From the Guidelines
For a patient with cervical spine pain who can lie down for an MRI, the best imaging protocol would be a multisequence MRI of the cervical spine without contrast, unless there are specific indications for contrast administration. This recommendation is based on the most recent and highest quality study available, which suggests that MRI is the preferred method for evaluating the cervical spine in patients with suspected nerve root impingement 1. The protocol should include T1-weighted, T2-weighted, and STIR (Short Tau Inversion Recovery) sequences in multiple planes (sagittal, axial, and sometimes coronal), as these sequences provide excellent anatomical detail and are sensitive for detecting pathology such as disc herniations, spinal cord compression, ligamentous injuries, and inflammatory changes.
Some key points to consider when ordering an MRI for cervical spine pain include:
- The use of a dedicated cervical spine coil to improve image quality
- Positioning the patient supine and instructing them to remain still throughout the examination
- Carefully evaluating axial images at each neural foramen level if radiculopathy is suspected
- Considering the addition of contrast if there are specific indications, such as suspected malignancy or infection
It's also important to note that degenerative findings on MRI are commonly observed in asymptomatic patients, and therefore, correlation with clinical symptoms is essential 1. Additionally, the American College of Radiology (ACR) Appropriateness Criteria suggest that MRI cervical spine without IV contrast is usually appropriate for the initial imaging of patients with cervical neck pain or cervical radiculopathy 1.
In terms of specific sequences, fluid-sensitive sequences (STIR or T2-weighted fat-saturated) are necessary to allow visual identification of acute inflammatory findings in bone, joints, and soft tissues 1. However, gadolinium enhancement is not required but may help in initial evaluation, improving conspicuity of inflammatory changes, especially in the discs, facet joints, and entheses 1.
Overall, a multisequence MRI of the cervical spine without contrast is the recommended imaging protocol for patients with cervical spine pain who can lie down for an MRI, unless there are specific indications for contrast administration.
From the Research
Best Image to Obtain for MRI of Cervical Spine
To determine the best image to obtain for an MRI of the cervical spine in a patient experiencing pain, several factors must be considered, including the type of sequence and the use of contrast agents.
- Sequence Selection: The choice between different MRI sequences (e.g., T1-weighted, T2-weighted, STIR) depends on the specific clinical question and the pathology suspected. For example, T2-weighted images are sensitive to changes in water content and are useful for detecting edema or inflammation, while T1-weighted images provide better anatomical detail 2.
- Use of Contrast Agents: The use of gadolinium-based contrast agents can enhance the visibility of certain lesions, particularly those involving inflammation or infection. However, the routine use of gadolinium is not warranted and should be reserved for specific clinical scenarios, such as suspected infection in or around a joint, or cases refractory to medical or surgical treatment due to possible abscess formation 3.
- Clinical Guidelines: Clinical guidelines for the authorization of MRI in the evaluation of neck pain and cervical radiculopathy vary among insurance carriers and may not always be based on evidence-based literature. This inconsistency highlights the need for standardized guidelines that reflect the best available evidence 4.
- Imaging of the Cervical Spine: MRI is the imaging modality of choice for assessing the cause and complicating features of spine pain, including the cervical spine. It allows for the differentiation of various sources of pain, such as degenerative changes, infection, and fractures, guiding appropriate therapy 5.
Considerations for Image Acquisition
When acquiring images for an MRI of the cervical spine, considerations include:
- Patient Positioning: The patient should be positioned in a way that minimizes discomfort and allows for the best possible image quality. For patients who can lie down, supine positioning is typically used.
- Sequence Protocol: The MRI protocol should include a combination of sequences that provide both anatomical detail and sensitivity to pathological changes. This may include T1-weighted, T2-weighted, and STIR sequences.
- Use of Fat Suppression: Fat suppression techniques can be useful in certain sequences to improve the visibility of lesions or areas of inflammation. However, the choice of fat suppression technique depends on the specific clinical question and the sequences used 3, 2.