Value of cervical spine radiographs as a screening tool

Comparison of Clinical Guidelines for Authorization of MRI in the Evaluation of Neck Pain and Cervical Radiculopathy in the United States

The American College of Radiology has published appropriateness criteria to help guide when to use MRI. Many health insurance carriers use proprietary clinical guidelines for prior authorization of imaging studies. The purpose of this study was to compare the specific criteria in those guidelines, for neck pain both with and without radicular symptoms. An online search was conducted to identify the guidelines for authorization of cervical spine MRI used by the largest commercial insurance carriers in the United States by market share. Guidelines were analyzed for neck pain with and without radiculopathy. Cervical trauma, myelopathy, infection, neoplasm, multiple sclerosis, and postprocedural care were excluded. The remaining criteria were broken down into categories including clinical symptoms, conservative therapy, other required radiologic studies, and clinical re-evaluation. Individual criteria within each of the categories were compared. After evaluation of the top 56 insurance companies in the United States, 30 companies using four main utilization management companies remained for analysis. After direct comparison of publicly available guidelines documents, notable discrepancies existed between the four companies in all subcategories analyzed. In addition, varying amounts of evidence-based literature was identified to support criteria requirements for prior authorization. This study demonstrates that the guidelines used by private health insurance companies for cervical MRI authorization in the setting of neck pain with and without cervical radiculopathy are inconsistent and use objective measures that have not been validated in the literature. We think this warrants additional scrutiny and investigation.

Automated detection of cervical ossification of the posterior longitudinal ligament in plain lateral radiographs of the cervical spine using a convolutional neural network

Cervical ossification of the posterior longitudinal ligament (OPLL) is a contributing factor to spinal cord injury or trauma-induced myelopathy in the elderly. To reduce the incidence of these traumas, it is essential to diagnose OPLL at an early stage and to educate patients how to prevent falls. We thus evaluated the ability of our convolutional neural network (CNN) to differentially diagnose cervical spondylosis and cervical OPLL. We enrolled 250 patients with cervical spondylosis, 250 patients with cervical OPLL, and 180 radiographically normal controls. We evaluated the ability of our CNN model to distinguish cervical spondylosis, cervical OPLL, and controls, and the diagnostic accuracy was compared to that of 5 board-certified spine surgeons. The accuracy, average recall, precision, and F1 score of the CNN for classification of lateral cervical spine radiographs were 0.86, 0.86, 0.87, and 0.87, respectively. The accuracy was higher for CNN compared to any expert spine surgeon, and was statistically equal to 4 of the 5 experts and significantly higher than that of 1 expert. We demonstrated that the performance of the CNN was equal or superior to that of spine surgeons.

Imaging Appropriateness for Neck Pain

Imaging of neck pain contributes to a significant proportion of health care costs and is expected to increase with current practices that heavily use radiologic studies as a diagnostic tool. Though consensus guidelines are available to assist physicians in selection of appropriate imaging examinations for neck pain, it is unclear if current ordering practices reflect their use and understanding. To investigate this, we analyzed the number and types of imaging examinations performed for neck pain at a university medical center over the past year. Current trends at our institution suggest that clinicians use consensus imaging guidelines, but there is still controversy in the cervical spine for when not to image. To promote appropriate imaging utilization, we developed an algorithm to guide imaging of neck pain, based upon clinical presentation, referral patterns for neck pain, and a review of the literature.

Cervical Discs as a Source of Neck Pain. An Analysis of the Evidence

OBJECTIVESBACKGROUND

Objectives To determine the extent and strength of evidence that supports the belief that cervical intervertebral discs are a source of neck pain.

DESIGN

Design The evidence from anatomical, laboratory, experimental, diagnostic, and treatment studies was summarized and analyzed for concept validity, face validity, content validity, and construct validity.

RESULTS

Results Evidence from basic sciences shows that cervical discs have a nociceptive innervation, and experimental studies show that they are capable of producing neck pain. Disc stimulation has been developed as a diagnostic test but has rarely been used in a disciplined fashion. The prevalence of cervical disc pain has not been properly established but appears to be low. No treatment has been established that reliably achieves complete relief of neck pain in substantial proportions of patients.

CONCLUSIONS

Conclusions Basic science evidence supports the concept of cervical disc pain, but epidemiologic and clinical evidence to vindicate the clinical application of the concept is poor or lacking.

Identifying and treating the causes of neck pain

Future studies are needed to further understand the pathophysiology of mechanical neck pain. Robust scientific evidence is sparse on which noninvasive treatments are the most beneficial and how to better select patients for particular noninvasive or invasive treatments.

The significance of facet joint cross-sectional area on magnetic resonance imaging in relationship to cervical degenerative spondylolisthesis

BACKGROUND CONTEXT

Characteristic changes of the facet joints, including synovial cysts, facet joint hypertrophy, and facet joint effusions, on magnetic resonance imaging (MRI) and computed tomography have been associated with lumbar degenerative spondylolisthesis. The cervical facets have not been examined for associations with cervical degenerative spondylolisthesis similar to those seen in the lumbar spine.

PURPOSE

To define abnormalities of the facet joints seen on supine MRI that correlate with cervical spondylolisthesis seen on upright radiographs.

STUDY DESIGN

Retrospective radiographic review of consecutive patients with a universally applied standard.

PATIENT SAMPLE

A total of 204 consecutive patients from a single institution, with both an MRI and upright radiographs, were reviewed.

OUTCOME MEASURES

Sagittal plane displacement on upright lateral radiographs was compared with MRI. The total area of the facet joint and the amount of facet joint asymmetry were measured on an axial MRI.

METHODS

The data were analyzed to determine a significant association between the cervical degenerative spondylolisthesis and the following: facet joint asymmetry, increased total area of the facet joint, and age.

RESULTS

Degenerative spondylolisthesis was seen in 26 patients at C3-C4 and in 27 patients at C4-C5. Upright radiographs identified significantly more degenerative spondylolisthesis than MRIs at levels C3-C4 and C4-C5, 26 versus 6 (p<.001) at C3-C4 and 27 versus 11 (p<.001) at C4-C5. Patients with degenerative spondylolisthesis were more likely to be older, have a larger total facet area, and more facet asymmetry at C3-C4 and C4-C5 (p<.05).

CONCLUSIONS

Supine MRIs underestimate sagittal displacement compared with upright lateral radiographs. Asymmetric facet hypertrophy at C3-C4 and C4-C5 is associated with degenerative spondylolisthesis on upright lateral films even in the absence of anterolisthesis on supine MRIs.

The anatomy and pathophysiology of neck pain

Neck pain should not, and must not, be confused with cervical radicular pain. Equating the two conditions, or confusing them, results in misdiagnosis, inappropriate investigations, and inappropriate treatment that is destined to fail. So critical is the difference that pedagogically it is unwise to include the two topics in the same book, let alone the same article. However, traditions and expectations are hard to break. In deference to habit, this article addresses both entities, but does so by underplaying cervical radicular pain so as to retain the emphasis on neck pain.

Utility of flexion-extension radiographs in evaluating the degenerative cervical spine

STUDY DESIGN

Retrospective cohort of 258 consecutive patients.

OBJECTIVE

The purpose of this study is to determine the: (1) percentage of flexion-extension radiographs that revealed pathology not appreciated on neutral radiographs in the nontrauma population, and (2) frequency that these views led to a change in the management of these patients.

SUMMARY OF BACKGROUND DATA

The utility of flexion-extension radiographs in the evaluation of the spine trauma or preoperative patient is well accepted, but the role of dynamic radiographs in the degenerative population is not well defined.

METHODS

Consecutive patients presenting with axial cervical, upper extremity radicular, or myelopathic symptoms underwent upright anteroposterior, neutral lateral, and flexion-extension lateral radiographs. Patients with recent trauma, rheumatoid arthritis, prior cervical fracture, prior cervical surgery, inadequate radiographs, or congenital anomalies were excluded. Three observers reviewed all radiographs after determining the best measurement method by a priori analysis of interobserver reliability.

RESULTS

Listhesis was observed on 23 of the neutral lateral images; 6 of these were found to have changes between flexion and extension (2-4 mm). Two patients (1%) had spondylolisthesis on flexion-extension radiographs not visualized on neutral lateral radiographs. A subsequent review of these patients' charts revealed no change in management based on these findings.

CONCLUSIONS

Cervical flexion-extension radiographs are a method of assessing potential instability. In the degenerative population studied here, 1% had spondylolisthesis noted only on the flexion-extension images, and 3% had a change in spondylolisthesis. None of these, however, led to a changes in clinical management. These data, in conjunction with the extra cost and radiation exposure associated with additional views, led us to no longer regard dynamic radiographs as a useful part of the initial imaging for the patient with degenerative cervical conditions.

Diagnostic Blocks

Malingering is not a diagnosis. It is a behavior for which there are no established diagnostic criteria. Guidelines have been published according to which malingering might be suspected, but those guidelines do not discriminate between patients who are malingering and ones with genuine sources of chronic pain. In such patients, malingering cannot be proven, but it can be refuted if a genuine source of pain can be established. In patients with no apparent cause of pain, the source of that pain can be established using controlled diagnostic blocks. A positive response to diagnostic blocks demonstrates that the complaint of pain is genuine and, by implication, refutes any contention that the patient is malingering. When positive, diagnostic blocks provide objective data by which disputes based on opinion can be resolved, as to whether a patient is malingering or not. Negative responses do not exclude a genuine complaint of pain, for patients may have a source of pain that is not amenable to testing with diagnostic blocks. Diagnostic blocks have proved particularly useful in the investigation of spinal pain for which the cause is not evident on conventional medical imaging. They can also confirm or refute purported mechanisms of certain clinical features in complex regional pain syndromes.

The anatomy and pathophysiology of neck pain

This article carefully itemizes the various anatomic structures that can evoke neck pain, putting in perspective what clinicians know, what they assume, and what they need to understand better about neck pain and pain referred from the neck. The critique of many of the accepted entities in the differential diagnosis of neck pain is crucial to an understanding of the causes of neck pain and an ability to implement appropriate therapies.

Regional musculoskeletal conditions: neck pain

Neck pain is second only to low back pain as the most common musculoskeletal disorder in population surveys and primary care, and, like low back pain, it poses a significant health and economic burden, being a frequent source of disability. While most individuals with acute neck pain do not seek health care, those that do account for a disproportionate amount of health care costs. Furthermore, in the setting of the whiplash syndrome, neck pain accounts for significant costs to society in terms of insurance and litigation, and days lost from work. Much neck pain is not attributable to a specific disease or disorder and is labelled as 'soft-tissue' rheumatism or muscular/mechanical/postural neck pain. Most chronic neck pain is attributed to whiplash injury, another enigmatic diagnosis. Despite decades of research and posturing to explain chronic neck pain on the basis of a specific disease or injury, and despite increasingly sophisticated radiological assessment, little advance has been made in either achieving a specific structural diagnosis or, more importantly, in reducing the health and economic burden of chronic neck pain. There is some evidence, however, that measures which address the psychosocial factors that promote pain chronicity, and shift the patient's view away from injury and disease to more benign perspectives on their condition, may be helpful. This chapter considers briefly the magnitude of the neck pain problem, our limitations in understanding it from a traditional medical perspective, and suggestions for therapeutic and societal approaches that appear more likely to be helpful.

Is the sagittal configuration of the cervical spine changed in women with chronic whiplash syndrome? A comparative computer-assisted radiographic assessment

OBJECTIVE

To reveal whether women with chronic whiplash-associated disorder (WAD) symptoms, grade I-II, demonstrate regional and/or segmental radiographic signs of altered cervical lordosis.

DESIGN

Case-control study.

SETTING

Radiography department at a university hospital.

PARTICIPANTS

Three age-balanced groups comprising 120 women. The case group included women with chronic whiplash syndrome (n = 41), and the control group included women with chronic insidious onset neck pain (n = 39) and an asymptomatic group (n = 40), who were given baseline data. The sample was referred from informed doctors and physiotherapists.

INTERVENTION

The women sat in a standardized sitting position and radiographs were taken in a lateral position with fluoroscopic control for alignment.

OUTCOME MEASURES

Two distinct measurements were taken; 1 of the angles of the upper and lower cervical curvatures, respectively, and 1 of the angles between the inferior borders of each pair of vertebrae in the lower cervical spine. The 3 groups were compared on the ratio of the lower to upper cervical spine angles and on the mean angular values for each segment in the cervical spine.

RESULTS

The whiplash group showed a decreased ratio between the lower versus upper cervical spine but comparisons between groups were not statistically significant. The whiplash group was in a significantly more flexed position at the C4-C5 level compared with the asymptomatic group (P =.007). The reliability measures have to be strengthened to render these results definitely conclusive.

CONCLUSION

The whiplash group exhibited a different configuration of cervical lordosis. This is clinically important and needs to be studied more closely.

Cervical SNAGs: a biomechanical analysis

A sustained natural apophyseal glide (SNAG) is a mobilization technique commonly used in the treatment of painful movement restrictions of the cervical spine. In the manual therapy literature, the biological basis and empirical efficacy of cervical SNAGs have received scant attention. In particular, an examination of their potential biological basis in order to stimulate informed discussion seems overdue. This paper discusses the likely biomechanical effects of both the accessory and physiological movement components of a unilateral cervical SNAG applied ipsilateral to the side of pain when treating painfully restricted cervical rotation. The use of flexion and extension SNAGS, and rotation SNAGS performed contralateral to the side of pain are not considered. Although a cervical SNAG may clinically be able to resolve painfully restricted cervical spine movement, it is difficult to explain biomechanically why a technique which first distracts (opens) and then compresses (closes) the zygapophyseal joint ipsilateral to the side of pain, and perhaps slightly distracts the uncovertebral cleft, would be superior to a technique which distracts the articular surfaces with both accessory and physiological movement components. Therefore, the reported clinical efficacy of cervical SNAGs cannot be explained purely on the basis of the resultant biomechanical effects in the cervical spine.

Cervical spine injuries among submersion victims

BACKGROUND

Submersion victims are frequently considered at high risk for cervical spine (C-spine) injury regardless of whether they sustain a traumatic injury. We hypothesized that C-spine injury is unlikely in submersion victims who do not sustain high-impact injuries.

METHODS

The study was a cohort study of all people who submerged between January 1974 and July 1996 and received medical care or were seen by the medical examiner in King, Pierce, and Snohomish counties in Washington State.

RESULTS

Eleven (0.5%) of 2,244 submersion victims had C-spine injuries. All 11 had submerged in open bodies of water; had clinical signs of serious injury; and had a history of diving, motorized vehicle crash, or fall from height. No C-spine injuries occurred in 880 low-impact submersions.

CONCLUSION

Submersion victims are at risk for C-spine injury only if they have also sustained a traumatic injury. Routine C-spine immobilization does not appear to be warranted solely on the basis of a history of submersion.

Correlation between a positive Hoffmann's reflex and cervical pathology in asymptomatic individuals

STUDY DESIGN

Asymptomatic patients with a positive Hoffmann's reflex were prospectively studied with cervical radiographs and magnetic resonance imaging.

OBJECTIVES

To determine a relationship between a positive Hoffmann's reflex and cervical pathology in asymptomatic patients and to evaluate if further work-up was necessary in this patient population.

SUMMARY OF BACKGROUND DATA

A positive Hoffmann's reflex usually implies an upper motor neuron lesion from spinal cord compression. Although this reflex is commonly tested, the significance of this reflex in asymptomatic patients is not known.

METHODS

Sixteen patients without cervical pain or radiculopathy and a positive Hoffmann's reflex were prospectively studied with cervical radiographs and magnetic resonance imaging. Positive findings were correlated with a detailed neurologic examination.

RESULTS

All 16 patients were asymptomatic. Fourteen patients (87.5%) demonstrated spondylosis on cervical radiographs. The magnetic resonance imaging studies showed pathologic findings in all 16 patients. Fifteen patients (94%) had cervical involvement with cord compression from a herniated nucleus pulposus. The remaining patient had a T5-T6 thoracic disc with resultant compression. No treatment was instituted, and the clinical course of each patient was not affected.

CONCLUSIONS

Although the presence of cervical cord impingement is extremely high in these patients, no treatment was rendered specifically to address the cervical pathology. Therefore, the presence of a positive Hoffmann's reflex in asymptomatic patients strongly suggests underlying cervical pathology, but it does not warrant further evaluation with either cervical radiographs or magnetic resonance imaging since the management and clinical course are not affected by positive studies.