What is the significance of straightening of the normal cervical lordosis on X-ray in a patient with acute neck pain, without radiculopathy, and who is requesting a Magnetic Resonance Imaging (MRI) scan?

From the Guidelines

For a patient with acute neck pain showing only straightening of normal cervical lordosis on X-ray without radiculopathy, an MRI is not initially indicated. I recommend conservative management first, including NSAIDs such as ibuprofen 400-600mg three times daily or naproxen 500mg twice daily for 7-10 days to reduce inflammation and pain 1. Physical therapy focusing on gentle stretching and strengthening exercises should be started within 1-2 weeks of symptom onset. Application of heat or ice for 15-20 minutes several times daily can provide symptomatic relief. Muscle relaxants like cyclobenzaprine 5-10mg at bedtime may help if muscle spasm is present. Straightening of cervical lordosis is a common finding that often represents muscle spasm rather than significant pathology.

Key Considerations

• The patient's presentation lacks red flags, which are critical indicators for immediate imaging, such as trauma, malignancy, or neurological deficits 1.
• The absence of radiculopathy suggests that the pain is likely musculoskeletal in origin, further supporting a conservative initial approach.
• Imaging, including MRI, is not required at the time of initial presentation in the absence of red flag symptoms or neurological symptoms 1.

Management Approach

• Conservative management should be the first line of treatment, aiming to reduce pain and inflammation, improve function, and prevent chronicity.
• If symptoms persist beyond 4-6 weeks despite conservative treatment, or if neurological symptoms develop (numbness, weakness, or radiating pain), then an MRI would become appropriate to rule out underlying structural causes that may require intervention. This approach is supported by evidence showing that most acute neck pain resolves with conservative care, and unnecessary imaging rarely changes management in the absence of red flags or neurological symptoms 1.

From the Research

Patient Presentation

• The patient presents with acute neck pain and straightening of the normal cervical lordosis on X-ray, but no radiculopathy.
• The patient is requesting an MRI.

Relevant Studies

• A study on the epidemiology, diagnosis, and treatment of neck pain 2 suggests that history and physical examination can provide important clues as to whether the pain is neuropathic or mechanical.
• The same study 2 also states that magnetic resonance imaging (MRI) should be considered for cases involving focal neurologic symptoms, pain refractory to conventional treatment, and when referring a patient for interventional treatment.
• However, another study on the evaluation and treatment of low back pain in adult patients 3 suggests that routine imaging should be avoided in the absence of red flags.

Treatment Options

• A study on pharmacologic therapy for acute pain 4 suggests that acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain.
• Another study on the comparison of ibuprofen, cyclobenzaprine, or both in patients with acute cervical strain 5 found that there was little benefit to routinely using or adding cyclobenzaprine to NSAIDs for patients with acute cervical strain.
• A study on low-dose cyclobenzaprine versus combination therapy with ibuprofen for acute neck or back pain with muscle spasm 6 found that combination therapy with cyclobenzaprine and ibuprofen was not superior to cyclobenzaprine alone in adult patients with acute neck and back pain with muscle spasm.

Imaging

• Given the patient's presentation and the absence of red flags, it is unclear if an MRI is necessary at this time 2, 3.
• The decision to order an MRI should be based on the patient's clinical presentation and the presence of any red flags 2.