Orthopedics Book

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Cervical Spine Imaging in Neck Pain

Aka: Cervical Spine Imaging in Neck Pain, Cervical Spine Imaging in Cervical Disc Disease
  1. See Also
    1. Neck Pain
    2. Cervical Disc Disease
    3. Cervical Spine Imaging in Acute Traumatic Injury
    4. Cervical Spine Injury
    5. Pediatric Cervical Spine Injury
    6. Cervical Spine XRay
    7. Cervical Spine CT
    8. Cervical Spine MRI
  2. Imaging: General
    1. Cervical Spine XRay
      1. Typically a first-line study, but limited efficacy in radiculopathy, and low Specificity in age over 50 years
      2. Indicated in persistent Neck Pain symptoms >4-6 weeks, Trauma, cancer red flags
      3. Cervical Spine CT is preferred for adults with Traumatic neck injury
      4. Views
        1. Standard: Anteroposterior, Lateral (and oblique views in suspected foraminal stenosis)
        2. Trauma: Anteroposterior Open Mouth Odontoid view (in addition to standard views)
        3. Additional views to consider: Flexion and extension views
    2. Cervical Spine CT
      1. Not as useful in evaluating cervical disc or radiculopathy (without myelography) as MRI
      2. Traumatic neck injury evaluation in adults at acute emergency visit
        1. First-line study to evaluate for Vertebral Fracture
      3. Avoid in children
        1. See CT-associated Radiation Exposure
        2. Children are higher risk for ligamentous instability (MRI) than Vertebral Fracture
        3. Consult with local experts
        4. Consider MRI Cervical Spine instead if XRay not diagnostic
    3. CT Cervical Spine with Myelography (requires spinal contrast injection)
      1. May offer definitive evidence where MRI is non-diagnostic in Cervical Radiculopathy
      2. Offers alternative for patients who cannot undergo MRI
    4. Cervical Spine MRI
      1. High rate of False Positives (57% over age 64 years) and False Negatives in Cervical Radiculopathy
      2. Urgent Indications
        1. Neck Pain Red Flags
        2. Progessive neurologic deficit over 3-4 weeks
        3. Cervical myelopathy
        4. Epidual abscess or other Spinal Infection suspected
        5. Signs of bony destruction on XRay (suggestive of Spinal Infection, requires IV contrast)
        6. Suspected Spinal Neoplasm (e.g. metastasis)
        7. Vertebral Fractures
        8. Degenerative osteophytes with suspected nerve compression
      3. Routine Indications (>6 weeks of symptoms)
        1. Refractory Neck Pain course beyond 6 weeks of conservative therapy
        2. Suspected Cervical Disc Herniation >6 weeks
        3. Persistent Whiplash Symptoms (to evaluate differential diagnosis including discs, spurs and ligament injury)
          1. Controversial as to benefit
  3. Imaging: Evaluation of chronic Neck Pain
    1. Step 1: All Patients with chronic Neck Pain
      1. Cervical Spine XRay with 5 views (AP, Lateral, odontoid, obliques)
    2. Step 2: MRI Cervical Spine indications (CXT myelography where MRI is contraindicated)
      1. No further imaging needed in Spondylosis without neurologic changes
      2. See MRI indications as above
  4. Imaging: Studies NOT helpful in diagnosis
    1. Chronic Neck Pain
      1. Provocative diagnostic discography is not reliable
  5. References
    1. Childress (2016) Am Fam Physician 93(9): 746-54 [PubMed]
    2. Daffner (2010) Am Fam Physician 82(8): 959-64 [PubMed]
    3. Eubanks (2010) Am Fam Physician 81(1): 33-40 [PubMed]
    4. Polston (2007) Neurol Clin 25(2): 373-85 [PubMed]
    5. Rhee (2007) J Am Acad Orthop Surg 15(8): 486-94 [PubMed]
    6. Tong (2003) J Neuroimaging 13(1): 5-16 [PubMed]

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