Associations between sum scores or combinations of MRI findings in the lumbar spine and low back pain-related outcomes: a systematic review

Key points

1. 0149 studies with 15,948 participants were included across population-based and clinical settings.
2. 02Increasing sum scores of disc degeneration were associated with greater low back pain in 10 of 16 studies and with disability in 7 of 9 studies.
3. 03Increasing sum scores of endplate-related changes were linked to more low back pain in 7 of 10 studies.
4. 04When different MRI findings were combined into a total score, 7 of 11 studies showed stronger associations with low back pain.
5. 05No single combination of MRI findings consistently outperformed others, and spinal stenosis sum scores showed no clear association with pain.

How it was conducted

Design

Systematic review of observational studies and baseline data from RCTs or longitudinal studies

Databases searched

Embase, PubMed, CINAHL, Scopus, SPORTDiscus (searched November 21, 2024, no date restrictions)

Included studies

49 articles reporting on 37 individual study populations

Participants

15,948 total across included studies

MRI categories

(1) Sum score of one specific finding across levels, (2) Sum score of different findings, (3) Specific co-occurring combinations

Primary outcome

Cross-sectional associations between MRI sum scores or combinations and low back pain, LBP-related disability, or LBP-related leg pain

What they found

• Disc degeneration sum scores: 10 of 16 studies (9 individual populations) found stronger associations with increasing sum score and LBP presence or severity.
• Disc degeneration sum scores and LBP-related disability: 7 of 9 studies reported stronger associations with increasing sum scores.
• Endplate-related changes sum scores and LBP: 7 of 10 studies reported stronger associations with increasing sum scores.
• Disc herniation sum scores and LBP: 2 of 3 studies reported stronger associations.
• Facet joint degeneration sum scores and LBP: association found in 2 of 3 studies; 1 of 3 reported a trend of increasing association.
• Spinal stenosis sum scores and LBP: 0 of 4 studies found an association.
• Sum scores of different MRI findings and LBP: 7 of 11 studies (6 individual populations) reported stronger associations with increasing total count.
• Sum scores of different MRI findings and LBP-related disability: 5 of 8 studies (3 individual populations) reported stronger associations.
• Sum scores of different MRI findings and LBP-related leg pain: 1 of 2 studies found a stronger association.
• Specific combinations of findings and LBP: 2 of 3 studies reported an association; no combination was consistently superior to others.
• 12 of 49 studies had low risk of bias across all domains.

Limitations

• Substantial heterogeneity in how MRI findings were defined, scored, and combined across studies prevented meta-analysis.
• Outcomes varied widely, including dichotomous pain reports, pain intensity scales, and multiple disability measures, making direct comparison difficult.
• Several studies shared overlapping populations, reducing the effective independent sample size and potentially overrepresenting some findings.
• Most included studies were cross-sectional, so causality between cumulative MRI findings and low back pain cannot be established.

Why it matters

For patients

Patients with multiple MRI abnormalities in their lower back may have more pain and disability than those with a single finding, suggesting the overall structural burden matters, not just one diagnosis.

For clinicians

Clinicians interpreting lumbar MRI should consider the cumulative number and type of degenerative findings rather than anchoring on any single abnormality when relating imaging to a patient's pain.

For readers

This review provides the first systematic synthesis of cumulative MRI scoring approaches, offering a foundation for more standardised methods and future research linking total spinal degeneration burden to clinical outcomes.