Should a cervical spine MRI for a post‑accident patient with cervical radiculopathy be performed with or without intravenous contrast?

Cervical Spine MRI for Post-Accident Cervical Radiculopathy: Without Contrast

For a post-accident patient with cervical radiculopathy, cervical spine MRI should be performed WITHOUT intravenous contrast. 1, 2

Primary Recommendation

• MRI cervical spine without IV contrast is the appropriate imaging modality for acute cervical spine trauma with confirmed or suspected nerve root injury. 1
• The American College of Radiology explicitly states that MRI without contrast is usually appropriate for patients with acute blunt cervical spine trauma and nerve root injury, whether or not traumatic injury is identified on CT. 1
• For cervical radiculopathy specifically, MRI without contrast correctly predicts 88% of lesions and provides superior visualization of disc herniations and nerve root compression—the primary pathology in radiculopathy. 2

Why Contrast Is Not Indicated in This Scenario

• No current literature supports the routine use of contrast-enhanced MRI in acute trauma evaluation. 3
• The ACR guidelines for cervical pain and radiculopathy state that MRI without IV contrast is the preferred study for uncomplicated cervical radiculopathy, providing adequate visualization of disc herniations and nerve-root compression. 3
• A 2015 study comparing MRI with and without contrast in traumatic spinal cord injuries found no significant differences in diagnosing major injuries (hematoma, edema, cord injury), with contrast only providing marginal benefit for soft tissue evaluation. 4
• Routine addition of IV contrast should be avoided as it does not add diagnostic value for uncomplicated radiculopathy and increases cost and potential adverse effects. 2

When Contrast WOULD Be Indicated (Red Flags to Watch For)

Contrast-enhanced MRI (with and without IV contrast) becomes appropriate only when specific "red flag" features are present: 3

• Suspected spinal infection (fever, elevated inflammatory markers, IV drug use history)—contrast demonstrates epidural abscess, discitis, or leptomeningeal involvement with sensitivity ≈96%. 3
• Known malignancy with new cervical symptoms—contrast detects soft-tissue tumor extension, leptomeningeal metastases, and intramedullary involvement. 3
• Prior cervical spine surgery with new neurological symptoms—contrast differentiates recurrent disc herniation from postoperative scar tissue. 3

Clinical Pitfalls to Avoid

• Do not order CT as initial imaging for radiculopathy—CT lacks the soft tissue resolution necessary to evaluate nerve roots and disc herniations adequately. 2
• Remember that degenerative findings are extremely common in asymptomatic individuals—approximately 65% of patients aged 50-59 show significant cervical spine degeneration on imaging, emphasizing the need for clinical correlation. 2, 5
• MRI demonstrates frequent false-positive findings in asymptomatic patients, and abnormal levels on MRI do not always correspond to clinical examination levels. 2

Imaging Algorithm for Post-Accident Cervical Radiculopathy

1. Initial evaluation: CT cervical spine without contrast (if trauma mechanism warrants imaging per NEXUS/CCR criteria). 1
2. Follow-up for radiculopathy/nerve root injury: MRI cervical spine WITHOUT contrast. 1, 2
3. Add contrast only if: Red flag symptoms emerge (infection, malignancy, prior surgery). 3