• 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.

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.

• 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.