Normal MRI result, but no relief from back pain. CMC Vellore neurologist shares the hidden cause behind patient's pain

When pain refuses to go away despite normal reports, it often leads to frustration, confusion, and sometimes the wrong diagnosis. A recent case shared by Dr Sudhir Kumar highlights how even detailed investigations can miss the real problem if the right questions are not asked. What seemed like routine back pain in a 55-year-old man turned out to be something far more serious, exposing a critical gap between test results and clinical thinking.

The patient had been dealing with persistent back pain for nearly four months. He followed every recommended step, consulting multiple doctors and undergoing a range of investigations. Blood tests, nerve conduction studies, and MRIs of the neck and lower back all came back normal. Despite this, his pain continued without any sign of improvement.

Like many similar cases, his condition was initially treated as chronic back pain. He was prescribed painkillers, muscle relaxants, and advised to rest. However, none of these interventions brought relief. The persistence of symptoms, despite normal findings, made the case more complex than it first appeared. The turning point came when Dr Sudhir Kumar paid close attention to the patient’s symptom pattern. Two details stood out immediately. The pain was located in the mid-back region rather than the neck or lower back, and it worsened during coughing and deep breathing.


These were not ordinary complaints. Pain that intensifies with coughing often points toward irritation or compression of spinal nerve roots. This observation shifted the entire direction of diagnosis, moving away from muscular causes toward a possible spinal pathology. Rather than repeating the same tests, the neurologist questioned whether the correct area had been examined. He recommended an MRI of the dorsal, or thoracic, spine, even though it meant additional expense for the patient. This decision proved crucial.

What was the diagnosis?

The new imaging revealed abnormalities in the D8–D9 vertebrae, along with disc edema and a paravertebral collection. These findings pointed clearly toward spinal tuberculosis, a condition that can often remain undetected in its early stages.


What made the case particularly challenging was the absence of typical tuberculosis symptoms. The patient had no fever, no weight loss, and none of the common warning signs usually associated with the disease. His only complaint was persistent back pain, which made the diagnosis easy to overlook.

Spinal tuberculosis

Spinal tuberculosis is known for its silent progression. It develops slowly and may not present obvious symptoms until it reaches an advanced stage. If left undiagnosed, it can lead to serious complications, including spinal deformity and even paralysis. The case underscores a critical lesson in medical practice: diagnostic accuracy depends not just on tests, but on interpretation. Even the most advanced imaging can fail if the wrong area is examined. Careful localisation of pain, attention to red flag symptoms, and clinical reasoning remain essential.


Dr Sudhir Kumar pointed out the takeaway for doctors—focus on understanding the patient’s symptoms in detail and avoid relying solely on reports. For patients, persistent or unusual pain, especially when it worsens with actions like coughing or breathing, should not be ignored. Early expert evaluation can make a significant difference in identifying conditions that might otherwise remain hidden.