Clinical guidance for MRI referral

MRI of the cervical spine

Cervical radiculopathy

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.

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

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

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

Grade: None given

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

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

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?


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

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

  1. Chou R, Qaseem A, Owens DK, Shekelle P. Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011;154(3):181–89.
  2. Brito JP, Morris JC, Montori VM. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours. BMJ 2013;347:f4706.
  3. Royal Australian and New Zealand College of Radiologists (RANZCR). Radiology written report guideline, (short) version 5 (final). Sydney: RANZCR, 2011.
  4. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol 2010;7(3):192– 97.
  5. Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ 2012;344:e3502.
  6. Royal Australian and New Zealand College of Radiologists (RANZCR). Guidance for GP referrals for MRI studies. Sydney: RANZCR, 2013.
  7. Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007;69(21):1996–2007.
  8. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of epilepsy in adults: a national clinical guideline. Edinburgh: SIGN, 2003.
  9. National Institute for Health and Clinical Excellence (NICE). The epilepsies: diagnosis and management of the epilepsies in adults in primary and secondary care. London: NICE, 2012.
  10. King MA, Newton MR, Jackson GD, et al. Epileptology of the first-seizure presentation: a clinical, electroencephalographic, and magnetic resonance imaging study of 300 consecutive patients. Lancet 1998;352(9133):1007–11.
  11. Wilden JA, Cohen-Gadol AA. Evaluation of first nonfebrile seizures. Am Fam Physician 2012;86(4):334.
  12. Berg AT. Risk of recurrence after a first unprovoked seizure. Epilepsia 2008;49:13–18.
  13. Pohlmann-Eden B, Beghi E, Camfield C, Camfield P. The first seizure and its management in adults and children. BMJ 2006;332(7537):339–42.
  14. Adams SM, Knowles PD. Evaluation of a first seizure. Am Fam Physician 2007;75:1342–47.
  15. Hamilton W, Kernick D. Clinical features of primary brain tumours: a case–control study using electronic primary care records. Br J Gen Pract 2007;57(542):695–9.
  16. Harden CL, Huff JS, Schwartz TH, et al. Reassessment: Neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2007;69(18):1772–80.
  17. Smirniotopoulos JG, Wippold FJ, Cornelius RS, Angtuaco EJ, Broderick DF, Brown DC. Expert panel on neurologic imaging. ACR appropriateness criteria – seizures and epilepsy Reston, VA: American College of Radiology (ACR), 2011. [Online publication].
  18. Morris Z, Whiteley WN, Longstreth WT, et al. Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2009;339:b3016.
  19. Vattipally VR, Bronen RA. MR imaging of epilepsy: strategies for successful interpretation. Neuroimaging Clin N Am 2004;14(3):349–72. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of headache in adults. A national clinical guide. Edinburgh: NHS Scotland, 2008.
  20. Frishberg BM, Rosenberg JH, Matchar DB, et al. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. The American Academy of Neurology, 2000.
  21. National Clinical Guideline Centre. Headaches: diagnosis and management of headaches in young people and adults. Methods, evidence and recommendations. London: NICE, 2012.
  22. Nunes VD, Sawyer L, Neilson J, Sarri G, Cross JH. Diagnosis and management of the epilepsies in adults and children: Summary of updated NICE guidance. BMJ 2012;344:e281.
  23. Steiner TJ, MacGregor EA, Davies PTG. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache. British Association for the Study of Headache 2007;2007:1–52.
  24. Bogduk N. The anatomical basis for cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1992;15(1):67–70.
  25. Carville S, Padhi S, Reason T, Underwood M. Diagnosis and management of headaches in young people and adults: summary of NICE guidance. BMJ 2012;345:e5765 doi:10.1136/bmj.e5765.
  26. Davies MB. How do I diagnose headache? J R Coll Physicians Edinb 2006;36(4):336.
  27. Zagami AS, Goddard SL. Recurrent headaches with visual disturbance. Med J Aust 2012;196(3):178–83.
  28. North American Spine Society (NASS). Diagnosis and treatment of cervical radiculopathy from degenerative disorders. Burr Ridge, Ill: NASS, 2010.
  29. National Institute for Health and Clinical Excellence (NICE). Clinical knowledge summaries: neck pain – cervical radiculopathy. Revised January 2009
  30. 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.
  31. Kuijper B, Beelen A, van der Kallen BF, et al. Interobserver agreement on MRI evaluation of patients with cervical radiculopathy. Clin Radiol 2011;66(1):25–29.
  32. Guzman J, Haldeman S, Carroll LJ, et al. Clinical practice implications of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders: from concepts and findings to recommendations. J Manipulative Physiol Ther 2009;32(2 Suppl):S227–S43.
  33. Reneman L, de Win MM, Booij J, et al. Incidental head and neck findings on MRI in young healthy volunteers: prevalence and clinical implications. Am J Neuroradiol 2012;33(10):1971–74.
  34. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990;72(3):403–8.
  35. Medical PA Criteria Proposal. MRI of cervical spine. ACS Heritage, 2005.
  36. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. J Trauma 2009;67(3):651–59.
  37. Bussières AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults – an evidence-based approach. Part 3: Spinal disorders. J Manipulative Physiol Ther 2008;31(1):33–88.
  38. Daffner RH, Weissman BN, Angtuaco EJ, et al. ACR appropriateness criteria® – suspected spine trauma Reston, VA: American College of Radiology, 2012. [Online publication].
  39. Blackmore CC. Evidence-based imaging evaluation of the cervical spine in trauma. Neuroimaging Clinics of North America 2003;13(2):283–91.
  40. National Institute for Health and Care Excellence (NICE). Clinical knowledge summaries: neck pain – whiplash injury
  41. National Institute for Health and Care Excellence (NICE). Clinical knowledge summaries: neck pain – non-specific
  42. Greenbaum J, Walters N, Levy PD. An evidence-based approach to radiographic assessment of cervical spine injuries in the emergency department. J Emerg Med 2009;36(1):64–71.
  43. Blackham J, Benger J. Clearing the cervical spine in the unconscious trauma patient. Trauma 2011;13(1):65–79.
  44. Kongsted A, Sorensen JS, Andersen H, Keseler B, Jensen TS, Bendix T. Are early MRI findings correlated with long-lasting symptoms following whiplash injury? A prospective trial with 1-year follow-up. Eur Spine J 2008;17(8):996–1005.
  45. Horn EM, Lekovic GP, Feiz-Erfan I, Sonntag VK, Theodore N. Cervical magnetic resonance imaging abnormalities not predictive of cervical spine instability in traumatically injured patients: invited submission from the joint section meeting on disorders of the spine and peripheral nerves. J Neurosurg Spine 2004;1(1):39–42.
  46. Muchow RD, Resnick DK, Abdel MP, Munoz A, Anderson PA. Magnetic resonance imaging (MRI) in the clearance of the cervical spine in blunt trauma: a meta-analysis. J Trauma Acute Care Surg 2008;64(1):179–89.
  47. Schuster R, Waxman K, Sanchez B, et al. Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits. Arch Surg 2005;140(8):762.
  48. New Zealand Guidelines Group. MRI guidelines for the diagnosis of soft tissue knee injuries: internal derangements updated by ACC. Auckland: Accident Compensation Corporation; 2010.
  49. Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res 2007;455:123–33.
  50. Tuite MJ, Daffner RH, Weissman BN, et al. ACR appropriateness criteria® – acute trauma to the knee. J Am Coll Radiol 2012;9(2):96–103.
  51. National Institute for Health and Care Excellence (NICE). Clinical knowledge summaries: knee pain – assessment
  52. Grover M. Evaluating acutely injured patients for internal derangement of the knee. Am Fam Physician 2012;85(3):247–52.
  53. Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a metaanalysis. J Orthop Sports Phys Ther 2006;36(5):267–88.
  54. Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg 2005;87(5):955–62.
  55. Mohan BR, Gosal HS. Reliability of clinical diagnosis in meniscal tears. Int Orthop 2007;31(1):57–60.
  56. Yao K, Haque T. The Ottawa knee rules – a useful clinical decision tool. Aust Fam Physician 2012;41(4):223–24.
  57. Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull 2007;84:5–23.
  58. Boks SS, Vroegindeweij D, Koes BW, Hunink MG, Bierma-Zeinstra SM. Follow-up of posttraumatic ligamentous and meniscal knee lesions detected at MR imaging: systematic review. Radiology 2006;238(3):863–71.
  59. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Republished research: Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Br J Sports Med 2013;47(6):373.
  60. Guermazi A, Niu J, Hayashi D, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ 2012;345:e5339.
  61. Ben-Galim P, Steinberg EL, Amir H, Ash N, Dekel S, Arbel R. Accuracy of magnetic resonance imaging of the knee and unjustified surgery. Clin Orthop Relat Res 2006;447:100–4.
  62. Englund M, Felson DT, Guermazi A, et al. Risk factors for medial meniscal pathology on knee MRI in older US adults: a multicentre prospective cohort study. Ann Rheum Dis 2011;70:1733–39.
  63. Behairy NH, Dorgham MA, Khaled SA. Accuracy of routine magnetic resonance imaging in meniscal and ligamentous injuries of the knee: comparison with arthroscopy. Int Orthop 2009;33(4):961–67.
  64. Oldrini G, Teixeira PG, Chanson A, et al. MRI appearance of the distal insertion of the anterior cruciate ligament of the knee: an additional criterion for ligament ruptures. Skeletal Radiol 2012;41(9):1111–20.
  65. Grant R. Overview: brain tumour diagnosis and management/Royal College of Physicians guidelines. J Neurol Neurosurg Psychiatry 2004;75(Suppl 2):ii18–23.
  66. Headache Classification Committee of the International Headache Society. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 2013;33(9):629–808.
This event attracts CPD points and can be self recorded

Did you know you can now log your CPD with a click of a button?

Create Quick log