Sent to attorneys August 13, 2026.
A short note on a pattern that comes up regularly in orthopaedic records review: the patient’s history and examination are consistent with a real spine problem, symptoms are provoked by movement or by everyday load, and the MRI report reads as normal, minor, or degenerative-only. That combination invites the oversimplification that a “normal” or minimally abnormal MRI means there is no injury and the complaints are exaggerated. It does not.
A standard MRI is a static, unloaded snapshot. It is acquired with the patient lying flat (supine) and at rest, the spine not carrying the person’s body weight, not extended, not rotated, and not being asked to do anything mechanical during the scan. Under those specific conditions, some real anatomic problems are less visible than they behave in daily life. Peer-reviewed work on axial-loaded MRI and upright / positional MRI has documented, in symptomatic patients, measurable reductions in the dural sac cross-sectional area and, at some levels, additional narrowing of the neural foramen that were not present on the same patient’s relaxed supine images. Willén and Danielson’s 2001 Spine paper and the earlier Danielson 1998 Acta Radiologica series established this in the workup of lumbar stenosis; a 2020 weight-bearing MRI series (Nordberg and colleagues) additionally reported that lumbar disc herniations were on average larger in standing than in supine position and more often in contact with the exiting nerve root; Michelini’s 2018 Acta Biomedica review summarizes the broader literature; Kanno’s 2011 Spine paper reported that the change in dural sac area between unloaded and loaded imaging correlated with clinical symptom severity. These are not fringe findings. They are also not a claim that every twisting or lifting movement causes unseen nerve compression, and they are not an argument that routine MRI is invalid. Routine supine MRI remains the first-line study and is diagnostically sufficient in most cases.
Separately, some symptom-provoking maneuvers rest on established physiology rather than on new imaging techniques. Coughing, sneezing, straining, and other Valsalva maneuvers briefly raise pressure inside the spinal canal, which is why they can worsen radicular pain when a nerve root is already being contacted or irritated (Dejerine’s sign is the century-old clinical description). Extension and rotation of the spine physiologically narrow the neural foramen at the moment of the movement. These are recognized clinical patterns captured on physical examination (straight-leg raise, Spurling’s maneuver, extension provocation); they do not, by themselves, prove nerve compression at rest, and they are not something a routine MRI records during the maneuver. What they do provide is real information about how the patient’s spine behaves under load, which is not information the resting supine MRI is designed to give.
The practical point for records review is a narrow one. When the clinical picture is credible, when the examination documents movement- or load-provoked symptoms, and when the routine MRI reads as minor or discordant, dynamic or intermittent pathology is one possibility that deserves consideration. Not a conclusion to be drawn, but an alternative to a reflexive “the MRI was normal, so nothing is really wrong.” In selected cases the appropriate next step in the medical record is a documented provocative physical examination and, where clinically indicated and locally available, an axial-loaded, flexion-extension, or upright MRI. In many cases the routine study will remain sufficient. The point is that a static supine MRI is a snapshot of one position at rest, a good one and usually the right one, but a snapshot, and its limitations, not the patient’s honesty, are what a thoughtful records review should weigh when the imaging and the clinical picture seem to disagree.
Educational only, not case-specific, and not legal or medical advice for any particular matter.
F. Allen Johnston, MD
Louisiana Orthopedic Institute
Baton Rouge
(225) 751-6666 Office
(225) 270-0000 Cell
