What imaging modality is appropriate for a patient with persistent cervical radiculopathy despite an adequate trial of activity modification, physical therapy, and nonsteroidal anti‑inflammatory drugs?

MRI Cervical Spine Without Contrast is the Appropriate Initial Imaging for Persistent Cervical Radiculopathy

For patients with persistent cervical radiculopathy despite adequate conservative management (activity modification, physical therapy, NSAIDs), MRI of the cervical spine without contrast is the imaging modality of choice. 1

Primary Recommendation

• MRI correctly predicts 88% of cervical radiculopathy lesions compared to 81% for CT myelography, 57% for plain myelography, and 50% for CT alone. 1
• MRI provides superior soft-tissue contrast and spatial resolution necessary to evaluate nerve root compression, disc herniations, and spinal cord pathology—the primary pathologic concerns in cervical radiculopathy. 1
• The American College of Radiology designates MRI cervical spine without contrast as the initial imaging modality of choice for patients with neck pain and radiculopathy or neurological deficits. 1, 2

Why Not Other Modalities?

CT Without Contrast

• CT offers superior visualization of bony structures (osteophytes, uncovertebral joints, facet joints) but is less sensitive than MRI for evaluating nerve root compression, particularly from herniated discs. 1
• CT provides complementary benefit to MRI in a subset of patients but should not replace MRI as first-line imaging. 1
• CT is most appropriate for assessing ossification of the posterior longitudinal ligament (OPLL) when suspected. 1

CT Myelography

• CT myelography has been largely supplanted by MRI as first-line imaging for cervical radiculopathy. 1
• Consider CT myelography only when: (1) MRI is contraindicated (pacemakers, claustrophobia), or (2) MRI findings are equivocal despite clinically apparent radiculopathy. 1
• CT myelography carries procedural risks—30% of patients report unexpected reactions and 14% experience maximum pain scores during the procedure. 1

Plain Radiographs

• Radiographs are insufficient for persistent radiculopathy evaluation, as approximately 65% of asymptomatic patients aged 50-59 demonstrate significant cervical spine degeneration on plain films. 1, 2
• Degenerative findings correlate poorly with symptoms and cannot evaluate soft tissue pathology. 1, 2

Critical Clinical Correlation Required

• MRI findings must always be correlated with clinical symptoms, as false-positive and false-negative findings are common. 1, 3
• A prospective study found high rates of both false-positive and false-negative MRI findings in recent-onset cervical radiculopathy. 1
• Degenerative findings on MRI are commonly observed in asymptomatic patients, making anatomic-clinical correlation essential. 1

Common Pitfalls to Avoid

• Do not order MRI prematurely—75-90% of cervical radiculopathy patients improve with conservative management alone. 1, 3
• Do not use MRI alone to diagnose symptomatic cervical radiculopathy—physical examination has limited accuracy for diagnosis compared to imaging or surgery. 1
• Do not assume all MRI abnormalities are symptomatic—spondylotic changes are common in patients >30 years and correlate poorly with neck pain. 2
• Avoid ordering CT as initial imaging unless MRI is contraindicated or you specifically need to evaluate bony pathology like OPLL. 1

When to Consider Alternative Imaging

• Post-surgical patients with new/worsening symptoms: CT is most sensitive for assessing spinal fusion and hardware complications. 1, 2
• MRI contraindications: CT myelography becomes the alternative, though it carries procedural risks. 1
• Equivocal MRI with strong clinical suspicion: CT myelography may clarify foraminal stenosis and nerve root compression. 1