When is a cervical MRI justified?

When to Order a Cervical MRI

MRI cervical spine without IV contrast is the preferred imaging modality for patients with new or increasing cervical radiculopathy, as it provides superior soft tissue contrast for nerve root evaluation and has the highest diagnostic accuracy for detecting nerve root impingement. 1

Clinical Indications for Cervical MRI

Neurological Symptoms and Red Flags

• MRI is justified in patients with neurological deficits including radiculopathy, as it correctly predicts 88% of lesions compared to lower accuracy rates with other imaging modalities 1
• Presence of "red flags" warrants immediate MRI evaluation, including:
  • Prior neck surgery 1
  • Suspected infection or history of intravenous drug use 1
  • Intractable pain despite therapy 1
  • Tenderness to palpation over a vertebral body 1
  • Systemic diseases (ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, inflammatory arthritis) 1
  • Abnormal laboratory values (elevated ESR, CRP, WBC) 1

Malignancy

• MRI without and with IV contrast is usually appropriate for patients with known malignancy and new or increasing cervical pain or radiculopathy 1
• The addition of contrast is preferred for assessment of leptomeningeal and soft tissue involvement, though non-contrast MRI also provides substantial diagnostic detail 1

Chronic Pain with Specific Findings

• For chronic cervical pain with no neurologic findings but with degenerative changes on radiographs, MRI cervical spine without IV contrast is usually appropriate as the next imaging study 1
• For patients with cervical radiculopathy, MRI has become the preferred method due to its superior soft-tissue contrast and ability to evaluate nerve root impingement 1

When to Start with Radiographs First

• For initial evaluation of chronic cervical or neck pain without red flags, radiographs of the cervical spine are usually appropriate as the first imaging study 1
• For cervicogenic headache with new or increasing nontraumatic cervical pain and no neurologic deficit, radiographs may be appropriate before considering advanced imaging 1

Limitations and Considerations

• Degenerative findings on MRI are common in asymptomatic patients, with one study showing that 65% of asymptomatic patients aged 50-59 have radiographic evidence of significant cervical spine degeneration 1
• A prospective study evaluating MRI in recent onset cervical radiculopathy found a high rate of both false-positive and false-negative findings 1
• MRI ordering appropriateness varies by specialty, with orthopedic surgeons ordering MRIs most appropriately (average ACR score of 8.4) and demonstrating more comprehensive physical examinations 2

Algorithm for Cervical MRI Decision-Making

1. Evaluate for presence of red flags or neurological deficits
   • If present → MRI without IV contrast (add contrast if infection or malignancy is suspected) 1
   • If absent → proceed to step 2
2. Assess duration and nature of symptoms
   • Acute trauma → Consider MRI if negative CT but persistent symptoms 3
   • Chronic pain without radiculopathy → Start with radiographs 1
   • Chronic pain with radiculopathy → MRI without IV contrast 1
3. For patients with prior imaging:
   • If radiographs show degenerative changes and symptoms persist → MRI without IV contrast 1
   • If radiographs show OPLL → CT without IV contrast is usually appropriate 1

By following these evidence-based guidelines for cervical MRI ordering, clinicians can improve resource utilization while ensuring appropriate diagnosis and treatment for patients with cervical spine conditions.