Should a cervical spine MRI be done with or without contrast for neck pain and headache?

From the Guidelines

For neck pain and headaches, a cervical spine MRI is typically performed without contrast initially. Contrast (gadolinium) is generally not necessary for evaluating common causes of neck pain and headaches such as disc herniations, degenerative changes, or muscle strain, as noted in the study by 1. However, contrast may be added if there is suspicion of infection, inflammation, tumors, or if the non-contrast MRI shows abnormalities that require further characterization. The decision ultimately depends on your specific clinical situation and should be made by your healthcare provider. Non-contrast MRIs are preferred as the first-line approach because they avoid potential risks associated with contrast agents, including allergic reactions and concerns about gadolinium retention in tissues. They are also less expensive and take less time to complete. If your symptoms suggest a more complex condition or if initial imaging is inconclusive, your doctor may then recommend an MRI with contrast as a follow-up study to provide additional diagnostic information, as suggested by 1 and 1.

Some key points to consider when deciding between a contrast and non-contrast MRI include:

• The presence of "red flag" symptoms, such as fever, weight loss, or recent trauma, which may necessitate the use of contrast to evaluate for infection or other serious conditions 1
• The presence of known malignancy, which may require the use of contrast to assess for leptomeningeal or soft tissue involvement 1
• The clinical suspicion of cervicogenic headache, which may not require MRI at all, but rather other diagnostic modalities such as radiographs or CT scans 1
• The potential risks and benefits of contrast agents, including allergic reactions and concerns about gadolinium retention in tissues, as noted in the study by 1

It's essential to weigh these factors and consider the individual patient's clinical situation when deciding whether to perform a cervical spine MRI with or without contrast. The most recent and highest quality study, 1, suggests that non-contrast MRI is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition. Ultimately, the decision should be made by a healthcare provider, taking into account the patient's specific symptoms, medical history, and other relevant factors.

From the Research

Cervical Spine MRI for Neck Pain and Headache

• The decision to perform a cervical spine MRI with or without contrast for neck pain and headache depends on various factors, including the clinical presentation and diagnostic criteria 2, 3.
• Studies have shown that MRI may not be an adequate method to detect pathological findings underlying the aetiology of cervicogenic headache, such as nerve roots, intervertebral joints, and periosteum 2.
• Diagnostic criteria for cervicogenic headache have been established by several expert groups, including the International Headache Society (IHS) and Cervicogenic Headache International Study Group (CHISG) 4.
• Cervical nerve block may confirm the nociceptive source in majority of cases and is included in CHISG criteria, while non-invasive diagnostic methods like echogenicity of muscles, diffusion tensor imaging (DTI), and single-photon emission tomography (SPECT) are proposed by some authors for avoiding complications associated with blocks 4.

Imaging Findings

• A study found that the distribution of pathological lesions in patients with cervicogenic headache and controls were not significantly different, suggesting that MRI may not be able to distinguish between the two groups 2.
• Another study noted that almost any pathology affecting the cervical spine has been implicated in the genesis of cervicogenic headache, but no specific pathology has been noted on imaging or diagnostic studies which correlates with cervicogenic headache 3.

Management Options

• The mainstay of management for cervicogenic headache is physical therapy, while surgical interventions for cervical degenerative disease may relieve an associated headache but are not performed solely for cervicogenic headache 4, 5.
• Exercise treatment appears to be beneficial in patients with neck pain, and there is some evidence to support muscle relaxants in acute neck pain associated with muscle spasm 5.