pain. Finding the most prevalent radiological anomalies and connecting them to clinical manifestations was the main goal. Making the right management options, especially when separating surgical from non-surgical situations, can be facilitated by an understanding of the patterns of spinal disease.

Furthermore, the kind and scope of MRI results might be influenced by demographic variables such age, sex, body mass index (BMI), employment, and length of symptoms. Prior research has demonstrated that while spondylotic alterations are more common in older people, disc degeneration and herniation are more common in those between the ages of 30 and 60.^[11] Kasch R. et al. (2022). Sedentary behaviour, poor lifting skills, and lifestyle choices all contribute to spine degeneration.

The objective of this 18-month cross-sectional research of 160 patients was to identify the patterns most pertinent to patient treatment in the Indian healthcare context and to close the gap between clinical and radiological assessment of low backache. Additionally, this study adds to the expanding corpus of data emphasising the value of prudent imaging in the treatment of LBA.

Study Design and Duration

This cross-sectional observational study was conducted in the Department of Radiodiagnosis at a tertiary care teaching hospital over a period of 18 months, from January 2023 to June 2024.

Sample Size

A total of 160 patients who presented with low backache and underwent MRI of the lumbosacral spine were included in the study.

Inclusion Criteria

• Patients aged 18–70 years
• Patients presenting with low backache of ≥4 weeks duration
• Patients who underwent MRI at the hospital during the study period

Exclusion Criteria

• History of trauma or spinal surgery
• Known malignancy, spinal tuberculosis, or congenital anomalies
• Patients with claustrophobia or contraindications to MRI (e.g., pacemakers)

Data Collection

Clinical data including age, gender, duration of symptoms, and associated complaints (e.g., radiculopathy, numbness) were recorded. MRI scans were performed using a 1.5 Tesla system (Philips Achieva) using standard spine protocols: sagittal T1, T2, STIR, and axial T2-weighted images.

MRI Parameters Evaluated

• Intervertebral disc degeneration
• Disc bulge
• Disc herniation (protrusion, extrusion, sequestration)
• Spinal canal stenosis
• Modic changes
• Facet joint arthropathy
• Ligamentum flavum hypertrophy

Statistical Analysis

Data were analyzed using SPSS version 25. Descriptive statistics were used to summarize the data. Chi-square test was applied for categorical variables. A p-value < 0.05 was considered statistically significant.

Ethical Approval

The study was approved by the Institutional Ethics Committee. Written informed consent was obtained from all participants.

Table 1: Demographic Characteristics

The study included a total of 160 participants presenting with lower back symptoms. The mean age of the study population was 44.5 ± 11.2 years, indicating a predominance of middle-aged adults. When categorized into age groups, the majority of patients fell within the 41–60 years age group (47.5%), followed by 28.1% in the 18–40 years category and 24.4% over 60 years, suggesting that degenerative spinal conditions were more prevalent among middle-aged individuals. Gender distribution showed a male predominance (55%), with females comprising 45% of the study cohort. This slight male preponderance is consistent with prior epidemiological studies on lumbar spine pathologies.

Figure 1

Table 2: Clinical Features

Analysis of clinical presentation revealed that back pain alone was the most common symptom, reported by 43.7% of patients (n=70). A substantial proportion, 40.6% (n=65), presented with pain associated with radiculopathy, reflecting nerve root involvement. Numbness was noted in 25.0% (n=40), suggesting sensory nerve compromise in a quarter of the cases. A history of lifting strain—a potential mechanical trigger—was present in 36.2% (n=58) of patients. Notably, a chronic duration of symptoms (greater than 3 months) was documented in 56.2% (n=90), indicating that more than half of the patients suffered from long-standing symptoms, which is characteristic of degenerative lumbar spine conditions.

Figure 2

Table 3: MRI Findings

Magnetic Resonance Imaging (MRI) findings demonstrated that intervertebral disc degeneration was the most frequent abnormality, present in 80% (n=128) of cases, reaffirming its role as the primary degenerative pathology in symptomatic patients. Disc bulge was identified in 65.6% (n=105), and disc herniation in 29.3% (n=47), both of which contribute significantly to nerve root compression syndromes. Additional findings included spinal canal stenosis in 20.6% (n=33), Modic changes in 25.6% (n=41)—indicative of vertebral endplate and marrow changes—facet joint arthropathy in 16.9% (n=27), and ligamentum flavum hypertrophy in 15.0% (n=24). These findings collectively highlight the multifactorial nature of spinal degeneration and its symptomatic manifestations.

Figure 3

Table 4: Level-wise Distribution of Findings

Multiple-level disc degeneration was seen in 68 (42.5%) cases.

The level-wise distribution of MRI abnormalities showed a clear predilection for lower lumbar segments. The L4–L5 level was the most commonly affected, with disc degeneration in 95 cases, herniation in 30, and stenosis in 20. The L5–S1 level closely followed, showing degeneration in 88 cases, herniation in 32, and stenosis in 15. These levels bear maximum mechanical stress and are biomechanically prone to early degeneration. Higher lumbar levels (L1–L2 and L2–L3) were less frequently involved. Additionally, multi-level disc degeneration was observed in 42.5% (n=68) of patients, reflecting widespread degenerative changes rather than isolated lesions in many cases.

Figure 4

The purpose of this study was to assess MRI results in individuals who had mild back pain and examine the distribution of spinal anomalies across various clinical and demographic groups. Consistent with previous research, our data indicated that the most common findings were disc herniation, disc bulging, and intervertebral disc degeneration ^[3,5]. Neural compression and Modic alterations were also seen in a significant proportion of individuals.
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n more than 70% of patients, degenerative disc disease was the most common anomaly. According to research by Brinjikji et al., disc degeneration is a frequent age-related alteration that becomes more prevalent during the third decade of life ^[6]. Our results support the notion that, even in the absence of significant clinical symptoms, degenerative alterations start early and worsen with age.

Since the L4-L5 and L5-S1 levels are the biomechanically most stressed areas of the lumbar spine, disc bulges and herniations were commonly found there. Adams MA and associates (2012) ^[12]. These results are consistent with earlier research that indicates excessive mobility and axial stress at these levels make them vulnerable to disc degeneration. KT Palmer and colleagues (2012) ^[13]. Compression of the nerve roots, frequently as a result of disc protrusion or extrusion, was substantially linked to radicular symptoms. As a result, MRI was crucial in determining which patients needed surgery.

It's interesting to note that a significant proportion of patients had modic changes, which are indicative of changes in the marrow signal and vertebral endplate next to degenerative discs. According to Scarcia L. et al. (2022), modic type 2 alterations suggested fatty degeneration, but modic type 1 changes were more prevalent and linked to active inflammation and discomfort ^[14]. Although there is ongoing discussion over the therapeutic significance of Modic changes, some research shows to a link with persistent low back pain (Li Z et al., 2023) ^[15].

Another important finding was that elderly people frequently have facet joint arthropathy and ligamentum flavum hypertrophy, which can lead to central canal stenosis. These results are consistent with earlier research that highlighted spinal stenosis as a major contributor to back pain in the elderly. When central canal stenosis is linked to neurogenic claudication, it must be identified quickly and frequently requires decompressive operations. DS Kreiner and associates (2013) ^[16].

Notably, several patients' MRI results did not match their clinical symptoms satisfactorily. This contradiction emphasises the necessity for a comprehensive clinical evaluation and draws attention to the limitations of MRI in identifying the sources of pain. According to Boden et al., a sizable fraction of asymptomatic people exhibit notable disc abnormalities, indicating that care shouldn't be determined just by imaging [9]. Despite having ongoing LBA symptoms, a subgroup of individuals in our research had normal MRI results. These situations might be caused by early inflammatory alterations that are not seen on MRI, psychological issues, or strains in the muscles or ligaments. It highlights how complicated LBA is and how crucial it is to take functional and psychological evaluations into account when treating chronic pain. Al-Subahi M et al. (2017)^[18].

The distribution of genders revealed a little male predominance, which is in line with exposure to strenuous physical labour at work. But there was no statistically significant change. In metropolitan areas, bad posture and a sedentary lifestyle are becoming risk factors for both sexes^[7]. Manual labourers and long-distance drivers had a greater prevalence of disc abnormalities according to occupational history, which suggests that inappropriate lifting techniques, repeated trauma, and vibration have a negative impact on spinal health (Macedo LG et al., 2019)^[19]. In order to avoid early-onset spine degeneration, our findings support the necessity of ergonomic treatments and workplace education.

In the LBA diagnostic method, MRI is still a vital tool, especially in cases when there are clinical red flags. It is perfect for identifying minute alterations in the spinal architecture because of its higher soft tissue resolution and non-invasive nature ^[10]. Its drawbacks, however, include the possibility of overdiagnosing and misinterpreting age-related changes as pathogenic, which might result in needless procedures.

The study's strength is its thorough analysis of a sizable sample size over a long period of time, which enables us to make insightful deductions about the patterns of spinal disease. To prevent the dangers of overusing imaging, the results must be evaluated in light of their clinical significance. The study concludes that MRI is an essential adjunct in the assessment of LBA, particularly when combined with a targeted clinical examination. When used appropriately, MRI can greatly enhance patient results for the treatment of low back pain when paired with preventative measures and therapy.

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     A                                        B                                         C

Figure 1: 65 year old male came with complaint of lower back pain and urinary complaints.

Sagittal T1W B) STIR and C) axial T2W image of lumbar spine at level of L5 shows facet joint arthropathy with right facet joint synovial cyst compressing cauda equina, right lateral recess, right traversing and exiting nerve root

A                                                  B

Figure 2 – Case of Spondylolytic anterolisthesis of L5 over S1 with associated A) T1W images & B) sagittal T2W Images showing Hyperintense signal in inferior end plate of L5 and superior end plate of S1. Indicative of Modic Type II end plate changes

     A                                                     B                                                     C

Figure 3: Case of Ligamentum filum hypertrophy A) transverse T2W image at level of L4 - L5 showing disc desiccation, diffuse asymmetric disc bulge and ligamentum flavum hypertrophy, causing compression over left exiting nerve roots. B) sagittal STIR and C) T2W images show disc desiccation changes with disc bulges at multiple levels.

A                                                         B                                                         C

Figure 4: Case of Paracentral disc protrusion with spinal cord narrowing. A) sagittal T2W B) STIR shows disc desiccation changes at multiple levels C) transverse T2W Image at level of L4 - L5 shows disc desiccation, diffuse disc bulge with left paracentral disc protrusion causing compression over left lateral recess and bilateral exiting nerve roots.

Degenerative disc degeneration, disc bulging, herniation, and Modic alterations are the most prevalent MRI findings, with L4-L5 and L5-S1 being the most impacted levels, according to this cross-sectional research of 160 patients who presented with low backache at a tertiary care hospital. In situations where there was neurological involvement or where traditional treatment was ineffective, MRI was essential in determining the structural reasons of low backache.

The significance of clinical connection was emphasised by the study, which also revealed a significant disparity between MRI results and clinical symptoms in a number of individuals. Even while MRI is essential for assessing infection, spinal stenosis, or radiculopathy, over use of the scan might result in incorrect diagnoses or overtreatment, particularly when age-related changes are present. The key to improving diagnosis and therapy is choosing the right patients for MRIs based on clinical evaluation and red flags. The study's conclusions highlight the importance of MRI in directing the treatment of LBA and the necessity of combining imaging with occupational and functional assessments to provide comprehensive therapy.

1. Single-center study: Because of demographic and geographic limitations, the findings might not apply to a larger population.
2. Absence of follow-up: Because the study was cross-sectional, it was not possible to evaluate long-term results or responsiveness to treatments.
3. Lack of control group: The assessment of incidental results was constrained by the lack of comparison with asymptomatic people.
4. Subjective symptom correlation: Standardised instruments like the Oswestry Disability Index were not used to measure the relationship between pain perception and disability levels.
5. Lack of inter-observer reliability: Multiple radiologists did not confirm MRI readings.

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