What imaging studies are recommended for patients presenting with intractable neck pain?

Imaging Studies for Intractable Neck Pain

For patients with intractable neck pain, MRI is the recommended imaging study when symptoms persist despite adequate conservative treatment, with CT being preferred initially for suspected fractures or bony abnormalities. 1

Initial Assessment and Imaging Decision Algorithm

The American College of Radiology recommends a graded approach to imaging based on neck pain severity:

1. Grade I & II Neck Pain (mechanical pain without neurological signs):

   • Initially avoid imaging
   • Consider MRI only if symptoms are intractable despite 6-8 weeks of adequate treatment 1

2. Grade III Neck Pain (with neurological signs of nerve compression):

   • MRI without contrast is appropriate
   • Add contrast if infection or malignancy is suspected 1

3. Grade IV Neck Pain (signs of major pathology):

   • Immediate MRI with appropriate protocol based on suspected pathology
   • Include contrast for suspected infection, inflammation, or malignancy 1

Red Flags Requiring Immediate Imaging

Immediate imaging is warranted with any of these red flags:

• Trauma history
• History of cancer or unexplained weight loss
• Fever or signs of infection
• Progressive neurological deficits
• Bladder/bowel dysfunction
• Severe unremitting night pain
• Prior neck surgery
• Systemic diseases
• History of intravenous drug use
• Age >50 with vascular disease risk factors
• Abnormal laboratory values 1

Imaging Modality Selection

MRI

• First-line imaging for:

  • Suspected cervical radiculopathy with radiating pain, motor weakness, sensory changes
  • Myelopathy (spinal cord compression)
  • Cranial neuropathies affecting lower cranial nerves
  • Non-pulsatile or pulsatile neck masses 1

• Protocol considerations:

  • Non-contrast MRI is usually sufficient for most indications
  • Contrast enhancement for suspected infection, known malignancy, and inflammatory conditions
  • Fat-suppressed T1-weighted sequences for detecting arterial dissection 1
  • Consider flexion and extension views in cases of suspected instability, particularly in rheumatoid arthritis patients 2

CT

• First-line imaging for:
  • Acute trauma with suspected fracture
  • Better bone detail for suspected bony abnormalities 1
  • Higher sensitivity (94-100%) compared to radiographs (49-82%) 1, 3

Radiographs and LODOX

• Not recommended as primary imaging for intractable neck pain
• Insufficient sensitivity for ruling out cervical spine injuries (X-ray: 36.4%, LODOX: 5.3%) 3

Special Considerations

Complementary Use of CT and MRI

Recent evidence shows that while CT offers high sensitivity for detecting traumatic cervical spine injuries, MRI can reveal injuries missed by CT in symptomatic patients 3. In a 2023 study, MRI correctly identified 14 cases of cervical spine injury that were misdiagnosed by CT 3.

Caution with Interventional Procedures

When considering interventional procedures for intractable neck pain, be aware of rare but serious complications. A case report documented a fatal cervical spinal cord infarction following a C6-nerve root blockade in a patient with unremarkable MRI findings 4. This underscores the importance of thorough imaging before invasive procedures.

Insurance and Documentation Tips

To maximize likelihood of insurance approval:

• Document neurological signs and symptoms, including specific nerve root compression signs
• Detail distribution of symptoms and functional limitations
• Record failed conservative treatments with specifics on treatments attempted and lack of improvement 1