Clinical guidance for MRI referral

MRI of the cervical spine

Cervical radiculopathy

Clinical guidance for MRI referral
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MBS item description

Referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of spine for a patient 16 years or older for suspected cervical radiculopathy (R) (K) (Contrast) (Anaes.)

Key information

  • There is a lack of evidence that MRI has led to improved health outcomes for patients with cervical radiculopathy.
  • GPs need to distinguish between patients with radicular signs and symptoms and those with musculoskeletal referred pain.
  • Most cases of cervical radiculopathy settle over time and conservative therapies are preferred in most patients.
  • Imaging studies often report findings that may have little to do with neck pain – incidental degenerative changes of the cervical spine may occur in 30–40% of asymptomatic young and middle-aged patients.
  • Although MRI is regarded as the preferred modality, the reliability of MRI readings for common degenerative or other pathologic findings in the cervical spine is moderate at best and its value is highly dependent on careful interpretation of the images in the context of the patient’s clinical presentation.

Explanation
Fair evidence (Level II or III studies with consistent findings) for or against recommending intervention For more information on levels of evidence see the US National Guideline Clearinghouse

Recommendation
MRI is suggested for the confirmation of correlative compressive lesions† of the cervical spine in patients who have failed a course of conservative therapy and who may be candidates for interventional or surgical treatment

Grade: None given

Explanation
Consider MRI when cervical radiculopathy has been present for 6 weeks and is not improving

  1. Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders. Eur Spine J 2008;17(1):101–22.

Grade: None given

Recommendation
Cervical X-rays and other imaging studies and investigations are not routinely required to diagnose or assess neck pain with radiculopathy

  1. Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders. Eur Spine J 2008;17(1):101–22.

Cervical radiculopathy is usually due to compression or injury to a nerve root by a herniated disc or degenerative changes. Levels C5 to T1 are the most commonly affected.30 It is usually, but not always, accompanied by cervical radicular pain, a sharp and shooting pain that travels from the neck and down the upper limb and may be severe. This needs to be differentiated from pain referred from the musculoskeletal (somatic) structures in the neck, which may be aching rather than sharp, and is more severe in the neck than in the upper limb.

The neurological signs of cervical radiculopathy depend on the site of the lesion. The patient may have motor dysfunction, sensory deficits or alteration in tendon reflexes. While pain is a common presenting symptom, not all radiculopathies are painful (i.e. only motor deficits may be obvious).30

Table 2.8 Neurological features associated with cervical radiculopathy

Table 2.8

Neurological features associated with cervical radiculopathy

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For most patients with cervical radiculopathy from degenerative disorders, it is likely that signs and symptoms will be self-limited and will resolve spontaneously over a variable length of time without specific treatment.29 Patient education and discussion about options and expectations are important.

What presenting symptoms suggest cervical radiculopathy?

History

Patients may report pain in the neck, shoulder and/or arm that is usually unilateral, but may be bilateral. The pain may be severe enough to wake the person at night.30

Neurological signs reported are altered sensation or numbness, or weakness in related muscles. Sensory symptoms are more common than motor symptoms.30

Physical examination

Look for features suggestive of a serious spinal or other abnormality, including compression of the spinal cord (myelopathy), cancer, severe trauma or skeletal injury, and vascular insufficiency. If these are present, arrange referral.

Table 2.9 Signs of serious spinal or other abnormalities

Table 2.9

Signs of serious spinal or other abnormalities

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Examine for signs of cervical radiculopathy:

  • Postural asymmetry: the head may be held to one side or flexed, as this decompresses the nerve root. If the asymmetry is long-standing, muscle wasting may be present.
  • Neck movements: these may be restricted, or sharp pain may radiate into the arms (especially on extension or on bending or turning to the affected side).
  • Dural irritation: assess with the Spurling test: the examiner extends the neck, sidebends it 30 degrees to the affected side and then applies axial compression to the head. The test is positive if this pressure causes the typical radicular arm pain.
  • Neurological signs: for example, upper limb weakness, paraesthesiae, dermatomal sensory or motor deficit, or diminished tendon reflexes at the appropriate level. Nerve root symptoms should normally arise from a single nerve root: involvement of more than one nerve root suggests a more widespread neurological disorder.30

Manual provocation tests (e.g. Spurling), designed to elicit nerve root compression in the cervical spine, have high positive predictive value.31

It is suggested that the diagnosis of cervical radiculopathy be considered in patients with arm pain, neck pain, scapular or periscapular pain, and paraesthesias, numbness and sensory changes, weakness, or abnormal deep tendon reflexes in the arm.29

Cervical radiculopathy can also be considered in patients with atypical findings such as deltoid weakness, scapular winging, weakness of the intrinsic muscles of the hand, chest or deep breast pain, and headaches.29

Both CT and MRI have been used to assess cervical radiculopathy; however, neither is required for diagnosis of cervical radiculopathy and neither is indicated unless patients have failed a (6-week) course of conservative therapy.29,30

CT scanning cannot accurately demonstrate the commonest cause for cervical radiculopathy (disc herniation) without myelography, which requires hospital admission, lumbar puncture and the use of contrast.

The assessment of root compression of the cervical spine by CT scan has fair-to-moderate reliability.31

In patients with cervical radiculopathy, MRI is the imaging technique of choice for the detection of root compression by disc herniation and osteophytes.32

MRI allows the nerve roots to be directly visualised. However, imaging studies often report findings that may have little to do with neck pain and there may be a high prevalence of incidental neck abnormalities with MRI.33 In one study of young, healthy volunteers, the prevalence of incidental neck abnormalities was 36.7%.34 Incidental findings would be expected to increase with age.

MRI allows visualisation of nerve root and the brachial plexus, which could be beneficial as brachial plexus signs mimic cervical radiculopathy. However, despite the potential advantages of MRI in detecting structural abnormalities, it does not appear to have any unique role, independent of the history and clinical examination, in detecting the cause of neck pain.31

There is no evidence that common degenerative changes on cervical MRI are strongly correlated with neck pain symptoms. Common degenerative changes are highly prevalent in asymptomatic subjects.33

In a 1990 study, approximately 30–40% of asymptomatic young and middle-aged patients had changes in the intervertebral discs, such as a protrusion or desiccation.35

Abnormal MRI findings of the cervical spine have also been found to increase with age.33

The indiscriminate use of imaging procedures for common and uncomplicated clinical presentations of the back and spine (e.g. chronic neck pain) has contributed to the perception of low value from these tests and to the high costs in managing these conditions.36

Combined with symptoms of radicular complaints and specific findings on examination, MRI may aid in determining the site and level of neurological compression. However, there is evidence that cervical MRI findings of disc or disc material extrusion through the cervical posterior longitudinal ligament do not correlate accurately with surgical findings.31

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