Should a magnetic resonance imaging (MRI) scan of the cervical spine be considered now to evaluate potential recurrence of symptoms in a patient with a history of cervicalgia and previous physical therapy?

MRI is NOT indicated at this time for recurrent cervicalgia without red flags or new neurological symptoms

For a patient with recurrent neck pain 8 months after physical therapy, without red flags or radicular symptoms, MRI should not be ordered now—start with plain radiographs if imaging is pursued at all. 1

Clinical Context and Natural History

Your patient's presentation represents chronic or recurrent neck pain, which is extremely common:

• Nearly 50% of patients with neck pain continue to experience residual or recurrent episodes up to 1 year after initial presentation 1, 2
• Most episodes resolve with or without treatment, making aggressive imaging premature 2
• The presence of degenerative changes alone in chronic, unchanging cervical pain does not require cross-sectional imaging 1

Why MRI is Inappropriate Now

MRI is characterized by a high rate of abnormalities in asymptomatic individuals and is not considered first-line imaging for uncomplicated neck pain. 1 The American College of Radiology explicitly states:

• MRI is not appropriate for chronic neck pain in the absence of radicular or myelopathic symptoms 1
• MRI findings must be interpreted cautiously as degenerative changes are common in asymptomatic individuals over age 30 3
• There is no evidence that imaging changes treatment outcomes in chronic neck pain without neurological symptoms 1

Red Flags That Would Change This Recommendation

You must actively assess for these red flags before dismissing imaging 1:

• Progressive motor weakness (not just pain)
• Bilateral arm symptoms suggesting myelopathy
• New bladder/bowel dysfunction
• Fever, elevated inflammatory markers, or immunosuppression (infection concern)
• History of malignancy
• Intractable pain despite appropriate therapy
• Tenderness to palpation over a vertebral body

Appropriate Imaging Algorithm if Needed

If you feel compelled to image due to persistent symptoms:

1. Start with plain radiographs (AP and lateral cervical spine) 1, 3

   • Useful to diagnose spondylosis, degenerative disc disease, malalignment, or spinal stenosis 1
   • Appropriate first-line study even for cervicogenic headache patterns 3
   • Therapy is rarely altered by radiographic findings in the absence of red flags 1

2. Consider MRI only if 3:

   • Radiographs show degenerative changes AND symptoms persist despite conservative therapy
   • New radicular symptoms develop (arm pain in nerve distribution, numbness, weakness)
   • Red flags emerge during follow-up

Management Without Imaging

The appropriate approach for recurrent neck pain without red flags 4, 5:

• Reassurance that 75-90% of cases resolve with conservative therapy 4
• NSAIDs or acetaminophen for pain control 4
• Physical therapy with structured exercise program 2, 5
• Short-term cervical collar if needed for acute exacerbations 5
• Re-evaluation in 6-12 weeks for persistent symptoms 4

Critical Pitfall to Avoid

Do not order MRI simply because the patient had symptoms before or is concerned about recurrence. 1 This leads to:

• Detection of incidental degenerative findings that don't correlate with symptoms
• Unnecessary patient anxiety about "abnormal" findings
• Potential cascade of unnecessary interventions
• Healthcare cost without benefit to morbidity, mortality, or quality of life