This is the current release of the guideline.

This guideline updates a previous version: 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]

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

Chronic neck pain

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

Patients with chronic neck pain regardless of the etiology (trauma, arthritis, neoplasm)

Utility of radiologic examinations in differential diagnosis

Literature Search Procedure

The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).

The search terms and parameters are manipulated to produce the most relevant, current evidence to address the American College of Radiology Appropriateness Criteria (ACR AC) topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.

The following criteria/limits are used in the searches.

1. Articles that have abstracts available and are concerned with humans.
2. Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 5 years unless the topic author provides other instructions.
3. May restrict the search to Adults only or Pediatrics only.
4. Articles consisting of only summaries or case reports are often excluded from final results.

The search strategy may be revised to improve the output as needed.

The total number of source documents identified as the result of the literature search is not known.

Strength of Evidence Key

Category 1 - The conclusions of the study are valid and strongly supported by study design, analysis and results.

Category 2 - The conclusions of the study are likely valid, but study design does not permit certainty.

Category 3 - The conclusions of the study may be valid but the evidence supporting the conclusions is inconclusive or equivocal.

Category 4 - The conclusions of the study may not be valid because the evidence may not be reliable given the study design or analysis.

The topic author drafts or revises the narrative text summarizing the evidence found in the literature. American College of Radiology (ACR) staff draft an evidence table based on the analysis of the selected literature. These tables rate the strength of the evidence for all articles included in the narrative text.

The expert panel reviews the narrative text, evidence table, and the supporting literature for each of the topic-variant combinations and assigns an appropriateness rating for each procedure listed in the table. Each individual panel member forms his/her own opinion based on his/her interpretation of the available evidence.

More information about the evidence table development process can be found in the American College of Radiology (ACR) Appropriateness Criteria® Evidence Table Development document (see "Availability of Companion Documents" field).

Modified Delphi Technique

The appropriateness ratings for each of the procedures included in the Appropriateness Criteria topics are determined using a modified Delphi methodology. A series of surveys are conducted to elicit each panelist's expert interpretation of the evidence, based on the available data, regarding the appropriateness of an imaging or therapeutic procedure for a specific clinical scenario. American College of Radiology (ACR) staff distributes surveys to the panelists along with the evidence table and narrative. Each panelist interprets the available evidence and rates each procedure. The surveys are completed by panelists without consulting other panelists. The ratings are a scale between 1 and 9, which is further divided into three categories: 1, 2, or 3 is defined as "usually not appropriate"; 4, 5, or 6 is defined as "may be appropriate"; and 7, 8, or 9 is defined as "usually appropriate." Each panel member assigns one rating for each procedure per survey round. The surveys are collected and the results are tabulated, de-identified and redistributed after each round. A maximum of three rounds are conducted. The modified Delphi technique enables each panelist to express individual interpretations of the evidence and his or her expert opinion without excessive bias from fellow panelists in a simple, standardized and economical process.

Consensus among the panel members must be achieved to determine the final rating for each procedure. Consensus is defined as eighty percent (80%) agreement within a rating category. The final rating is determined by the median of all the ratings once consensus has been reached. Up to three rating rounds are conducted to achieve consensus.

If consensus is not reached, the panel is convened by conference call. The strengths and weaknesses of each imaging procedure that has not reached consensus are discussed and a final rating is proposed. If the panelists on the call agree, the rating is accepted as the panel's consensus. The document is circulated to all the panelists to make the final determination. If consensus cannot be reached on the call or when the document is circulated, "No consensus" appears in the rating column and the 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.

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 without or with a history of previous trauma, first study.

Radiologic Procedure	Rating	Comments	RRL*
X-ray cervical spine	9	AP, lateral, open mouth, both obliques.
MRI cervical spine without contrast	2		O
Facet injection/arthrography cervical spine selective nerve root block	2
X-ray myelography cervical spine	2
CT cervical spine without contrast	2
Tc-99m bone scan neck	2
Myelography and post myelography CT cervical spine	2
MRI cervical spine without and with contrast	1		O
CT cervical spine with contrast	1
CT cervical spine without and with contrast	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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

Variant 2: Patient with history of previous malignancy, first study.

Radiologic Procedure	Rating	Comments	RRL*
X-ray cervical spine	9	AP, lateral, open mouth, both obliques.
MRI cervical spine without contrast	2		O
CT cervical spine without contrast	2
Tc-99m bone scan neck	2
MRI cervical spine without and with contrast	1		O
CT cervical spine with contrast	1
CT cervical spine without and with contrast	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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

Variant 3: Patient with history of previous neck surgery, first study.

Radiologic Procedure	Rating	Comments	RRL*
X-ray cervical spine	9	AP, lateral, open mouth, both obliques.
MRI cervical spine without contrast	2		O
MRI cervical spine without and with contrast	2		O
CT cervical spine without contrast	2
CT cervical spine with contrast	2
CT cervical spine without and with contrast	2
Tc-99m bone scan neck	2
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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

Variant 4: Radiographs normal. No neurologic findings.

Radiologic Procedure	Rating	Comments	RRL*
X-ray myelography cervical spine	2
MRI cervical spine without contrast	2		O
CT cervical spine without contrast	2
Tc-99m bone scan neck	2
Facet injection/arthrography cervical spine selective nerve root block	2
Myelography and post myelography CT cervical spine	2
MRI cervical spine without and with contrast	1		O
CT cervical spine with contrast	1
CT cervical spine without and with contrast	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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 Procedure	Rating	Comments	RRL*
MRI cervical spine without contrast	9		O
Myelography and post myelography CT cervical spine	5	If MRI contraindicated.
MRI cervical spine without and with contrast	2		O
X-ray myelography cervical spine	2
CT cervical spine without contrast	2
CT cervical spine with contrast	2
CT cervical spine without and with contrast	2
Tc-99m bone scan neck	2
Facet injection/arthrography cervical spine selective nerve root block	2
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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 Procedure	Rating	Comments	RRL*
X-ray myelography cervical spine	2
CT cervical spine without contrast	2
MRI cervical spine without contrast	2		O
Myelography and post myelography CT cervical spine	2
Tc-99m bone scan neck	2
Facet injection/arthrography cervical spine selective nerve root block	2
MRI cervical spine without and with contrast	1		O
X-ray discography cervical spine	1
CT cervical spine with contrast	1
CT cervical spine without and with contrast	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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 Procedure	Rating	Comments	RRL*
MRI cervical spine without contrast	9		O
Myelography and post myelography CT cervical spine	5	If MRI contraindicated.
X-ray myelography cervical spine	2
CT cervical spine without contrast	2
Tc-99m bone scan neck	2
Facet injection/arthrography cervical spine selective nerve root block	2
MRI cervical spine without and with contrast	1		O
X-ray discography cervical spine	1
CT cervical spine with contrast	1
CT cervical spine without and with contrast	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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 Procedure	Rating	Comments	RRL*
X-ray myelography cervical spine	2
CT cervical spine without contrast	2
MRI cervical spine without contrast	2		O
Myelography and post myelography CT cervical spine	2
Tc-99m bone scan neck	2
Facet injection/arthrography cervical spine selective nerve root block	2
MRI cervical spine without and with contrast	1		O
X-ray discography cervical spine	1
CT cervical spine with contrast	1
CT cervical spine without and with contrast	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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 Procedure	Rating	Comments	RRL*
MRI cervical spine without contrast	9		O
Myelography and post myelography CT cervical spine	5	If MRI contraindicated.
X-ray myelography cervical spine	2
CT cervical spine without contrast	2
Tc-99m bone scan neck	2
Facet injection/arthrography cervical spine selective nerve root block	2
MRI cervical spine without and with contrast	1		O
X-ray discography cervical spine	1
CT cervical spine with contrast	1
CT cervical spine without and with contrast	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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 Procedure	Rating	Comments	RRL*
MRI cervical spine without contrast	9		O
MRI cervical spine without and with contrast	9		O
CT cervical spine with contrast	5	CT with contrast should be performed if MRI is unavailable or cannot be performed for any suspected disc space infection.
X-ray myelography cervical spine	2
CT cervical spine without contrast	2
CT cervical spine without and with contrast	2
Myelography and post myelography CT cervical spine	2
TC-99m bone scan neck	2
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

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

Summary

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 radiographic examination (anteroposterior [AP], lateral, open mouth, both obliques).
• Patients with a history of previous malignancy should initially undergo a 5-view radiographic examination. Radionuclide bone scanning should not be the initial procedure of choice (Spitzer et al., 1995).
• Patients with a history of neck surgery in the remote past should initially undergo a 5-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 cervical magnetic resonance imaging (MRI) that includes the craniocervical junction (CCJ) and the upper thoracic region (Kaale et al., 2005; Boutin, Steinbach, & Finnesey, 2000; Chen et al., 2003). If there is a contraindication to the MRI examination such as a cardiac pacemaker or severe claustrophobia, computed tomography (CT) myelography with multiplanar reconstruction is recommended.
• Patients with whiplash-associated disorders (WAD) should undergo MRI looking for disc herniations, spur encroachment of the vertebral canal, or ligament abnormalities of the lower cervical region. The value of MRI of the CCJ in patients with WAD is controversial (Vetti et al., 2009; Johansson, 2006; Krakenes & Kaale, 2006; Ichihara et al., 2009; Kongsted et al., 2008; Myran et al., 2008).
• Patients with chronic neck pain from whiplash should undergo imaging following the guidelines above.
• 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. 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; Nordin et al., 2008).
• 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.

Abbreviations

• AP, anteroposterior
• CT, computed tomography
• MRI, magnetic resonance imaging
• Tc, technetium

Relative Radiation Level Designations

Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
	<0.1 mSv	<0.03 mSv
	0.1-1 mSv	0.03-0.3 mSv
	1-10 mSv	0.3-3 mSv
	10-30 mSv	3-10 mSv
	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as "Varies".

Algorithms were not developed from criteria guidelines.

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) Information

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. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults (see Table in the "Major Recommendations" field). 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).

Contraindications to magnetic resonance imaging (MRI) examination include presence of a cardiac pacemaker or severe claustrophobia.

The 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 examinations 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.

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

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 (Principal Author; Panel Chair); Barbara N. Weissman, MD (Panel Vice-Chair); Peter D. Angevine, MD, MPH; Erin Arnold, MD; Laura Bancroft, MD; D. Lee Bennett, MD, MA; Judy S. Blebea, MD; Michael A. Bruno, MD; Ian Blair Fries, MD; Langston Holly, MD; Jon A. Jacobson, MD; Jonathan S. Luchs, MD; William B. Morrison, MD; Charles S. Resnik, MD; Catherine C. Roberts, MD; Mark E. Schweitzer, MD; Leanne L. Seeger, MD; David W. Stoller, MD; Mihra S. Taljanovic, MD; James N. Wise, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: 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]

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

Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site.

Print copies: Available from the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

The following are available:

• ACR Appropriateness Criteria®. Overview. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site.
• ACR Appropriateness Criteria®. Literature search process. Reston (VA): American College of Radiology; 1 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.
• ACR Appropriateness Criteria®. Evidence table development. Reston (VA): American College of Radiology; 4 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.
• ACR Appropriateness Criteria®. Radiation dose assessment introduction. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.

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. This NGC summary was updated by ECRI Institute on December 6, 2010.

Instructions for downloading, use, and reproduction of the American College of Radiology (ACR) Appropriateness Criteria® may be found on the ACR Web site .