Magnetic resonance imaging (MRI) can provide detailed information about spinal anatomy and disc morphology. For chiropractors and other clinicians, MRI spine interpretation involves more than recognizing an abnormality on an image. The clinical challenge is to understand what the finding describes, determine whether it fits the patient’s presentation, and decide when additional evaluation or collaborative care may be appropriate.
In this educational presentation, Mark Studin, DC, reviews foundational terminology for disc bulges, annular fissures, disc herniations, protrusions, and extrusions. The discussion below expands on those concepts with practical guidance on clinical correlation, diagnostic terminology, and responsible decision-making.
Watch the MRI Spine Interpretation Presentation
Watch Mark Studin, DC, introduce common spinal disc findings and explain terminology used in MRI interpretation.
Transcript: Download the presentation transcript. The original page notes that the transcript may contain spelling or grammatical errors and recommends watching the video while reading it. Restore the existing transcript URL before publication.
What Is MRI Spine Interpretation?
MRI spine interpretation is the assessment of magnetic resonance images to characterize spinal anatomy and abnormalities, including disc degeneration, disc displacement, and possible neural structure involvement. A useful interpretation describes the finding accurately and considers its location, extent, and relationship to the patient’s symptoms and examination.
An MRI finding is not automatically the cause of a patient’s pain. Disc abnormalities and degenerative changes can occur in people without symptoms. Clinicians should therefore interpret imaging alongside the history, physical examination, neurological findings, and the patient’s clinical course.
Understanding Common Disc Findings on MRI
Disc bulge
A disc bulge describes disc tissue extending beyond the normal margins of the intervertebral disc across a relatively broad portion of its circumference. Bulging is not synonymous with a herniation. It may occur with disc degeneration or other changes in spinal anatomy, and the term alone does not establish the cause of symptoms or the need for treatment.
Annular fissure
An annular fissure is a separation within fibers of the annulus fibrosus, the outer portion of the intervertebral disc. MRI may demonstrate a fissure, but the finding alone does not establish when it developed, what caused it, or whether it explains a patient’s pain. Interpret it in the context of the complete examination and imaging report.
Disc herniation
A disc herniation describes localized displacement of disc material beyond the intervertebral disc space. The accepted terminology distinguishes protrusions from extrusions according to the shape and dimensions of the displaced material. A herniation may or may not affect a nearby nerve root or other neural structure.
Disc protrusion
A protrusion is a type of disc herniation in which the displaced material has a broader base than its outward-projecting portion, based on the accepted radiological definition. The term describes morphology; it does not independently establish symptom severity, cause, or prognosis.
Disc extrusion and sequestration
An extrusion occurs when the displaced portion extends farther than its base in at least one imaging plane, or when displaced material no longer remains continuous with the disc of origin. A sequestration is a form of extrusion in which the displaced fragment has lost continuity with the parent disc. Reports may also describe migration when disc material has moved away from the original herniation site.
These distinctions follow the consensus terminology described by Fardon and colleagues in Lumbar disc nomenclature: version 2.0, developed with the North American Spine Society, the American Society of Spine Radiology, and the American Society of Neuroradiology.
Why MRI Views and Anatomical Location Matter
Axial and sagittal images provide complementary perspectives. Axial images show cross-sectional anatomy, while sagittal images show structures in a side-oriented plane. Additional sequences and planes may help characterize disc morphology, the spinal canal, neural foramina, and adjacent structures.
- Identify the level: Document the specific vertebral level and side when relevant.
- Describe the morphology: Distinguish bulging from herniation and, where appropriate, protrusion from extrusion.
- Assess neural relationships: Note reported or observed contact, displacement, or compression of relevant neural structures.
- Review the complete study: Do not base a conclusion on a single image when the complete examination is available.
- Use appropriate expertise: Seek interpretation or consultation from a qualified radiologist or other appropriately trained specialist when findings are uncertain or consequential.
How Should Clinicians Correlate MRI Findings With Symptoms?
Clinical correlation means evaluating whether an imaging finding fits the patient’s history and examination. A disc abnormality may be relevant when its location and effects correspond with the patient’s symptoms or neurological findings. However, an image alone cannot establish that relationship with certainty.
For example, a reported disc herniation may warrant closer evaluation when the patient also demonstrates findings consistent with nerve-root involvement. Conversely, an imaging abnormality that does not fit the patient’s presentation should not automatically become the primary diagnosis.
Research underscores the importance of careful interpretation. A 2015 cross-sectional diagnostic-accuracy study compared MRI readings by chiropractors, chiropractic radiologists, and medical radiologists. The investigators reported that agreement and validity were modest at best. The results support caution about assuming that any professional group can interpret every MRI finding accurately without appropriate training and quality controls.
Source: de Zoete A, Ostelo R, Knol DL, et al. Diagnostic Accuracy of Lumbosacral Spine Magnetic Resonance Image Reading by Chiropractors, Chiropractic Radiologists, and Medical Radiologists. Spine. 2015;40(11):E653-E660. doi:10.1097/BRS.0000000000000896.
When Should MRI Findings Prompt Referral or Co-Management?
Imaging findings should inform, not replace, clinical judgment. A potentially significant MRI abnormality requires interpretation in the context of the patient’s neurological status, symptoms, medical history, and the applicable standard of care.
- Escalate urgent concerns: New urinary retention, loss of bowel or bladder control, saddle sensory changes, or rapidly progressive neurological deficits may indicate a time-sensitive spinal emergency. Arrange emergency evaluation when clinically indicated rather than relying on routine follow-up.
- Consider specialist assessment: Significant or progressive motor deficits, suspected serious pathology, or imaging findings that may materially alter management warrant timely evaluation by an appropriately qualified clinician.
- Coordinate care: Communicate relevant examination findings, imaging reports, and the reason for referral. Seek specialist input when the diagnosis or appropriate management remains uncertain.
- Stay within scope: Follow applicable licensing requirements, professional standards, imaging interpretation rules, and referral obligations.
Do not infer that every disc herniation requires surgery or that every abnormal MRI makes spinal manipulation inappropriate. Management depends on the patient’s complete presentation, the specific pathology, neurological findings, treatment risks, and professional judgment. When a potentially serious lesion or significant neural compromise is suspected, defer interventions that could create undue risk until appropriate evaluation clarifies the situation.
When Is MRI Appropriate for Low Back Pain?
More imaging is not always better. Evidence-based imaging guidance generally discourages routine MRI for uncomplicated low back pain when there are no red flags or other indications that imaging will change management. MRI may be appropriate when serious pathology is suspected, neurological deficits are severe or progressive, or symptoms persist despite appropriate management and imaging could guide the next clinical decision.
For additional context, review the evidence-based spinal imaging guideline published in the Journal of Manipulative and Physiological Therapeutics: Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—Part 3: Spinal Disorders. Although this guideline is an important reference, clinicians should also consult current local guidance and the patient’s individual circumstances.
Documentation: Turning Imaging Into Clear Clinical Communication
Accurate documentation helps other clinicians understand the reasoning behind an assessment and treatment plan. When reviewing MRI information, record:
- The clinical indication for imaging and relevant history.
- The source of the MRI findings, including the radiology report and any additional review.
- The level, side, and morphology of relevant abnormalities.
- How the findings do or do not correspond with symptoms and examination findings.
- Any neurological deficits, concerning findings, or clinical uncertainty.
- The rationale for the management plan, referral, consultation, or decision to defer an intervention.
- Patient communication, informed consent where applicable, and follow-up arrangements.
Documentation should distinguish the radiologist’s reported findings from the treating clinician’s assessment. Avoid unsupported claims about the age, cause, or clinical significance of a lesion. Clear, measured language supports continuity of care and makes clinical decisions easier to review.
Frequently Asked Questions About MRI Spine Interpretation
Does a disc bulge mean a patient has a herniated disc?
No. Under accepted nomenclature, a bulge is distinct from a localized disc herniation. The terms describe different patterns of disc morphology and should not be used interchangeably.
Does a disc herniation always cause pain?
No. A herniation may be asymptomatic. Its clinical significance depends on the patient’s presentation and whether the finding plausibly corresponds with symptoms or neurological involvement.
What is the difference between a protrusion and an extrusion?
The distinction is based on the shape of displaced disc material relative to its base and, for extrusion, may include loss of continuity with the parent disc. Both are forms of disc herniation.
Can chiropractors interpret spinal MRI scans?
Training, legal authority, and professional scope vary by jurisdiction. Chiropractors should understand relevant imaging terminology, follow applicable requirements, and obtain qualified radiological or specialist consultation when appropriate. Educational familiarity does not replace formal training or authorize practice beyond one’s scope.
Should every patient with low back pain receive an MRI?
No. Routine MRI is generally not recommended for uncomplicated low back pain without concerning features or a clinical reason the result would change management. The decision should reflect the patient’s presentation and applicable imaging guidance.
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Educational Disclaimer
This article and the accompanying presentation are for educational purposes only. They do not provide patient-specific medical advice, establish a standard of care, or replace formal imaging education, qualified radiological interpretation, clinical judgment, current practice guidelines, or applicable legal and professional requirements. Clinical decisions should reflect the individual patient’s presentation and the clinician’s training and scope of practice.
Conclusion
MRI spine interpretation requires more than recognizing disc abnormalities. Clinicians should understand accepted terminology, assess the full study, correlate findings with the history and examination, recognize potentially serious presentations, and document the reasoning behind clinical decisions. Used appropriately, MRI can contribute valuable information to patient assessment and collaborative care without replacing clinical judgment.