Should I order a CT (Computed Tomography) cervical spine with or without contrast for a patient with cervicalgia?

CT Cervical Spine Imaging for Cervicalgia: Contrast Decision

For a patient with simple cervicalgia (neck pain) without red flag symptoms, CT cervical spine WITHOUT contrast is the appropriate choice if CT imaging is pursued at all, though imaging is often unnecessary in this clinical scenario. 1

Clinical Context Determines Imaging Approach

The decision to use contrast depends entirely on whether red flag symptoms are present:

Uncomplicated Cervicalgia (No Red Flags)

• CT without contrast is sufficient if CT is deemed necessary, as it provides superior bone detail compared to radiographs for evaluating degenerative changes, osteophytes, and facet joints 1
• Adding IV contrast provides no additional value in the absence of red flag symptoms 1
• Important caveat: In uncomplicated cervicalgia without radiculopathy or red flags, imaging is often not indicated at all, as radiographs and CT frequently do not influence management or improve clinical outcomes 1

When Red Flags Are Present

For suspected infection:

• CT with IV contrast is appropriate as it allows detection of peripherally enhancing collections, epidural abscesses, mass effect on the venous plexus, and assessment of thecal sac compression 1
• CT without contrast can detect early bone changes (osteolysis, erosions, endplate irregularities) within the first 2 weeks of infection, but contrast enhances soft tissue evaluation 1
• MRI remains the gold standard for suspected infection (96% sensitivity, 93% specificity), making CT with contrast complementary rather than first-line 1

For suspected malignancy:

• CT with IV contrast may be appropriate to assess paraspinal or epidural tumor extension 1
• CT has 73% sensitivity and 94% specificity for bone metastasis but poor sensitivity for marrow-restricted disease 1
• MRI without and with contrast is preferred as the initial imaging modality for malignancy with cervical pain 1

For acute radiculopathy:

• CT without contrast is less sensitive than MRI for evaluating nerve root compression, particularly from herniated discs 1
• MRI without contrast is the modality of choice for radiculopathy evaluation 1, 2

Practical Algorithm

1. Assess for red flag symptoms: fever, weight loss, night sweats, known malignancy, immunosuppression, progressive neurological deficit, bowel/bladder dysfunction 2

2. If NO red flags present:

   • Consider whether imaging is necessary at all 1
   • If CT is ordered: use CT without contrast 1
   • Radiographs may be adequate for initial screening 1

3. If red flags ARE present:

   • Suspected infection: CT with contrast or proceed directly to MRI 1
   • Suspected malignancy: MRI with and without contrast preferred; CT with contrast is complementary 1
   • Radiculopathy: MRI without contrast is first-line 1, 2

Common Pitfalls to Avoid

• Ordering CT with contrast for simple degenerative cervicalgia adds cost and radiation without diagnostic benefit 1
• Using CT as first-line for radiculopathy misses soft tissue pathology that MRI would detect 1
• Assuming CT without contrast rules out infection in high-risk patients; contrast or MRI is needed for complete soft tissue evaluation 1
• Over-imaging chronic neck pain without radiculopathy or red flags, as MRI has high false-positive rates in asymptomatic patients 1, 2