What is the initial diagnostic test for a patient presenting with cervical spine symptoms?

Initial Diagnostic Test for Cervical Spine Symptoms

Plain radiographs of the cervical spine are the recommended initial diagnostic test for patients presenting with cervical spine symptoms in the absence of red flags. 1

Diagnostic Algorithm for Cervical Spine Symptoms

Step 1: Evaluate for Red Flags

• Assess for red flags that would warrant immediate or advanced imaging, including:
  • Trauma history
  • Malignancy concerns
  • Prior neck surgery
  • Spinal cord injury symptoms
  • Systemic diseases (ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, inflammatory arthritis)
  • Suspected infection
  • History of intravenous drug use
  • Intractable pain despite therapy
  • Tenderness to palpation over a vertebral body
  • Neurological deficits 1, 2

Step 2: Initial Imaging Selection

• For patients WITHOUT red flags:

  • Plain radiographs of the cervical spine are the first-line imaging modality 1
  • Radiographs are useful for initial assessment and screening of spondylosis, degenerative disc disease, and malalignment 1
  • In the absence of red flags, therapy is rarely altered by radiographic findings, but they provide a useful baseline 1

• For patients WITH red flags or radiculopathy:

  • MRI without contrast is the preferred advanced imaging modality for suspected soft tissue abnormalities, nerve compression, or cord involvement 1
  • CT may be considered if bony detail is specifically needed 1

Evidence Quality and Considerations

• The American College of Radiology (ACR) Appropriateness Criteria provides the most recent and comprehensive guidance on cervical spine imaging, with the 2024 update offering the most current recommendations 1

• While MRI is the most sensitive test for detecting soft tissue abnormalities, it has a high rate of abnormal findings in asymptomatic individuals (false positives), making it inappropriate as a first-line test in uncomplicated cases 1

• CT offers superior depiction of cortical bone compared to radiographs but is not recommended as a first-line examination for chronic neck pain in the absence of red flags or neurological symptoms 1

Common Pitfalls and Caveats

• Overreliance on imaging findings: Degenerative changes are common in asymptomatic individuals, with one study showing 53.9% of individuals demonstrating disc degenerative changes, with prevalence increasing with age 1

• Unnecessary advanced imaging: Ordering MRI or CT without appropriate indications rarely changes management in acute, uncomplicated neck pain and may lead to unnecessary interventions 1, 2

• Missing ligamentous injuries: While CT is excellent for bony evaluation, it may overlook ligamentous instability. Consider flexion-extension radiographs if there is concern for instability despite negative CT 3

• Correlation with clinical findings: MRI alone should not be used to diagnose symptomatic cervical radiculopathy and should always be interpreted in combination with clinical findings, given frequent false-positive and false-negative MRI findings 1

• Incidental findings: The presence of structural abnormalities like altered cervical curvature may be coincidental and not necessarily indicative of the cause of pain 4