You sit in the third exam room of the year.
Your back hurts. Your leg does not.
If that has been your experience, same imaging report, same shrug, same pain, this article is for you.
Read the Full Video Transcript
DISCLAIMER:
Transcript lightly edited for clarity and readability. The views expressed are intended to explore the full range of clinical considerations in spine care and do not constitute medical advice. Outcomes vary by patient and pain pattern. For guidance specific to your situation, consult a spine specialist.
TRANSCRIPT TEXT:
Why Your Back Pain Can Be Real Even When Your MRI Looks Normal
Back pain that stays in the back, with no leg pain at all, is one of the most commonly dismissed types of pain in modern medicine.
In this explainer, we are looking at a common medical challenge that leaves many patients feeling unheard. For anyone who has ever received a “normal” imaging report, only to go home with the same debilitating symptoms, this discussion will help explain what may be getting missed.
Many patients with axial low back pain sit in an exam room and hear that their imaging looks fine. A doctor may suggest that it is stress, early arthritis, or something that should improve with stretching, time, or basic conservative care.
But patients often leave with the same pain, the same questions, and a growing concern that no one is truly listening.
Axial low back pain is exactly what it sounds like. It is pain that stays primarily in the lower back without traveling down the leg. It does not usually have the sharp, electric, shooting quality often associated with a classic pinched nerve or sciatica.
Instead, axial low back pain may feel like a deep ache. Sometimes it is dull. Sometimes it is sharp. It may worsen with sitting, standing too long, bending, lifting, or certain movements.
Because axial low back pain does not always follow the dramatic pattern of a pinched nerve, it can look less obvious on medical charts. And when imaging does not show a dramatic finding, the conversation in the exam room can become shorter, quieter, and less complete.
That is when patients are often dismissed.
But back pain is not really a diagnosis. It is a symptom. It is an alarm bell telling us that something is wrong.
In modern medicine, however, this is often where the conversation stops.
Vague labels can leave patients stranded without a clear explanation or a real plan. And the uncertainty can become its own kind of suffering.
It creates a frustrating cycle where people feel like they have to constantly prove their pain is real, or simply accept a lifetime of discomfort without meaningful answers.
This brings us to an important medical paradox: a clean scan does not always mean a pain-free life.
There is a real disconnect in spine care between severe daily pain and clean-looking imaging. On one hand, a person can have severe, life-altering back pain with no obvious structural cause showing up on MRI.
On the other hand, someone else may have no pain at all, yet their MRI may show disc degeneration, disc bulges, or other age-related changes.
Research supports this paradox. For many people with low back pain, no single specific structural cause can be clearly identified on standard imaging. That does not mean the pain is not real. It means imaging is only one part of the story.
To put that into perspective, a systematic review of more than 3,000 asymptomatic people found that approximately 37% of pain-free individuals in their 20s already show signs of disc degeneration. That percentage continues to increase with age.
Findings such as disc degeneration, disc bulges, and other so-called abnormalities are very common in people who do not have pain.
This means an MRI is only one piece of a much larger puzzle.
A scan full of findings does not automatically explain severe pain. And a clean scan does not mean a patient is perfectly healthy or that their pain is not real.
So if the pain is not always explained by the scan, what else could be happening?
One important part of the answer involves the nervous system.
There is a process known as central sensitization. In simple terms, this is when the nervous system turns up the volume on pain.
The structures in the back — including the discs, facet joints, muscles, ligaments, and other tissues — all send signals. But it is the nervous system that receives, interprets, and sometimes amplifies those signals.
When pain has been present for a long time, the nervous system itself can become more sensitive. That means a person with chronic low back pain and an unremarkable MRI is not making it up.
Their nervous system may have adapted in a way that amplifies pain.
That is biology. It is not weakness. It is not exaggeration. And it is not simply stress.
Recent medical research continues to validate the complexity of chronic low back pain. The old assumption that back pain simply resolves within a few weeks with rest does not match the reality for many patients.
For pain lasting longer than three months, the clinical course can be much longer and more variable. Many people experience only modest improvement over time, even with standard care.
The bottom line is this: chronic pain is biologically complex. It is not a personal failure, and it should not be dismissed as “just stress.”
When standard imaging fails to tell the whole story, it becomes necessary to take a more complete approach and look beyond a basic MRI report.
At Vertrae®, a comprehensive spine center specializing in minimally invasive and robotic spine surgery in Dayton, Ohio, Dr. Kamal Woods, MD, MBA, takes this kind of deeper approach.
Dr. Woods is a dual fellowship-trained neurosurgeon and spine surgeon specializing exclusively in minimally invasive spine surgery. His evaluation does not begin and end with reading a radiology report.
It starts by looking at the whole person.
A thorough evaluation with Dr. Kamal Woods at Vertrae® includes a detailed pain history: when the pain started, what makes it better or worse, and how it behaves in daily life.
It also includes a hands-on physical exam to assess nerve responses, movement patterns, strength, and spinal function in real life.
And importantly, it involves reviewing the actual images, not just the summary report.
The MRI report is one piece of information. The patient’s history, physical exam, movement patterns, and lived experience all matter deeply in forming a complete medical story.
So, what are the next steps for patients who feel dismissed?
First, dismissal does not have to be the end of the road.
Before even arriving at a consultation, many patients can begin reclaiming movement in safe, simple ways. One powerful example comes from the WalkBack trial, published in The Lancet in 2024.
This study followed more than 700 adults and found that an individualized, gradually progressive walking program delayed recurrence of low back pain to a median of 208 days, compared with 112 days for those who received no specific intervention.
In other words, walking nearly doubled the time before pain returned.
Walking is accessible, low-cost, and does not require a prescription. For many people, it can be a practical first step toward rebuilding confidence and movement.
Ultimately, seeking a second opinion from a spine expert like Dr. Kamal Woods at Vertrae® in Dayton, Ohio, can be a reasonable next step when a patient’s case has resulted in dismissal.
Medicine is constantly advancing. Conditions such as vertebrogenic pain, which can originate where the disc meets the bone, and multifidus dysfunction, which involves the deep stabilizing muscles of the spine, are much better understood today than they were 10 or 15 years ago.
Many patients previously labeled with “nonspecific back pain” may actually fit into categories that were not fully recognized or evaluated before.
Getting a fresh evaluation does not automatically mean surgery is the next step.
It simply means replacing uncertainty with a thoughtful, personalized, and actionable plan.
If you have been told there is nothing wrong, but your pain is real, a thorough evaluation at Vertrae® in Dayton, Ohio may be worth a conversation.
Quick Answer:
If you have been told “nothing is wrong” but your back still hurts every day, this article is for you.
Back pain without leg pain is often called axial low back pain. It can be dismissed because the pain does not follow a classic “pinched nerve” pattern, and imaging may not show one obvious cause. The pain can still be real. The key is matching the imaging, the exam, the history, and the way pain behaves in daily life into one coherent story.
The doctor glances at the imaging report and says it looks fine. Maybe it is stress. Maybe a little arthritis. Try some stretches. Come back if it gets worse.
You leave with the same pain, the same questions, and the same quiet fear that no one has actually been listening.
One patient described their father’s experience this way: “His diagnosis was back pain, too.”
But “back pain” is not a diagnosis. It is often where the conversation stops.
This blog is for the person who has been told there is nothing wrong, but who knows their body well enough to know something is. We will walk through why this happens, what a more thorough look may reveal, and what an evaluation looks like at Vertrae® in Miamisburg, Ohio.
“His diagnosis was back pain, too.” — a patient describing the dismissal a family member faced |
What is axial low back pain, in plain English?
Axial low back pain is back pain that stays in the lower back. It does not radiate down a leg. It is not the sharp, electric, shooting pain people associate with a pinched nerve. It is a deep, sometimes dull, sometimes sharp ache that often gets worse with sitting, standing too long, bending, or lifting.
Because it does not travel down the leg, it tends to look less dramatic on paper than radiating pain. That can lead to a quieter conversation in the exam room — even when the pain itself is anything but quiet.
Possible structural sources of axial low back pain may include the disc itself, the small facet joints at the back of the spine, the sacroiliac joints, or the muscles and ligaments that hold everything together. The nervous system also plays a role in how pain is felt and how long it lasts. We will come back to that.
In specialty spine settings, a more detailed history, exam, and image review may reveal patterns that were not obvious in a shorter visit. Sometimes the source becomes clearer. Sometimes the next step is better testing. And sometimes the most valuable outcome is knowing which treatments are unlikely to help.
Some categories of back pain are also better understood today than they were ten or fifteen years ago.
Vertebrogenic pain can come from the endplates — the area where the disc meets the bone of the vertebra. Multifidus dysfunction involves the deep stabilizing muscles of the lower spine, which can lose their normal coordination after an earlier injury and may contribute to ongoing pain even when the discs and joints look reasonable on imaging.
These patterns may not jump out on a routine report. They require someone to connect the scan, the symptoms, the exam, and the way the pain behaves in real life. Many patients labeled with “nonspecific back pain” over the last decade may belong in one of these categories — they were just not yet being looked for. That is part of why a fresh evaluation can sometimes change the conversation.
Snippet — What axial low back pain is
Axial low back pain is pain that stays in the lower back without radiating down a leg. It can come from discs, facet joints, sacroiliac joints, or surrounding tissues, and the nervous system itself can amplify how the pain is felt over time.
Why does this kind of pain get dismissed?
There are a few reasons, and most of them have nothing to do with the patient.
Imaging may not show a single clear cause
Most low back pain does not trace to a specific finding on a scan. A large international review in The Lancet examined how common low back pain is worldwide and its causes, and the authors found that for nearly all people with low back pain, no single specific structural cause can be identified on imaging (Hartvigsen et al., 2018). That is not a comment on whether the pain is real. It is a comment on the limits of what a scan can tell us.
“Abnormal” MRI findings are common in people with no pain
A systematic review of imaging findings in people without back pain examined 33 studies and over 3,000 people. The reviewers found that disc degeneration, disc bulges, and other findings often labeled as “abnormal” were present in many people who had no pain at all. Disc degeneration showed up in about thirty-seven percent of people in their twenties and rose with age (Brinjikji et al., 2015).
That is the puzzle. A patient with severe pain may have a clean-looking scan. Another person with no pain may have a scan full of findings. The imaging alone often does not settle the question.
Pain that does not radiate gets less attention
Radiating leg pain points clearly toward a nerve. Axial pain points toward a longer list of possible sources. That can mean a shorter visit, a quicker conclusion, and a patient who leaves feeling unheard. “They make me feel like I’m crazy and it’s not as bad as I’m saying,” one patient put it. “My doctor said it’s just stress.”
“They make me feel like I’m crazy and it’s not as bad as I’m saying.” |
Stress can play a role in pain. So can sleep, mood, and other parts of life. But “it’s just stress” as the whole answer often misses what is actually happening underneath.
Why does a “normal” scan not mean that nothing is wrong?
Pain is processed by the nervous system. The disc, the joint, the muscle — those send signals. The nervous system receives, interprets, and amplifies those signals. When pain has been present for a long time, the nervous system itself can become more sensitive to pain signals. Researchers call this central sensitization.
A 2021 systematic review examined how central sensitization is defined and measured, and how often it occurs in people with chronic low back pain. The authors used the term human assumed central sensitisation — a careful way of saying that the nervous system’s role in chronic pain is real, and is one of the underlying mechanisms in chronic low back pain (Schuttert et al., 2021).
In plain English: a person with chronic low back pain whose scan looks unremarkable is not making it up. The pain may be biological even when the imaging is quiet.
There is something else worth saying out loud. The old story about back pain — that almost everyone gets better in a few weeks if they just rest, stretch, and wait — has been substantially revised. A 2024 systematic review and meta-analysis of 95 studies and nearly 18,000 people found that low back pain often follows a longer, more variable course than that. People with pain that has lasted longer than three months tend to see only modest changes over the following year, even with usual care (Wallwork et al., 2024). That is not a sentence designed to scare anyone. It is a sentence designed to validate the person who has been told their pain “should have resolved by now” and quietly wondered what was wrong with them. Pain that has stayed around is not a personal failure. It is a known clinical course.
This may be the most important sentence in this blog. “I still don’t know if it’s something I did, if it’s a pinched nerve, or if it’s something I’m going to have to live with the rest of my life,” one patient said. The not-knowing is its own kind of pain. A thorough evaluation can take some of that not-knowing off the table.
The goal is not to force your symptoms to match the report. The goal is to ask whether the report, the images, the exam, and your real-life pain pattern are all telling the same story.
The MRI shows anatomy. Your story shows whether that anatomy matters. |
Snippet — Pain is real even when imaging is quiet
Chronic low back pain involves both the structures of the spine and the nervous system that processes pain signals. The nervous system can become more sensitive over time — a process called central sensitization. A clean-looking scan does not mean nothing is wrong.
What does a thorough evaluation look like at Vertrae®?
Dr. Kamal Woods, MD, MBA, is dual fellowship-trained in minimally invasive spine surgery, with training that includes Cedars-Sinai. At Vertrae® in Miamisburg, Ohio, his evaluation does not start at the imaging report. It starts at the patient’s story.
A more thorough look may include:
- The full pain history. When it started. What it feels like. What helps. What makes it worse. How it shapes the day.
- A hands-on exam. How the spine moves. Where it is tender. How the nerves test. How the pain reproduces with specific motions.
- A second look at the imaging — not just the report. Woods pulls up the actual images, not just the radiologist’s narrative, and reads them in the context of the patient’s feelings and movement. Two thoughtful spine surgeons can read the same scan differently. That is one reason second opinions are reasonable.
- A conversation about what comes next. Sometimes a more targeted study is appropriate. Sometimes a non-surgical pathway is the right first step. Sometimes a procedure that did not exist ten or fifteen years ago turns out to be a good fit for a carefully selected patient. The right answer depends on the patient, not on a single label.
This is the through-line of MotionFirst™ spine care: a thorough evaluation, a clear, full range of options, and a recovery experience designed to preserve motion when possible.
If a patient who saw three doctors and was told “nothing is wrong” walks into Vertrae®, the goal is not to overturn the previous visits. The goal is to take a careful, current look — because medicine moves, and what was unanswered before may be answerable now.
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“I still don’t know if it’s something I did, if it’s a pinched nerve, or if it’s something I’m going to have to live with the rest of my life.” A thorough evaluation can replace not-knowing with a plan. |
When may a second opinion be worth considering?
There is no single rule. A few situations where another set of eyes often helps:
- The pain has lasted longer than expected and the answers have not changed.
- Several visits have ended without a working plan.
- The imaging report and how the pain feels in real life seem mismatched.
- A treatment was offered without a clear discussion of alternatives.
- Daily life — work, sleep, family, hobbies — keeps shrinking around the pain.
A second opinion is not a critique of an earlier doctor. It is a normal step in caring for a body that has been hurting for a while.
A thorough evaluation does not mean surgery is the next step. Often, it means finally understanding the options clearly — including non-surgical care, targeted therapy, injections, newer procedures for carefully selected patients, or simply a better plan for what to watch and what to try next.
Is there anything I can do right now, before a consultation?
Before we talk about consultations and next steps, it is worth naming one thing patients can often begin reclaiming right away: movement.
One of the simplest steps on the list also turns out to be one of the best studied.
In 2024, researchers in Australia published the WalkBack trial in The Lancet. They took seven hundred and one adults who had recently recovered from a low back pain episode, and they randomized them into two groups. One group received an individualized, gradually increasing walking program supported by a few visits with a physical therapist over six months. The other group received no specific intervention. Then the researchers tracked them — for at least 12 months, in some cases up to 3 years — to see when the next episode of activity-limiting back pain occurred.
The walking group lasted, on average, 208 days before the next episode. The no-intervention group lasted 112. Walking nearly doubled the time before pain came back (Pocovi et al., 2024).
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Walking nearly doubled the time before back pain came back. WalkBack trial, The Lancet, 2024 — N=701 |
Walking is not a cure. It will not solve every kind of back pain, and people whose pain is currently severe may need a different starting point. But for many patients with axial low back pain, a regular walking practice is one of the most reasonable first steps. It is accessible. It is low-cost. It does not require a referral or a prescription. It can be started today.
A practical starting point: a comfortable pace, on a flat surface, several times a week, building gradually. The exact target is best individualized — a person’s starting fitness, age, and other health conditions all matter — and a thorough evaluation can help shape it.
We mention this here because patients who have been dismissed often leave the office feeling like there is nothing for them to do. There is. One of the best-studied and most accessible steps is walking.
Start gently. Build gradually. And if your pain is not improving, that is when a more thorough conversation may help.
Snippet — Walking and back pain recurrence
A 2024 trial in The Lancet found that an individualized, progressive walking program nearly doubled the time before a low back pain episode recurred — 208 days versus 112 days in the no-intervention group. Walking is one of the most accessible, lowest-cost, evidence-based steps a patient with axial low back pain can take while exploring further evaluation.
What this does not mean
This does not mean MRI is useless. It does not mean pain is “all in your head.” And it does not mean every patient with back pain needs advanced testing or surgery.
It means back pain deserves context.
An imaging report is one piece of the puzzle. Your symptoms, your exam, how you move, your strength, your sleep, your function, and your goals all matter too. The most useful conversation is the one where all of those pieces are looked at together.
Key Takeaway
Back pain that does not radiate down a leg is real, common, and often misunderstood. Imaging tells part of the story; the exam, the history, and how the pain behaves in daily life tell the rest. A thorough evaluation may turn a years-long dismissal into a working plan.
Listen to This Topic: What Spinal Cord Stimulation Actually Is — And Whether It Could Help You
Prefer to listen? This episode breaks down why back pain can still be real even when an MRI report looks “normal” or “unremarkable.” In a clear, conversational format, we discuss axial low back pain, why imaging does not always reveal the full cause of pain, how the nervous system can amplify chronic pain, and when a more complete spine evaluation may help patients find answers.
Read the Full Podcast Transcript
DISCLAIMER:
Transcript lightly edited for clarity and readability. The conversational format is designed to explore concepts and tradeoffs, not to provide medical advice or apply to any individual patient. Outcomes vary by patient, pain pattern, technology used, and study population, and findings from one clinical trial may not generalize to every situation. For guidance specific to your situation, consult a spine specialist.
TRANSCRIPT TEXT:
Speaker 1:
Picture this scene.
You are sitting in a sterile exam room. It is probably your third one this year. You reach into your pocket, pull out a folded piece of paper, and smooth it out on your lap. It is a list of all the doctors you have already seen.
Your back has been hurting for a year, maybe two years, sometimes even longer.
Speaker 2:
Exactly. Sometimes longer. But here is the important detail: the pain stays right there in your back. It does not shoot down your leg.
Speaker 1:
And because of that, your MRI reports keep coming back with incredibly frustrating words — words like “mild,” or maybe the most frustrating one: “unremarkable.”
Speaker 2:
Patients really struggle with that word. It can feel dismissive, especially when their pain is anything but mild.
Speaker 1:
And somewhere along the way, three different doctors may have looked at the same picture of your spine, looked back at you, and essentially shrugged.
Speaker 2:
It is a very common and painful scenario. The patient walks out to their car with the same pain, the same questions, and a quiet but growing fear that no one in the medical system actually believes them.
Speaker 1:
Today, the goal of this conversation is to explore what those previous evaluations may have missed.
We are unpacking a topic from Vertrae® and Dr. Kamal Woods, and we are exploring why back pain without leg pain is one of the most commonly dismissed conditions in modern medicine.
Speaker 2:
It really is.
Speaker 1:
Let’s start there. What is actually happening in a standard 15-minute visit when the doctor seems to shrug?
Speaker 2:
To understand the dismissal, we have to look at the clinical distinction between two very different types of pain.
On one side, you have radiating leg pain.
Speaker 1:
Sciatica.
Speaker 2:
Exactly. Sciatica is often described as a sharp, electric, shooting pain that travels from the back down the leg.
On the other side, you have what is called axial low back pain, where the pain stays primarily in the lower back.
Speaker 1:
So it does not travel.
Speaker 2:
Right. It is usually more of a deep ache. Sometimes it is dull. Sometimes it is sharp. It may flare up when you sit too long, bend forward, or lift something.
Speaker 1:
Why does that specific type of pain — axial pain — get brushed off so easily?
Speaker 2:
It often comes down to structural mechanics and time.
Radiating pain often points more clearly toward a specific issue, usually a pinched nerve. For a busy clinician, radiating pain can look like a more straightforward puzzle. The symptom points toward the source, which allows for a shorter visit and a quicker conclusion.
Axial pain, however, does not follow that classic pinched nerve pattern.
Speaker 1:
It is more complex.
Speaker 2:
Much more complex. It can point to a longer list of possible sources.
Speaker 1:
Here is one way to think about it.
Radiating pain is like a fire alarm going off in one specific room of your house. It is loud and obvious. You walk into the kitchen and say, “Okay, the toaster is on fire.”
Speaker 2:
That is a good analogy.
Speaker 1:
But axial pain is more like a faint burning smell drifting through the entire house. You know something is wrong, but you have to check the basement, inspect the wiring, and look in the attic. It requires a more thorough search.
Speaker 2:
Exactly.
Speaker 1:
So are we saying the medical system is often too rushed to hunt down the source of that burning smell?
Speaker 2:
That is part of the challenge. A standard 15-minute clinic visit is not always designed to find a complex pain source.
When a patient has axial pain, the source could be the discs themselves. It could be the small facet joints at the back of the spine. It could be the sacroiliac joints, or even the surrounding muscles and ligaments.
Speaker 1:
The source material also mentions terms like vertebrogenic pain and multifidus dysfunction. What are those actually doing in the body? Because that sounds like much more than a generic muscle ache.
Speaker 2:
It can be much more complex than a generic ache.
Vertebrogenic pain is a good example of a mechanism that has become much better understood over the past 10 or 15 years.
Speaker 1:
That recently?
Speaker 2:
Yes. Between your spinal discs and the actual bone of your vertebrae, there are areas called endplates. When those endplates undergo wear and tear, they can develop inflammatory changes or microdamage.
In response, a specific nerve inside the bone, called the basivertebral nerve, can become involved in transmitting pain signals.
Speaker 1:
So the bone itself can generate pain signals from the inside out?
Speaker 2:
Exactly. That can create a deep, persistent pain that is not always obvious from a basic scan summary.
Speaker 1:
And what about multifidus dysfunction?
Speaker 2:
The multifidus is a group of deep stabilizing muscles that run along the spine. Think of them like a supportive corset for the spine.
They help keep the spine stable when you move. But after an injury or prolonged pain, those stabilizing muscles can stop firing properly. They can weaken, atrophy, or become less effective over time.
That can leave the spine feeling unsupported, which may contribute to chronic daily pain.
Speaker 1:
But because neither of those issues looks like one obvious pinched nerve, the patient may still get dismissed.
Speaker 2:
Exactly.
There is a quote in the source material from a patient that is heartbreaking: “They make me feel like I’m crazy, and it’s not as bad as I’m saying. My doctor said it’s just stress.”
Stress can certainly influence how the brain processes pain signals. Sleep, mood, and stress all matter. But saying “it’s just stress” as the entire medical conclusion can completely invalidate the patient’s biological reality.
Speaker 1:
There is another quote from a patient talking about their father’s experience. They said his diagnosis was “back pain,” which is not really a diagnosis at all.
That is just a description of the symptom.
Speaker 2:
Exactly. It is like going to a mechanic because your car will not start, and the mechanic writes down, “car will not start,” charges you a copay, and sends you home.
Speaker 1:
Right.
Speaker 2:
Back pain is often where the medical conversation stops, when it should actually be where the conversation begins.
And a major part of this roadblock comes down to how both patients and clinicians sometimes misunderstand medical imaging.
Speaker 1:
This is the part of the research that really stands out, because the natural assumption is that an MRI should hold all the answers.
Speaker 2:
Exactly. Many people assume that if the back hurts, the MRI should show exactly why.
Speaker 1:
And that is not always the case.
Speaker 2:
Correct. We have to look at what imaging actually tells us, and just as importantly, what it does not tell us.
Speaker 1:
Walk us through that.
Speaker 2:
In 2015, a landmark systematic review by Brinjikji and colleagues was published in the American Journal of Neuroradiology. They looked at 33 studies involving more than 3,000 people who had no back pain.
Speaker 1:
No pain at all?
Speaker 2:
Completely asymptomatic. They were going about their lives — lifting groceries, playing sports, doing normal activities — without back pain.
Speaker 1:
So what did the researchers find?
Speaker 2:
They found that MRI changes were very common in people with no pain.
Disc degeneration, disc bulges, and other structural findings that are often labeled as abnormal were seen in many people who felt completely fine.
Speaker 1:
Really?
Speaker 2:
Yes. Disc degeneration showed up in about 37% of people in their 20s.
Speaker 1:
So almost 40% of healthy 20-somethings with no back pain can still show disc degeneration on MRI?
Speaker 2:
Exactly. And that percentage rises with age. By the time people reach their 50s and 60s, many pain-free individuals have these so-called abnormalities.
Speaker 1:
So if a pain-free person can have a messy-looking MRI, and a person in severe pain can have a relatively clean MRI, what are we supposed to do with these scans?
Speaker 2:
We have to stop asking scans to do something they cannot do.
An MRI shows anatomy. It is a high-resolution picture. It does not directly show pain.
A major 2018 review published in The Lancet looked at the global burden of low back pain and emphasized that, for many people with low back pain, no single specific structural cause can be identified on imaging alone.
Speaker 1:
So for many people, the picture does not point clearly to the source.
But I want to ask the question many patients would ask: Isn’t the radiologist the expert in reading the scan? If they say it is unremarkable, shouldn’t we trust them?
Speaker 2:
The radiologist is absolutely an expert in anatomy. But they are often reading the scan without the full clinical context.
Speaker 1:
What do you mean by that?
Speaker 2:
They may be looking at the images without meeting the patient. They may not know what movements trigger the pain, whether it hurts more with sitting or standing, whether the pain wakes the patient at night, or how it affects daily life.
Speaker 1:
So that context is missing.
Speaker 2:
Exactly. Two thoughtful spine specialists can read the same scan differently depending on the clinical context.
This is part of the clinical precision Dr. Woods uses at Vertrae®. He looks at the actual images, not just the radiology summary, and matches the anatomy to the reality of what the patient is experiencing.
Speaker 1:
That is important to say carefully, because if the scan is clean, people may start to wonder if they are imagining things.
Speaker 2:
Absolutely. We need to be very clear.
Saying that the MRI cannot identify the exact cause is not a comment on whether the pain is real. It is a comment on the limits of imaging.
A clean scan is information. It is not a verdict.
Speaker 1:
That is a strong way to put it.
But let’s say Dr. Woods looks at the scan and it really is quiet. There is no major structural damage, no severe disc bulge, but the patient is sitting right in front of him in significant pain.
Where is the pain actually coming from?
Speaker 2:
To answer that, we have to move beyond the bones and discs. We have to look at the system running the whole show: the nervous system.
Speaker 1:
The nervous system.
Speaker 2:
Right. Pain is not created only in the lower back. Pain is processed by the central nervous system.
The structures in the back — discs, joints, muscles, ligaments — send signals. But the brain and spinal cord receive, interpret, and sometimes amplify those signals.
Speaker 1:
So if the structural signal in the lower back is just a whisper, the nervous system can turn it into a scream.
Speaker 2:
Exactly.
Speaker 1:
How does that happen biologically?
Speaker 2:
Think about a car alarm. If your car alarm goes off every day for months, eventually the internal sensor can become overly sensitive.
Instead of going off only when someone breaks a window, it starts blaring when a leaf blows past the tire. The threshold for triggering the alarm has dropped.
Speaker 1:
So it becomes hypersensitive.
Speaker 2:
Right. In the human body, when pain is present for months or years, the nervous system can adapt. Nerve pathways can become more efficient at transmitting pain. The brain’s filtering system can lower its threshold.
This is not just psychological. It is a physical, biological change in how the nervous system processes pain.
Speaker 1:
That is important. If someone is listening right now with chronic low back pain and a scan that looks unremarkable, they are not making it up.
Speaker 2:
Exactly. The pain may be biological even when the imaging is quiet.
When we connect this to the bigger picture, dismissing the role of the nervous system is one reason patients get stranded in what the source material calls the “not knowing” phase of pain.
Speaker 1:
The not knowing phase. That sounds incredibly difficult.
Speaker 2:
It is. Patients are told nothing is wrong, but their body is telling them something is wrong. They do not know if it is a pinched nerve, something they did, something dangerous, or something they will have to live with forever.
That uncertainty can become its own kind of secondary suffering.
Speaker 1:
And we have all heard the old advice: rest for a few weeks, take it easy, maybe take some ibuprofen, and back pain usually goes away on its own.
Speaker 2:
That narrative has been substantially revised by modern research. It has also created unnecessary guilt for many patients.
Speaker 1:
Guilt because if you rest for a month and you are not better, you may assume you failed — like your body is broken.
Speaker 2:
Exactly. But the data tells a different story.
A 2024 systematic review and meta-analysis looked at the clinical course of low back pain across 95 studies involving nearly 18,000 people.
Speaker 1:
So a significant amount of data.
Speaker 2:
Yes. And what the researchers found is that people with pain lasting longer than three months often see only modest changes over the following year, even with usual care.
Speaker 1:
So pain sticking around is not unusual.
Speaker 2:
Correct. And we need to frame that as validation, not discouragement.
If your pain has lasted for months or years, it is not a personal failure. You did not do something wrong by failing to heal. It is a known, documented clinical course for many people with chronic low back pain.
Speaker 1:
That is validating. But it also raises a difficult question.
If rest does not always fix it, and the pain can be that persistent, what can actually help? We do not want anyone listening to feel hopeless.
Speaker 2:
Far from it. This is where the research turns toward action. There is compelling evidence about practical steps that can help, including the WalkBack trial.
Speaker 1:
The WalkBack trial.
Speaker 2:
Right. Published in The Lancet in 2024.
Speaker 1:
I saw the WalkBack trial in the notes, and it almost sounded too simple to be true. They had people walk. How does something that basic help so much?
Speaker 2:
The researchers followed 701 adults in Australia who had recently recovered from an episode of low back pain and split them into two groups.
One group received no specific intervention beyond standard advice. The other group received an individualized, gradually progressive walking program.
They were also supported by a physical therapist for a few visits over six months to help them scale the program correctly.
Speaker 1:
I want to clarify something, because we just said that telling a patient to go home and wait it out can be dismissive. Now we are saying walking helped.
How is that different from the old “walk it off” mentality?
Speaker 2:
That is an important distinction.
The WalkBack trial was not about telling patients to grit their teeth and push through a flare-up. It was not generic advice. It was individualized, gradual, and supported.
Walking can help through several biological mechanisms.
First, it increases blood flow, which may help support healing and reduce inflammatory irritation.
Second, gentle, rhythmic loading can support the health of spinal tissues.
Third, repetitive, rhythmic movement can help calm the nervous system. It sends a signal to that hypervigilant car alarm that it does not have to keep blaring.
Speaker 1:
So walking may support circulation, spinal mechanics, and the nervous system at the same time.
Speaker 2:
Exactly.
Speaker 1:
What were the actual results of the trial?
Speaker 2:
The researchers tracked how long it took for back pain to return in a way that limited activity.
For the no-intervention group, pain returned after a median of 112 days. For the walking group, it took a median of 208 days.
Speaker 1:
So an individualized walking program nearly doubled the time before pain returned.
Speaker 2:
Exactly. Walking is accessible, low cost, and evidence-based.
But the key word is individualized.
Speaker 1:
Individualized.
Speaker 2:
Yes. The right pace, distance, surface, and progression should be tailored to the person’s age, fitness level, health conditions, and pain pattern.
Speaker 1:
Which brings us back to why a rushed 15-minute appointment can fall short.
Speaker 2:
Exactly. You cannot build an individualized plan if the doctor barely knows who the patient is.
Speaker 1:
So what does this mean for the person listening who is exhausted? The person who is tired of being dismissed, tired of their daily life shrinking around their pain, and tired of hearing, “Your scan is fine.”
What does a thorough evaluation actually look like?
Speaker 2:
If we look at the Vertrae® approach, based on Dr. Kamal Woods’ motion-first spine care model, a true evaluation does not start with the MRI report alone. It starts with the patient’s full context.
It begins with a complete pain history — not just a quick “rate your pain from one to ten.”
Speaker 1:
Not at all.
Speaker 2:
A full history means understanding when the pain started, what it feels like, what makes it worse, and what makes it better.
It also means understanding how the pain shapes the patient’s day.
Speaker 1:
How the pain shapes the day.
Speaker 2:
Exactly. Can you pick up your grandchildren? Does it wake you up at three in the morning? Does it keep you from sitting through dinner, working, exercising, or driving?
The context of your life is actual medical data.
Speaker 1:
So after understanding how the pain shapes daily life, the next step is seeing how the person actually moves.
Speaker 2:
Right. The hands-on physical exam is critical.
How does the spine move in space? Where is it tender to touch? How do the nerves respond to testing? What specific motions reproduce the pain the patient feels at home?
You are matching the physical mechanics to the symptom.
Speaker 1:
And I am guessing that is when Dr. Woods looks at the MRI, because now he actually knows what he is looking for.
Speaker 2:
Exactly. Dr. Woods reviews the actual high-resolution images, not just the radiologist’s summary. He looks at the anatomy with the patient’s pain history and physical exam fresh in mind.
He is looking for the story the images tell when combined with the patient’s real-life experience.
Speaker 1:
Which naturally leads to a conversation about what comes next.
I think people often fear that part. They think, “If I go to a spine surgeon for a thorough evaluation, they are just going to want to operate.”
Speaker 2:
That is a common fear, but in a modern comprehensive spine practice, it is often misplaced.
A thorough evaluation does not automatically mean surgery is the next step.
Often, it reveals non-surgical pathways. That may include targeted therapy, specific injections, medication management, activity modification, or tailored physical rehabilitation.
Speaker 1:
Or some of the newer procedures we discussed earlier — the ones for vertebrogenic pain or multifidus dysfunction.
Speaker 2:
Exactly. Some procedures that exist today were not widely available or well understood 10 or 15 years ago.
The goal is to give the patient a clearer, more complete understanding of their options.
It is about replacing the frightening “not knowing” phase with a concrete, actionable plan.
Speaker 1:
So if you have been told there is nothing wrong, but your pain is real — if your back has been hurting, your leg does not hurt, and you keep being told to wait it out — Dr. Kamal Woods sees patients at Vertrae® in Miamisburg, serving Dayton and Southwest Ohio.
You can request a consultation at Vertrae.com.
Getting a second opinion is not a critique of your earlier doctors. It is a normal and often necessary step in caring for a body that has been hurting for a long time.
Medicine moves quickly. What was unanswered a few years ago may have a much clearer answer today.
Speaker 2:
I want to leave listeners with one final thought.
Consider the power of words in a doctor’s office.
Calling a painful spine “unremarkable,” or telling a patient their severe daily ache is “just stress,” may not only be medically incomplete. That kind of dismissive language can add another layer of emotional stress.
And as we discussed today, the central nervous system can respond to stress by becoming more hypervigilant and amplifying physical pain.
Speaker 1:
So is it possible that sitting in a room with a doctor who looks at your folded piece of paper, listens to your story, and says, “I believe you,” is not just good bedside manner?
What if being heard and believed is one of the first steps toward helping the nervous system calm down and helping the body begin to recover?
Something to think about.
Thanks for listening to this deep dive.
Ready to Get Honest Answers to Your Questions? Request an Evaluation at Vertrae®
If your back has been hurting, your leg does not hurt, and you keep being told “nothing is wrong,” you do not have to keep cycling through the same unanswered visit. A thorough second look may help connect the imaging, the exam, and your real-life symptoms into a clearer plan.
Serving: Dayton • Miamisburg • Centerville • Kettering • Beavercreek • Springboro • West Chester • Cincinnati • Southwest Ohio
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Dr. Kamal Woods, MD, MBA: Dual fellowship-trained neurosurgeon • Cedars-Sinai trained • Mazor X™ robotic-assisted surgery • exclusively minimally invasive spine
Frequently Asked Questions
Why does my back hurt but not my leg?
Back pain without leg pain often means the pain is staying in the structures of the lower back rather than traveling along a nerve into the leg. Possible sources include discs, facet joints, sacroiliac joints, muscles, ligaments, or pain-processing changes in the nervous system. A careful exam helps narrow the possibilities.
Can you have a pinched nerve without leg pain?
Sometimes nerve irritation can cause mostly back pain, but classic lumbar nerve compression usually causes symptoms that travel into the buttock, hip, or leg. If pain stays only in the lower back, doctors often consider other sources, including discs, joints, sacroiliac joint pain, muscle dysfunction, or vertebrogenic pain.
My doctor said my back pain is just stress — is that all it is?
Stress can affect pain, but “just stress” rarely tells the full story. Chronic low back pain often involves the discs, joints, and the nervous system’s response to pain. A thorough evaluation that looks at imaging, exam, and how pain behaves in real life often reveals more than a single explanation.
Can back pain be real if my MRI looks normal?
Yes. Many people have findings on MRI without pain, and many people have pain without dramatic findings on MRI. The nervous system can become more sensitive over time, and pain may be present even when a scan looks unremarkable. A clean scan is information, not a verdict.
What is axial low back pain?
Axial low back pain is pain that stays in the lower back and does not radiate down a leg. It can come from discs, facet joints, sacroiliac joints, surrounding muscles, or how the nervous system processes pain signals. It is one of the most common reasons people seek spine care.
How is axial low back pain different from sciatica?
Sciatica is pain that travels from the lower back down one leg, usually because a nerve is being irritated. Axial low back pain stays in the lower back. Both can be serious. Both can interfere with daily life. They are evaluated and treated differently because the source of the pain often differs.
When should I get a second opinion on my back pain?
Another look may help when pain has lasted longer than expected, when several visits have ended without a working plan, when the imaging report and the pain do not seem to match, or when daily life keeps shrinking around the pain. A second opinion is a normal step, not a critique.
Does walking really help with chronic back pain?
For many people with axial low back pain, yes. A 2024 trial in The Lancet found that an individualized walking program nearly doubled the time before low back pain came back. Walking is accessible, low-cost, and supported by good evidence. The right pace and distance are best individualized to the person.
What does a thorough spine evaluation include at Vertrae®?
Dr. Kamal Woods, MD, MBA, reviews the full pain history, performs a hands-on exam, and looks at the actual MRI images, not only the radiology report. The conversation covers options, including non-surgical pathways and newer procedures, before any decision about treatment is made.
Where is Vertrae® located?
Vertrae® is located in Miamisburg, Ohio, and serves patients across Dayton, Miamisburg, and the wider Southwest Ohio community. Consultations can be requested at vertrae.com.
References (APA 7th Edition)
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811–816. https://doi.org/10.3174/ajnr.A4173
Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., Karppinen, J., Pransky, G., Sieper, J., Smeets, R. J., & Underwood, M. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356–2367. https://doi.org/10.1016/S0140-6736(18)30480-X
Pocovi, N. C., Lin, C. C., French, S. D., Graham, P. L., van Dongen, J. M., Latimer, J., Merom, D., Tiedemann, A., Maher, C. G., Clavisi, O., Tong, S. Y. K., & Hancock, M. J. (2024). Effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention for the prevention of low back pain recurrence in Australia (WalkBack): A randomised controlled trial. The Lancet, 404(10448), 134–144. https://doi.org/10.1016/S0140-6736(24)00755-4
Schuttert, I., Timmerman, H., Petersen, K. K., McPhee, M. E., Arendt-Nielsen, L., Reneman, M. F., & Wolff, A. P. (2021). The definition, assessment, and prevalence of (human assumed) central sensitisation in patients with chronic low back pain: A systematic review. Journal of Clinical Medicine, 10(24), 5931. https://doi.org/10.3390/jcm10245931
Wallwork, S. B., Braithwaite, F. A., O’Keeffe, M., Travers, M. J., Summers, S. J., Lange, B., Hince, D. A., Costa, L. O. P., Menezes Costa, L. C., Chiera, B., & Moseley, G. L. (2024). The clinical course of acute, subacute and persistent low back pain: A systematic review and meta-analysis. CMAJ, 196(2), E29–E46. https://doi.org/10.1503/cmaj.230542
