Neck Pain in Adults _________________________________________________________________________
fractures, herniated disks, spinal and foraminal stenosis, and osteophyte formation, especially when not clearly shown on x-ray [23; 24; 50; 58; 103]. It is important to avoid unnecessary CT scanning to limit patient radiation exposure and associated carcinogenic risk [103]. CT Myelography Myelogram followed by CT scan evaluates the spinal canal, its relationship to the spinal cord, and nerve root impingement from disk, spur, or foraminal encroachment. CT myelography is superior to MRI in detecting encroachment but is reserved for complex cases due to greater expense and morbidity or when MRI is unavailable, intolerable to the patient, or contraindicated [19; 51]. Provocative Cervical Diskography Provocative cervical diskography is the only procedure that can identify a disk as the pain generator. In this test, contrast dye is injected into the nucleus pulposus to visualize disk architecture and provoke a pain response. Discomfort and invasiveness make this procedure less desirable than cervical MRI, which provides much of the anatomic information. Possible complications include diskitis, epidural abscess, quadriplegia, stroke, pneumothorax, and nerve and spinal cord injury [51]. MRI often misses significant tears, which diskography can reveal as diskogenic source of cervical pain. As noted, while MRI can identify most painful disks, it has relatively high error rates [41]. Electrodiagnostic Tests Electromyography and nerve conduction studies are the standard for evaluating cervical spine neurologic function and have advantages of limited cost and morbidity [51]. With persistent radicular symptoms, electromyography can help identify injuries to cervical nerve roots, brachial plexus, or peripheral nerves [16]. It may show nerve injury missed by imaging studies that only show structural injury [41]. Electromyography shows abnormalities with high specificity in cervical radiculopathy, diagnosed when two muscles innervated from the same nerve root are abnormal. Multiple muscles should be examined, including the paraspinals [11; 12; 22]. Nerve conduction studies are useful when extremity pain rather than cervical pain is more severe [7]. Initial Imaging Initial imaging is recommended for some patients when they first present for medical attention with neck pain or symptom complaints. Acute Cervical Spine Injury The Canadian C-spine Rule identifies patient risk of cervical spine injury and appropriate diagnostic imaging. “Dangerous mechanism of injury” is defined as falling from a height greater than 3 feet or axial load to the head from diving, high-speed or
According to the American College of Radiology (ACR), in absence of red flag symptoms, imaging may not be required at the time of initial presentation and the results rarely alter therapy. However, radiographs are widely accessible and
useful to diagnose spondylosis, degenerative disc disease, malalignment, or spinal canal stenosis. As such, the ACR states that cervical spine x-ray is usually appropriate for initial imaging of patients with new or increasing nontraumatic cervical or neck pain with no red flags. (https://acsearch.acr.org/docs/69426/Narrative. Last accessed September 26, 2025.) Level of Evidence : Expert Opinion/Consensus Statement Magnetic Resonance Imaging (MRI) Magnetic resonance imaging (MRI) is the imaging study of choice for most cervical spinal abnormalities. MRI can add important information about soft tissue injuries related to bony injuries seen on x-ray or computed tomography (CT) or disk or ligamentous injuries suggested by x-ray, CT, or clinical findings [108]. It can also distinguish hematoma from edema. MRI is highly accurate in identifying disk injury and ligament injuries [19; 109]. It is able to detect ligament disruption and subtle vertebral fracture, but is unreliable in depicting sources of cervical diskogenic pain because significant annular tears can escape MRI detection [16; 41]. Indications for cervical spine MRI at four to six week follow-up include [22; 41; 47]: • Persistent arm pain, neurologic deficits, or clinical signs of nerve root compression • Cervical radiculopathy signs and symptoms • Cervical disk injuries with any neurologic decline • Failure of axial neck pain to resolve as expected Patients with progressive neurologic deficit should receive MRI without delay. MRI is contraindicated in patients with certain implanted devices, but MRI scanners compatible with pacemakers are now available. Some patients have panic reactions during MRI from claustrophobia and require mild sedation [51; 103]. Computed Tomography (CT) MRI is superior at imaging soft tissue abnormalities and potential neurologic compromise, while CT better delineates bony pathology by producing multiple 2- and 3-dimensional images of spinal segments [7]. CT alone has limited value in assessing cervical radiculopathy but is useful for visualizing degenerative spine and facet changes, spinal alignment,
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