• Daffner RH, Weissman BN, Bennett DL, Blebea JS, Jacobson JA, Morrison WB, Resnik CS, Roberts CC, Rubin DA, Schweitzer ME, Seeger LL, Taljanovic M, Wise JN, Payne WK, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic neck pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 7 p. [27 references]

This is the current release of the guideline.

This guideline updates a previous version: Daffner RH, Dalinka MK, Alazraki NP, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Pavlov H, Rubin DA, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Chronic neck pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 7 p. [21 references]

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Chronic neck pain

Diagnosis
Evaluation

Family Practice
Internal Medicine
Neurology
Nuclear Medicine
Orthopedic Surgery
Radiology

Health Plans
Hospitals
Managed Care Organizations
Physicians
Utilization Management

To evaluate the appropriateness of initial radiologic examinations for patients with chronic neck pain

Patients with chronic neck pain

1. X-ray (anteroposterior [AP], lateral, open mouth, both obliques)
2. X-ray myelography
3. Computed tomography (CT) without contrast
4. Magnetic resonance imaging (MRI) without contrast
5. Myelography and post myelography CT
6. Nuclear medicine (NUC), technetium (Tc)-99m bone scan
7. Invasive (INV), facet injection/arthrography, selective nerve root block

Note: X-ray discography was considered but not recommended.

Utility of radiologic examinations in differential diagnosis

Searches of Electronic Databases

The guideline developer performed literature searches of peer-reviewed medical journals, and the major applicable articles were identified and collected.

Not stated

Weighting According to a Rating Scheme (Scheme Not Given)

Not stated

Systematic Review with Evidence Tables

One or two topic leaders within a panel assume the responsibility of developing an evidence table for each clinical condition, based on analysis of the current literature. These tables serve as a basis for developing a narrative specific to each clinical condition.

Expert Consensus (Delphi)

Since data available from existing scientific studies are usually insufficient for meta-analysis, broad-based consensus techniques are needed for reaching agreement in the formulation of the appropriateness criteria. The American College of Radiology (ACR) Appropriateness Criteria panels use a modified Delphi technique to arrive at consensus. Serial surveys are conducted by distributing questionnaires to consolidate expert opinions within each panel. These questionnaires are distributed to the participants along with the evidence table and narrative as developed by the topic leader(s). Questionnaires are completed by the participants in their own professional setting without influence of the other members. Voting is conducted using a scoring system from 1 to 9, indicating the least to the most appropriate imaging examination or therapeutic procedure. The survey results are collected, tabulated in anonymous fashion, and redistributed after each round. A maximum of three rounds is conducted and opinions are unified to the highest degree possible. Eighty percent agreement is considered a consensus. This modified Delphi technique enables individual, unbiased expression, is economical, easy to understand, and relatively simple to conduct.

If consensus cannot be reached by this Delphi technique, the panel is convened and group consensus techniques are utilized. The strengths and weaknesses of each test or procedure are discussed and consensus reached whenever possible. If "No consensus" appears in the rating column, reasons for this decision are added to the comment sections.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

ACR Appropriateness Criteria®

Clinical Condition: Chronic Neck Pain

Variant 1: Patient of any age, without or with a history of previous trauma, first study.

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.

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.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 4: Radiographs normal. No neurologic findings.

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.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 6: Radiographs show spondylosis. No neurologic findings.

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.

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.

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.

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.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Recommendations

These guidelines apply to imaging of patients with chronic neck pain regardless of the etiology (trauma, arthritis, neoplasm):

• Patients of any age with chronic neck pain without or with a history of remote trauma should initially undergo a 5-view (anteroposterior [AP], lateral, open mouth, both obliques) radiographic examination.
• 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. (Barton et al., 1993).
• Patients with a history of neck surgery in the remote past should initially undergo a 3-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 magnetic resonance imaging (MRI). (Anderberg et al., 2004; Arana et al., 2004; Boutin, Steinbach, & Finnesey, 2000; Chen et al., 2003; Kaale et al., 2005). If there is a contraindication to the MRI examination such as a cardiac pacemaker or severe claustrophobia, computed tomography (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 MRI. (Anderberg et al., 2004; Arana et al., 2004; Boutin, Steinbach, & Finnesey, 2000; Chen et al., 2003; Kaale et al., 2005). If there is a contraindication to MRI, CT myelography is recommended.
• Patients with radiographic evidence of bone or disc margin destruction should undergo MRI. If an epidural abscess is suspected, the examination should be performed with intravenous contrast. CT is indicated only if MRI 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. (Aprill & Bogduk, 1992; Bogduk & Aprill, 1993).
• Patients with chronic neck pain from "whiplash" should undergo imaging following the guidelines above.

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.

MRI should be performed on all patients who have chronic neck pain with neurologic signs or symptoms, or both. If there is a contraindication to MRI, CT myelography is recommended.

The use of additional imaging procedures should be determined in a case-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
• INV, invasive
• Med, medium
• MRI, magnetic resonance imaging
• NUC, nuclear medicine
• Tc, technetium

None provided

The recommendations are based on analysis of the current literature and expert panel consensus.

Selection of appropriate radiologic imaging procedures for diagnosis and evaluation of patients with chronic neck pain

Relative Radiation Level (RRL)

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Additional information regarding radiation dose assessment for imaging examinations can be found in the American College of Radiology (ACR) Appropriateness Criteria® Radiation Dose Assessment Introduction document (see "Availability of Companion Documents" field).

An American College of Radiology (ACR) Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those exams generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

An implementation strategy was not provided.

Living with Illness

Effectiveness

• Daffner RH, Weissman BN, Bennett DL, Blebea JS, Jacobson JA, Morrison WB, Resnik CS, Roberts CC, Rubin DA, Schweitzer ME, Seeger LL, Taljanovic M, Wise JN, Payne WK, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic neck pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 7 p. [27 references]

Not applicable: The guideline was not adapted from another source.

1998 (revised 2008)

American College of Radiology - Medical Specialty Society

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Musculoskeletal Imaging

Panel Members: Richard H. Daffner, MD; Barbara N. Weissman, MD; D. Lee Bennett, MD; Judy S. Blebea, MD; Jon A. Jacobson, MD; William B. Morrison, MD; Charles S. Resnik, MD; Catherine C. Roberts, MD; David A. Rubin, MD; Mark E. Schweitzer, MD; Leanne L. Seeger, MD; Mihra Taljanovic, MD; James N. Wise, MD; William K. Payne, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Daffner RH, Dalinka MK, Alazraki NP, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Pavlov H, Rubin DA, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Chronic neck pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 7 p. [21 references]

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

None available

This summary was completed by ECRI on May 6, 2001. The information was verified by the guideline developer as of June 29, 2001. This NGC summary was updated by ECRI on January 27, 2006. This NGC summary was updated by ECRI Institute on June 30, 2009.