For a 45-year-old male with lumbar radiculopathy symptoms down the right leg, on testosterone therapy with elevated hematocrit levels, does an MRI need to be with or without contrast?

MRI for Lumbar Radiculopathy: Without Contrast

For lumbar radiculopathy with symptoms down the right leg, MRI lumbar spine WITHOUT IV contrast is the appropriate imaging study. 1, 2

Standard Imaging Protocol

MRI lumbar spine without IV contrast is the imaging modality of choice for evaluating mechanical nerve root compression from disc herniation causing radiculopathy. 1, 2 This provides excellent soft-tissue contrast and accurately depicts disc degeneration, the thecal sac, neural structures, and nerve root compression that correlates with clinical symptoms. 2

When Contrast IS Indicated

Contrast should only be added (MRI without AND with IV contrast) when there is clinical suspicion for:

• Underlying malignancy 1
• Infection or inflammation 1
• Post-operative evaluation 1

These scenarios are NOT suggested by your patient's presentation of straightforward mechanical radiculopathy in a 45-year-old on testosterone therapy. 1

Timing Considerations

Imaging should only be obtained after 6 weeks of failed conservative therapy in patients who are potential candidates for surgery or epidural steroid injection. 1, 3, 2 The exception is immediate imaging for "red flags" including:

• Progressive motor deficits (such as worsening foot drop) 3, 2
• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction) 3, 2
• Suspected malignancy, infection, or fracture 1, 3

Important Clinical Context

The elevated hematocrit from testosterone therapy is a separate issue requiring monitoring (increased cardiovascular risk) but does not change the imaging approach for radiculopathy. 4, 5 The radiculopathy evaluation follows standard protocols regardless of testosterone use.

Most lumbar disc herniations show reabsorption or regression by 8 weeks after symptom onset, supporting initial conservative management without imaging. 3, 2 Routine imaging provides no clinical benefit in uncomplicated cases and leads to increased healthcare utilization without improving outcomes. 1, 2

Common Pitfall

Never order MRI with contrast as the initial study for mechanical radiculopathy—it adds unnecessary cost, time, and gadolinium exposure without diagnostic benefit. 1 Contrast-only sequences are not performed independently because interpretation requires correlation with standard noncontrast sequences. 1