For patients presenting with neck pain accompanied by neurological symptoms, the recommended imaging study is magnetic resonance imaging (MRI) of the cervical spine. MRI is preferred to confirm the diagnosis, assess nerve root compression, and guide further management including consideration of invasive procedures or surgery if indicated NICE CKS.
If cervical radiculopathy symptoms have persisted for 4–6 weeks or more, or if objective neurological signs such as progressive motor weakness or sensory loss are present, urgent referral for MRI is advised to evaluate the extent of nerve root involvement and spinal cord status NICE CKS.
In cases where MRI is contraindicated or unavailable, computed tomography (CT) scanning is the alternative imaging modality to assess spinal pathology NICE NG234. CT may also be used following trauma or when bony injury is suspected, especially if neurological deficits are present NICE NG41.
Plain X-rays are generally not recommended for diagnosing cervical radiculopathy or spinal metastases but may be considered in children under 16 when MRI is not indicated and clinical suspicion remains NICE NG234,NICE NG41.
For patients with suspected spinal metastases or metastatic spinal cord compression presenting with neurological symptoms, urgent MRI of the whole spine including sagittal T1, STIR, and T2 sequences is essential to identify lesions and cord compression NICE NG234.
In the context of neck pain with neurological symptoms, imaging should be guided by clinical findings such as severity, progression of neurological deficits, and presence of red flags indicating serious spinal pathology NICE CKS,NICE NG232.
Recent literature supports the use of MRI as the most appropriate imaging modality for neck pain with neurological symptoms due to its superior soft tissue contrast and ability to detect nerve root and spinal cord involvement Costello et al. 2020. CT is reserved for cases where MRI is contraindicated or to evaluate bony structures in trauma Cohen 2015.
Key References
- CKS - Radiculopathy (cervical) - neck pain
- CKS - Cervical radiculopathy - neck pain
- CKS - Neck pain - cervical radiculopathy
- NG234 - Spinal metastases and metastatic spinal cord compression
- NG232 - Head injury: assessment and early management
- NG41 - Spinal injury: assessment and initial management
- (Cohen, 2015): Epidemiology, diagnosis, and treatment of neck pain.
- (Costello et al., 2020): Imaging Appropriateness for Neck Pain.