X-ray of the Neck for Patient with Neck Pain Radiating to Head and Negative MRI
Radiographs of the cervical spine are usually appropriate as the initial imaging study for a patient with neck pain radiating to the head, even with a negative MRI of the head. 1, 2
Rationale for Cervical Spine X-ray
- Radiographs are the most appropriate initial imaging test for nontraumatic cervical pain without "red flags," providing valuable information about bone structure and alignment 2
- For cervicogenic headache with neck pain and no neurologic deficit, radiographs of the cervical spine are an appropriate first-line imaging study 1
- Conventional radiography plays an important role in diagnostic evaluation as pathological changes in cortical bone are detectable even if only a few millimeters wide 1
Clinical Considerations
- Neck pain radiating to the head may indicate cervicogenic headache, for which imaging can lend support to diagnosis, though it is not always diagnostic for the specific etiology 1
- Nontraumatic neck pain is a leading cause of disability, with nearly 50% of individuals experiencing ongoing or recurrent symptoms 1
- The American College of Radiology recommends five radiographic views (anteroposterior, lateral, open-mouth, and both oblique views) for comprehensive evaluation of patients with chronic neck pain 3
Limitations of X-ray
- Spondylotic changes are commonly identified on radiographs and may result in both false-positive and false-negative findings 1
- Osteolytic changes may only be detectable after 50% of bone substance has been destroyed, and lesions up to 1 cm may not be detectable 1
- Radiographs alone are not sufficient to exclude all pathologies in the setting of persistent neck pain 1
When to Consider Advanced Imaging
- If radiographs show degenerative changes and the patient has persistent symptoms, MRI cervical spine without IV contrast is usually appropriate as the next imaging study 1, 4
- MRI is preferred for patients with neurological deficits including radiculopathy, as it correctly predicts 88% of lesions compared to lower accuracy rates with other imaging modalities 4
- The presence of "red flags" (prior neck surgery, suspected infection, intractable pain despite therapy, tenderness over a vertebral body, systemic diseases) warrants immediate MRI evaluation 4
Important Caveats
- A negative MRI of the head does not rule out cervical spine pathology as a cause of pain radiating to the head 1
- Imaging findings must be interpreted in the context of clinical symptoms, as degenerative changes are common in asymptomatic individuals over age 30 2
- CT is not currently recommended as a first-line examination for neck pain in the absence of red flags or neurological symptoms 1