What cervical spine MRI protocol should be ordered for a patient with neck pain and ipsilateral arm numbness?

MRI Cervical Spine Without IV Contrast

Order an MRI of the cervical spine without IV contrast for a patient presenting with neck pain and ipsilateral arm numbness. 1, 2

Rationale for This Recommendation

The combination of neck pain with arm numbness represents cervical radiculopathy until proven otherwise, and MRI without contrast is the single most accurate imaging modality for this clinical presentation, correctly predicting 88% of cervical radiculopathy lesions compared to 81% for CT myelography, 57% for plain myelography, and only 50% for CT alone. 1

Why MRI Without Contrast Is Superior

• MRI provides the highest soft-tissue resolution necessary to evaluate nerve root compression, disc herniations, and spinal cord pathology—the primary concerns when arm numbness accompanies neck pain. 1, 2
• The American College of Radiology designates non-contrast MRI as the initial imaging modality of choice for patients with neck pain and radiculopathy or neurological deficits. 1, 2
• Contrast is not needed in the absence of "red flag" symptoms such as known malignancy, prior neck surgery, suspected infection, or concern for leptomeningeal disease. 3

When to Skip Radiographs and Go Directly to MRI

• For patients with radicular symptoms (arm numbness), you should proceed directly to MRI rather than starting with plain radiographs. 1, 2
• Plain radiographs are appropriate only for chronic neck pain without neurological findings, but your patient has arm numbness, which changes the algorithm entirely. 1, 2
• Approximately 65% of asymptomatic patients aged 50-59 have significant cervical spine degeneration on radiographs, making these findings correlate poorly with symptoms and unlikely to change management. 1

Alternative Imaging Modalities and Their Limitations

CT Without Contrast

• CT is inadequate as first-line imaging because it lacks the soft-tissue resolution necessary to evaluate nerve root compression from disc herniations. 1
• CT excels at visualizing bony structures (osteophytes, facet joints) but is less sensitive than MRI for detecting the nerve root compression causing your patient's arm numbness. 1
• Reserve CT for evaluating suspected ossification of the posterior longitudinal ligament (OPLL) or post-surgical patients with hardware complications. 1

CT Myelography

• CT myelography has been largely supplanted by MRI and should only be considered when MRI is contraindicated (pacemaker, severe claustrophobia) or when MRI findings are equivocal despite clear clinical radiculopathy. 1
• Procedural risks include unexpected reactions in approximately 30% of patients and maximum pain scores in approximately 14%. 1

Critical Clinical Correlation Required

You must correlate MRI findings with the clinical examination because false-positive and false-negative results are common. 1, 2

• Degenerative changes on MRI are frequently observed in asymptomatic individuals, so anatomic-clinical correlation is essential. 1
• Physical examination findings correlate poorly with MRI evidence of cervical nerve root compression, with high rates of both false-positive and false-negative findings. 1

Red Flags That Would Modify This Recommendation

Evaluate for red flags that may warrant MRI with and without contrast instead: 1, 2

• Known malignancy with new cervical symptoms
• Prior neck surgery with new or worsening symptoms
• Suspected infection or history of intravenous drug use
• Fever, unexplained weight loss, or constitutional symptoms
• Progressive neurological deficits beyond radiculopathy
• Intractable pain despite therapy

Common Pitfalls to Avoid

• Do not order CT as the initial study unless MRI is contraindicated or specific bony pathology must be evaluated. 1
• Do not rely on MRI alone for diagnosing symptomatic radiculopathy; the anatomic findings must match the clinical distribution of symptoms. 1
• Avoid premature imaging if the patient has not yet tried conservative management (activity modification, physical therapy, NSAIDs), as 75-90% of patients improve with conservative management alone. 1
• Do not add contrast routinely—the addition of IV contrast is not routinely used in the absence of red flag symptoms. 3