Patient Guides · Diagnosis

Finding the Real Source
of Your Pain

An MRI can show a dozen findings that look alarming and have nothing to do with your symptoms. Treating the wrong issue is one of the most common reasons spine care fails. Every evaluation starts with you, not your scan.

Step one

A thorough history and physical exam

We talk through where your pain is, what makes it better or worse, and how it has changed. Then I examine your strength, reflexes, sensation, gait and range of motion, and use specific tests that point to a nerve root, a joint or the spinal cord.

The exam tells me which imaging findings matter.

“We always look at the x-rays, MRIs and any available imaging together. We work hard to make sure we understand what is driving the pain.”

Dr. Robert J. Ames

Step two

The right imaging for the question

Standing side-view X-ray of the lower spine with an interbody implant

Alignment

Plain X-rays

Standing and bending views show alignment, slippage and instability that can be missed lying down. Full-length films measure scoliosis and balance.

Two sagittal T2 MRI views of the lower lumbar spine

Nerves & discs

MRI

The best test for herniated discs, stenosis and nerve or spinal cord compression. I review the images themselves with you, not just the report.

Sagittal CT of the cervical spine showing two disc replacements

Bone detail

CT scan

The clearest view of bone: fractures, bone spurs, fusion healing and surgical planning. An option when MRI isn't possible.

Coronal SPECT/CT showing intense uptake in both lowest lumbar facet joints

Active inflammation

SPECT/CT

A bone scan fused with CT that lights up the joint, endplate or implant that is actively reacting, when an MRI shows changes at several levels.

Sagittal cervical SPECT/CT showing intense uptake at two disc replacement levels, beside a CT showing bone loss around the implants
SPECT/CT (left) shows intense uptake at two cervical disc replacement levels; CT (right) shows bone loss around the implants at the same levels.

Case example

When the scan and the symptoms point to the same spot

Here, a patient with neck pain years after disc replacement had imaging that could have pointed several directions. SPECT/CT showed the problem was active at exactly the two implanted levels, and CT confirmed loosening there. That made the treatment decision clear.

More case examples

The X-ray shows the structure. SPECT/CT shows what's active.

Each case pairs the patient's X-rays with the SPECT/CT done before surgery, which showed exactly which level was active.

Standing X-rays of a multilevel lumbar fusion above SPECT/CT images showing intense uptake around the upper screws at L5 and the L3-4 and L4-5 facets
Pain after a prior fusionBefore revision, SPECT/CT showed intense activity around the upper screws at L5 and the facets at L3-4 and L4-5. The radiotracer uptake informed our surgical plan for revision fusion, L3-S1.
X-rays of a lateral lumbar interbody fusion above SPECT/CT images showing intense uptake at the endplates around the cage
Finding the one active levelBefore surgery, SPECT/CT showed intense endplate activity at a single level while the levels above and below were quiet, so treatment was directed in an ultra-minimally invasive way at the involved level, L3-4.
Standing lumbar X-rays above SPECT/CT images showing intense uptake in both L5-S1 facet joints
Facet joints vs. a transitional vertebraBefore treatment, SPECT/CT showed both L5-S1 facets hot while the pseudojoint from a transitional vertebra was cold, so treatment targeted the facets.
SPECT/CT showing focal lower lumbar uptake above intraoperative X-rays of a fusion limited to that segment
Choosing which levels to fuseBefore surgery, SPECT/CT (top) showed focal lower lumbar uptake with quiet levels above, so the fusion was limited to the active segments (bottom, during surgery).

Step three, when needed

Diagnostic injections

A targeted numbing injection into a specific joint or nerve can confirm the source. If the pain goes away for a few hours, we have likely found the pain generator.

Putting it together

No single test gives the answer

When the exam, the imaging and your symptoms line up, we can recommend treatment with confidence, whether that is physical therapy, an injection or surgery. When they don't, that tells us something important too.

Not sure what's causing your pain? Let's look at it together.