From the Guidelines
Imaging of the cervical spine should be performed in patients with neck pain when there is suspicion of serious underlying pathology or trauma, as indicated by clinical decision rules such as the Canadian C-spine Rule or NEXUS criteria, and in the presence of red flags or risk factors, including age over 65, dangerous mechanism of injury, focal neurological deficits, midline tenderness, or altered mental status 1.
Key Considerations
- The decision to image should be guided by clinical decision rules, which help identify patients at higher risk for fracture or serious underlying pathology.
- Imaging is indicated for patients with trauma and risk factors, including age over 65, dangerous mechanism of injury, focal neurological deficits, midline tenderness, or altered mental status.
- Non-traumatic neck pain warrants imaging when red flags are present, such as fever, unexplained weight loss, history of cancer, immunosuppression, intravenous drug use, severe or progressive neurological deficits, or pain that persists despite conservative treatment for 4-6 weeks.
Imaging Modalities
- Plain radiographs are typically the initial imaging modality, but CT scans provide better visualization of bony structures and are preferred in trauma cases 1.
- MRI is the modality of choice when neurological deficits are present or to evaluate soft tissue structures, disc pathology, or spinal cord compression.
Rationale for Selective Imaging
- The rationale for selective imaging is to avoid unnecessary radiation exposure and healthcare costs while ensuring that potentially serious conditions are not missed.
- CT may be adequate for excluding clinically significant cervical spine injury in patients without neurologic symptoms, even in the setting of neck tenderness 1.
Clinical Decision Rules
- The Canadian C-spine Rule and NEXUS criteria are well-established clinical decision rules for excluding clinically significant cervical spine injury.
- These rules help identify patients at higher risk for fracture or serious underlying pathology, and guide the decision to image.
From the Research
Imaging of the C-Spine in Patients with Neck Pain
Imaging of the c-spine (cervical spine) is an important diagnostic tool in patients with neck pain. The decision to image the c-spine should be based on the patient's clinical presentation and medical history.
Indications for Imaging
The following are indications for imaging of the c-spine in patients with neck pain:
- Trauma: Patients who have experienced trauma, especially those with high-risk mechanisms of injury, should undergo imaging of the c-spine to rule out fractures or ligamentous injuries 2.
- Neurologic symptoms: Patients with neurologic symptoms such as numbness, tingling, or weakness in the arms or legs should undergo imaging of the c-spine to rule out conditions such as herniated discs or spinal stenosis 3, 4.
- Red flags: Patients with red flags such as fever, weight loss, or history of cancer should undergo imaging of the c-spine to rule out conditions such as infection or tumor 3, 4.
- Chronic neck pain: Patients with chronic neck pain who have not responded to conservative treatment may undergo imaging of the c-spine to rule out underlying conditions such as degenerative disc disease or spinal stenosis 4, 5.
Imaging Modalities
The following are imaging modalities that can be used to evaluate the c-spine:
- X-ray: X-ray is a useful initial imaging modality for evaluating the c-spine, especially in patients with trauma 2.
- Computed Tomography (CT): CT is a more sensitive imaging modality than X-ray and can be used to evaluate the c-spine in patients with trauma or suspected fractures 2.
- Magnetic Resonance Imaging (MRI): MRI is the most sensitive imaging modality for evaluating the c-spine and can be used to evaluate patients with neurologic symptoms or suspected soft tissue injuries 3, 4.
Clinical Decision Rules
Clinical decision rules such as the Canadian C-Spine Rule or the National Emergency X-Radiography Utilization Study (NEXUS) criteria can be used to determine which patients with neck pain require imaging of the c-spine 2. These rules take into account factors such as the patient's mechanism of injury, medical history, and physical examination findings.