When is a radiograph not recommended for patients with cervicalgia?

Reasons Not to Do Radiographs on Cervicalgia Patients

Radiographs are often not needed in patients with cervicalgia in the absence of "red flag" symptoms and do not influence management or improve clinical outcomes. 1

When to Avoid Cervical Spine Radiographs

Absence of Red Flags

• Radiographs should be avoided in patients with neck pain who do not present with any "red flag" symptoms 1
• Red flags that would warrant imaging include:
  • Trauma history
  • Osteoporosis
  • Unexplained weight loss
  • History of cancer
  • Fever
  • Immunosuppression
  • IV drug use
  • Elevated inflammatory markers 2
  • Neurological deficits 1

Limited Clinical Utility

• Radiographs have poor sensitivity for detecting many cervical spine abnormalities compared to more advanced imaging modalities 1
• A high rate of degenerative findings are noted in asymptomatic individuals, making correlation with symptoms difficult 1
• Radiographic findings often do not influence management decisions in uncomplicated cervical pain 1

Low Diagnostic Value

• Radiographs have been largely supplanted by CT for assessment of traumatic cervical spine injury, with radiographs identifying only about one-third of fractures visible on CT 1
• The specificity of lateral plain films for cervical spine injuries is poor at only 47-70% 1
• Flexion-extension views rarely demonstrate cervical instability not identified on conventional cervical radiographs 1

When MRI is Preferred Over Radiographs

• MRI is the most sensitive imaging modality for assessment of soft tissue abnormalities that may cause cervical pain 1
• MRI should be considered instead of radiographs when:
  • Focal neurologic symptoms are present
  • Pain is refractory to conventional treatment
  • Soft tissue pathology is suspected 2
  • There is concern for spinal cord or nerve root compression 1

When CT is Preferred Over Radiographs

• CT offers superior depiction of bones compared to radiographs, particularly for:
  • Structures relevant to degenerative disease (end plates, disc space, facet joints)
  • Potential nerve-impinging osseous structures (osteophytes, uncovertebral joints, facet joints) 1
• CT is the gold standard for identification of cervical spine fractures 1

Clinical Decision Rules to Avoid Unnecessary Imaging

• The NEXUS criteria can identify patients with extremely low probability of cervical spine injury who do not need imaging 3
• Patients meeting all five NEXUS criteria (no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful distracting injury) have a 99.8% negative predictive value for cervical spine injury 3
• Application of clinical decision rules could reduce unnecessary imaging by approximately 12.6% 3

Common Pitfalls to Avoid

• Ordering unnecessary imaging studies in the absence of red flags 2, 4
• Overreliance on imaging findings that may not correlate with clinical symptoms 2
• Inadequate radiographic technique leading to missed injuries (the most common reason for missed cervical spine injuries) 5
• Failure to recognize that most cases of acute cervical neck pain resolve spontaneously or with conservative treatment 6