Is cervical spine MRI or radiography best for evaluating tingling and weakness?

MRI is the Best Imaging Choice for Cervical Tingling/Weakness

MRI of the cervical spine without IV contrast is the most appropriate first-line imaging modality for evaluating tingling and weakness, as it provides superior visualization of soft tissue structures including the spinal cord and nerve roots that are likely causing these neurological symptoms.

Rationale for MRI as First Choice

MRI offers significant advantages over radiography for neurological symptoms:

• MRI is the most sensitive imaging modality for assessment of soft tissue abnormalities, including cervical spine soft tissues and is superior to CT in identifying soft-tissue injuries of the cervical spine 1
• MRI has become the modality of choice for the assessment of suspected nerve root impingement in patients with cervical radiculopathy 1
• MRI allows for assessment of compression and spinal cord signal abnormality, which is crucial when evaluating neurological symptoms like tingling and weakness 1
• In a study of patients with clinically diagnosed cervical radiculopathy who subsequently underwent surgery, preoperative MRI correctly predicted 88% of lesions compared to only 57% for radiography 1

Limitations of Radiography

Radiography has significant limitations when evaluating neurological symptoms:

• Radiographs have largely been supplanted by advanced imaging for assessment of cervical spine pathology 1
• Radiographs depict only about one-third of abnormalities visible on CT, and are even more limited for soft tissue visualization 1
• Radiographs cannot adequately visualize the spinal cord, nerve roots, or soft tissue structures that typically cause tingling and weakness 1
• While radiographs may serve as an initial screen for spondylosis or degenerative disc disease, they have poor sensitivity and specificity for assessing soft-tissue injury causing neurological symptoms 1

Clinical Algorithm for Imaging Selection

1. For patients presenting with tingling/weakness (neurological symptoms):

   • MRI cervical spine without IV contrast is the first-line imaging study
   • No need for preliminary radiographs when neurological symptoms are present

2. Special circumstances:

   • For patients with contraindications to MRI (pacemakers, claustrophobia, etc.):
     • CT myelography can be considered as an alternative 1
   • For patients with suspected trauma in addition to neurological symptoms:
     • CT cervical spine without contrast first, followed by MRI 1

Important Considerations

• MRI findings must be correlated with clinical symptoms, as MRI can show abnormalities in asymptomatic patients 1
• Abnormal levels on MRI do not always correspond to abnormal clinical-physical examination levels 1
• The addition of IV contrast to MRI is generally not necessary unless there are "red flag" symptoms suggesting infection, malignancy, or post-surgical changes 1

MRI provides the most comprehensive evaluation of potential causes of tingling and weakness, including disc herniation, spinal cord compression, foraminal stenosis, and other soft tissue abnormalities that cannot be adequately visualized with radiography.