ACR Appropriateness Criteria®
Clinical Condition: Chronic Neck Pain
Variant 1: Patient of any age, without or with a history of previous trauma, first study.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, cervical spine, AP, lateral, open mouth |
9 |
|
X-ray, cervical spine, AP, lateral, open mouth, oblique, flexion/extension |
2 |
|
X-ray, cervical spine, flexion/extension only |
2 |
|
X-ray, cervical spine, AP, lateral, open mouth, oblique |
No Consensus |
At discretion of clinician. |
CT, cervical spine |
2 |
|
MRI, cervical spine, routine |
2 |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
|
NUC, bone scan |
2 |
|
Facet injection/arthrography, cervical spine |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: Patients of any age. History of previous malignancy. First study.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, cervical spine, AP, lateral, open mouth |
9 |
|
X-ray, cervical spine, AP, lateral, open mouth, oblique, flexion/extension |
2 |
|
X-ray, cervical spine, flexion/extension only |
2 |
|
X-ray, cervical spine, AP, lateral, open mouth, oblique |
2 |
|
Computed tomography, cervical spine |
2 |
|
MRI, cervical spine, routine |
No Consensus |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
|
NUC, bone scan |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Patients of any age. History of previous neck surgery. First study.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, cervical spine, AP, lateral, open mouth |
9 |
|
X-ray, cervical spine, AP, lateral, open mouth, oblique, flexion/extension |
2 |
|
X-ray, cervical spine, flexion/extension only |
2 |
|
X-ray, cervical spine, AP, lateral, open mouth, oblique |
2 |
|
CT, cervical spine |
2 |
|
MRI, cervical spine, routine |
2 |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
|
NUC, bone scan |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: Radiographs normal. No neurologic findings.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
CT, cervical spine |
2 |
|
MRI, cervical spine, routine |
2 |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
|
NUC, bone scan |
2 |
|
Facet injection/arthrography, cervical spine |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 5: Radiographs normal. Neurologic signs or symptoms present.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MRI, cervical spine, routine |
9 |
|
CT, cervical spine |
2 |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
Indicated if patient cannot undergo MRI. |
NUC, bone scan |
2 |
|
Facet injection/arthrography, cervical spine |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 6: Radiographs show spondylosis. No neurologic findings.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
CT, cervical spine |
2 |
|
MRI, cervical spine, routine |
2 |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
|
NUC, bone scan |
2 |
|
Facet injection/arthrography, cervical spine |
2 |
|
Discography, cervical spine |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 7: Radiographs show spondylosis. Neurologic signs or symptoms present.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MRI, cervical spine, routine |
9 |
|
CT, cervical spine |
2 |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
Indicated if MRI cannot be performed. |
NUC, bone scan |
2 |
|
Facet injection/arthrography, cervical spine |
2 |
|
Discography, cervical spine |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 8: Radiographs show old trauma. No neurologic findings.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
CT, cervical spine |
2 |
|
MRI, cervical spine, routine |
2 |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
|
NUC, bone scan |
2 |
|
Facet injection/arthrography, cervical spine |
2 |
|
Discography, cervical spine |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 9: Radiographs show old trauma. Neurologic signs or symptoms present.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MRI, cervical spine, routine |
9 |
|
CT, cervical spine |
2 |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
Indicated if MRI cannot be performed. |
NUC, bone scan |
2 |
|
Facet injection/arthrography, cervical spine |
2 |
|
Discography, cervical spine |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 10: Radiographs show bone or disc margin destruction.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MRI, cervical spine, routine |
9 |
|
CT, cervical spine |
2 |
|
Myelogram, cervical spine, routine |
2 |
|
Myelogram, cervical spine, with CT |
2 |
|
NUC, bone scan |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Recommendations
Patients of any age with chronic neck pain without or with a history of remote trauma should initially undergo a 3-view (AP, lateral, open mouth) radiographic examination. Oblique radiographs may be performed at the discretion of the attending physician.
Patients with a history of previous malignancy should initially undergo a 3-view radiographic examination. Radionuclide bone scanning should not be the initial procedure of choice.
Patients with a history of neck surgery in the remote past should initially undergo a three view radiographic examination.
Patients with normal radiographs and no neurologic signs or symptoms need no further imaging.
Patients with normal radiographs and neurologic signs or symptoms should undergo MR imaging. If there is a contraindication to the MR examination such as a cardiac pacemaker or severe claustrophobia, CT myelography, preferably using spiral technology and multiplanar reconstruction is recommended.
Patients with radiographic evidence of cervical spondylosis or of previous trauma without neurologic signs or symptoms need no further imaging.
Patients with radiographic evidence of cervical spondylosis or of previous trauma and neurologic signs or symptoms should undergo MR imaging. If there is a contraindication to MR, CT myelography is recommended.
Patients with radiographic evidence of bone or of disc margin destruction should undergo MR imaging. If an epidural abscess is suspected, the examination should be performed with intravenous contrast. CT is indicated only if MR cannot be performed.
Facet injection and arthrography are useful for patients with multilevel disease diagnosed by any imaging modality to identify the specific level(s) producing symptoms.
Discography is not recommended.
Summary
There are no existing guidelines for the evaluation of the patient with chronic neck pain.
All investigators generally agree that plain radiographs should be the initial study performed for evaluating these patients. However, there is no consensus on exactly which views should be obtained for the initial study. The guideline developers recommend a basic 3-view study, with oblique radiographs added at the discretion of the attending physician.
MR imaging should be performed on all patients who have chronic neck pain with neurologic signs, or symptoms, or both. If there is a contraindication to MR, CT myelography is recommended.
The use of additional imaging procedures should be determined by case manner, and the evaluation of patients with chronic neck pain should follow this "tailor-made" approach. Discography is not recommended.
Abbreviations
- AP, anteroposterior
- CT, computed tomography
- MRI, magnetic resonance imaging
- NUC, nuclear medicine