MRI Cervical Spine Without Contrast
For a patient presenting with neck pain, radiculopathy, and arm paresthesias, order an MRI of the cervical spine without IV contrast as the initial imaging study. 1
Rationale for MRI Without Contrast
MRI without contrast is the imaging modality of choice for evaluating cervical radiculopathy, correctly predicting 88% of lesions compared to 81% for CT myelography and 57% for conventional myelography. 1
MRI provides superior visualization of soft tissue abnormalities including disc herniations, nerve root compression, and spinal cord pathology that are the primary concerns in radiculopathy. 1
The addition of IV contrast is not necessary for routine evaluation of cervical radiculopathy unless there is suspicion for infection, malignancy, or other "red flag" symptoms requiring soft tissue or leptomeningeal assessment. 1
Why Not Other Imaging Modalities?
Plain radiographs are appropriate for chronic neck pain without neurological findings, but are insufficient when radiculopathy is present, as they cannot evaluate nerve root compression or disc pathology. 1, 2
CT cervical spine offers superior bone detail but is significantly less sensitive than MRI for evaluating nerve root compression, particularly from disc herniation. 1, 2
CT myelography has been supplanted by MRI as first-line imaging and should only be considered when MRI is contraindicated (pacemaker, severe claustrophobia) or when MRI findings are equivocal despite clear clinical radiculopathy. 1
Clinical Correlation Is Essential
Degenerative findings on MRI are extremely common in asymptomatic individuals, with approximately 65% of patients aged 50-59 showing significant cervical spine degeneration on imaging. 2
MRI demonstrates frequent false-positive findings in asymptomatic patients, and abnormal levels on MRI do not always correspond to clinical examination levels. 1
Physical examination findings correlate poorly with MRI evidence of nerve root compression, emphasizing the need to interpret imaging in the context of clinical symptoms. 3
Critical Pitfalls to Avoid
Do not order CT as initial imaging for radiculopathy—it lacks the soft tissue resolution necessary to evaluate the nerve roots and disc herniations that cause radicular symptoms. 2
Avoid adding IV contrast routinely—it does not add diagnostic value for uncomplicated radiculopathy and increases cost and potential adverse effects. 1
Do not over-interpret degenerative findings—correlate all imaging abnormalities with the specific dermatomal distribution of symptoms, as multilevel degeneration is common but may not be clinically relevant. 4