What is the appropriate imaging order for cervical neck pain with bilateral upper extremity numbness?

Appropriate Imaging Order for Cervical Neck Pain with Bilateral Upper Extremity Numbness

Plain radiographs of the cervical spine (anteroposterior and lateral views) are recommended as the first-line imaging for evaluating cervical neck pain with bilateral upper extremity numbness. 1

Initial Imaging Approach

Plain Radiographs

• Start with cervical spine radiographs including:
  • Anteroposterior (AP) view
  • Lateral view
  • Consider adding flexion/extension views to assess for instability 2

These views are useful to:

• Evaluate for degenerative changes
• Identify alignment issues
• Assess for fractures
• Provide initial screening before advanced imaging

When to Order Advanced Imaging

After initial radiographs, proceed to advanced imaging if:

• Radiographs show abnormalities requiring further characterization
• Patient has persistent symptoms despite normal radiographs
• There are neurological deficits (bilateral upper extremity numbness suggests possible cervical radiculopathy or myelopathy)

Advanced Imaging Options

MRI Cervical Spine

• Indicated when radiographs are normal but symptoms persist
• Best for evaluating:
  • Disc herniations
  • Spinal cord compression
  • Nerve root impingement
  • Soft tissue abnormalities

CT Cervical Spine

• Superior to radiography for detecting:
  • Bony abnormalities
  • Erosive changes
  • Facet joint arthropathy 2
• Consider when MRI is contraindicated or unavailable

How to Write the Order

For Mobile X-ray:

1. Examination: Cervical spine radiographs
2. Views: AP and lateral views
3. Clinical Indication: Cervical neck pain with bilateral upper extremity numbness, concern for radiculopathy
4. Special Instructions: Mobile study, patient unable to be transported to radiology department

Important Considerations

Red Flags Requiring Immediate Attention

• Progressive neurological deficits
• Signs of myelopathy
• History of malignancy 1
• Fever, leukocytosis, elevated ESR or CRP (suggesting infection) 2

Common Pitfalls to Avoid

1. Inadequate visualization: Ensure C7-T1 junction is visible on lateral view (may require swimmer's view)
2. Relying solely on lateral view: Although some studies suggest lateral views alone can detect most unstable injuries 3, the ACR recommends both AP and lateral views 2, 1
3. Missing ligamentous injuries: Plain radiographs may miss ligamentous injuries that could be detected with flexion/extension views or MRI 4

Diagnostic Accuracy

• Plain radiographs have sensitivity of 49-82% for cervical spine injuries 1
• CT has superior sensitivity (94-100%) 1
• Consider MRI for patients with persistent neurological symptoms despite normal radiographs and CT 5

Follow-up Imaging

If initial radiographs are negative but symptoms persist:

1. Proceed to MRI cervical spine to evaluate for disc herniation, nerve compression, or spinal cord pathology
2. Consider CT myelography if MRI is contraindicated
3. Flexion/extension views may be added to assess for instability not apparent on static images

Remember that most patients with cervical radiculopathy improve over time with appropriate conservative management 5, but proper imaging is essential for accurate diagnosis and treatment planning.