For cervicalgia, is an MRI (Magnetic Resonance Imaging) or CT (Computed Tomography) scan of the spine more appropriate?

MRI is Superior to CT for Cervicalgia

For cervicalgia (neck pain), MRI of the cervical spine without IV contrast is the preferred initial imaging modality, as it is the most sensitive test for evaluating soft tissue abnormalities, disc pathology, and nerve root impingement that cause neck pain. 1

Primary Recommendation: MRI Without Contrast

• MRI cervical spine without IV contrast is the modality of choice for assessment of suspected nerve root impingement and soft tissue pathology in cervicalgia. 1

• MRI correctly predicted 88% of lesions requiring surgery in patients with cervical radiculopathy, compared to only 81% for CT myelography and 50% for CT alone. 1

• MRI offers superior visualization of intervertebral discs, spinal cord, nerve roots, ligaments, and other soft tissue structures that are the primary causes of neck pain. 1

• Contrast enhancement is not routinely needed unless there are "red flag" symptoms suggesting infection, malignancy, or other serious pathology. 1

When CT Has a Role

• CT cervical spine without contrast is appropriate when evaluating bony pathology, including neuroforaminal stenosis from uncovertebral or facet joint hypertrophy, particularly when C6-C7 levels are not well visualized on radiographs. 1

• CT is less sensitive than MRI for nerve root compression and soft tissue evaluation. 1

• CT is the gold standard for fracture detection in trauma settings, but this is not the primary concern in non-traumatic cervicalgia. 1

Important Clinical Context

Red Flags Requiring Imaging

Look for these specific findings that mandate imaging rather than conservative management: 1

• History of trauma
• Known or suspected malignancy
• Prior cervical spine surgery
• Suspected spinal cord injury
• Systemic inflammatory diseases (ankylosing spondylitis, rheumatoid arthritis)
• Suspected infection or history of IV drug use
• Intractable pain despite conservative therapy
• Tenderness to palpation over vertebral body
• Neurological deficits on examination
• Abnormal laboratory values (elevated ESR, CRP, WBC)

Critical Pitfalls to Avoid

• Do not over-interpret MRI findings in isolation. Degenerative changes are present in approximately 65% of asymptomatic patients aged 50-59 years, and MRI abnormalities do not always correlate with clinical symptoms or physical examination findings. 1

• MRI demonstrates frequent false-positive and false-negative findings, with detected abnormalities not always associated with acute symptoms. 1

• The segmental level of abnormality on MRI may not correspond to the clinical examination level or the patient's pain distribution. 1

• Most cases of acute cervicalgia with radicular symptoms resolve spontaneously or with conservative treatment, so imaging may not be required at initial presentation in the absence of red flags. 1

Alternative Imaging Options

CT Myelography

• CT myelography can be considered when MRI is contraindicated (pacemakers, certain implants, severe claustrophobia) or when MRI findings are equivocal. 1

• Offers higher spatial resolution than MRI and excellent depiction of the thecal sac and small nerve roots. 1

• Has been largely supplanted by MRI as first-line imaging but remains a viable alternative in specific circumstances. 1

Plain Radiography

• Radiographs alone are insufficient for evaluating the soft tissue causes of cervicalgia and show degenerative changes in most patients over age 50 regardless of symptoms. 1

• May be useful as an initial screening tool but should not be the definitive imaging study for persistent or concerning cervicalgia. 1

Special Populations

Post-Surgical Patients

• For patients with prior cervical spine surgery presenting with new or increasing cervicalgia, MRI without IV contrast is usually appropriate for detecting adjacent level disease, disc herniations, and nerve impingement. 1, 2

• CT without contrast is superior for evaluating hardware integrity, fusion status, and bony continuity at the fusion site. 2

• Consider adding contrast to MRI if infection is suspected. 1, 2

Trauma Patients with Cervicalgia

• In the trauma setting with cervicalgia after negative CT, MRI identified additional soft tissue injuries in 23.6% of patients, including ligamentous injury (16.6%), though the clinical significance of these findings remains uncertain. 1, 3

• CT remains the initial modality for trauma, but MRI should follow if there are neurological symptoms or persistent cervicalgia despite negative CT. 1