MRI Cervical Spine - CAM 741

(Combination requests at end of the document)

For evaluation of neurologic deficits
(Acharya, 2019; ACR, 2013; NASS, 2010; Stolper, 2017; Teoli, 2021)

  • With any of the following new neurological deficits documented on physical exam
    • Extremity muscular weakness
    • Pathologic (e.g., Babinski, Lhermitte's sign, Chaddock Sign, Hoffman’s) or abnormal reflexes
    • Absent/decreased sensory changes along a particular cervical dermatome (nerve distribution): pin prick, touch, vibration, proprioception, or temperature
    • Upper or lower extremity increase muscle tone/spasticity
    • New onset bowel or bladder dysfunction (e.g., retention or incontinence)
    • Gait abnormalities (see Table 1 for more details)
  • Suspected cord compression with any neurological deficits as listed above

For evaluation of neck pain with any of the following
(Allegri, 2016; AANSCNS, 2014; Jarvik, 2015)

  • With new or worsening objective neurologic deficits on exam
  • Failure of conservative treatment* for at least six (6) weeks within the last six (6) months (ACR, 2013; Eubanks, 2010)
  • With progression or worsening of symptoms during the course of conservative treatment*
  • With an abnormal electromyography (EMG) or nerve conduction study (if performed) indicating a cervical radiculopathy. (EMG is not recommended to determine the cause of axial lumbar, thoracic, or cervical spine pain (NASS, 2013))
  • Isolated neck pain in pediatric population (ACR, 2016) – conservative care not required if red flags present (see combination request below thoracic and lumbar spine may also be indicated)
    • Red flags that prompt imaging should include the presence of the following: age 5 or younger, constant pain, pain lasting >4 weeks, abnormal neurologic examination, early morning stiffness and/or gelling; night pain that prevents or disrupts sleep; radicular pain; fever; weight loss; malaise; postural changes (e.g., kyphosis or scoliosis); and limp (orrefusal to walk in a younger child <5yo) AND initial radiographs have been performed (Bernstein, 2007; Feldman, 2006)
    • Neck pain associated with suspected inflammation, infection, or malignancy 

As part of initial post-operative/procedural evaluation ("CT best examination to assess for hardware complication, extent of fusion" [ACR, 2015; Rao, 2018] and MRI for cord, nerve root compression, disc pathology or post-op infection)

  • For preoperative evaluation/planning
  • CSF leak highly suspected and supported by patient history and/or physical exam findings (leak (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula))
  • A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery in the last 6 months. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested (routine surveillance post-op not indicated without symptoms)
  • Changing neurologic status post-operatively
  • Surgical infection as evidenced by signs/symptoms, laboratory, or prior imaging findings
  • Residual or new neurological deficits or symptoms (Rao, 2018); see neurological deficit section above
  • When combo requests are submitted (e.g., MRI and CT of the spine), the office notes should clearly document the need for both studies to be done simultaneously (e.g., the need for both soft tissue and bony anatomy is required) (Fisher, 2013)
    • Combination requests where both cervical spine CT and MRI cervical spine are both approvable (not an all-inclusive list): 
      • OPLL (Ossification of posterior longitudinal ligament)(Choi, 2011)
      • Pathologic or complex fractures
      • Malignant process of spine with both bony and soft tissue involvement
      • Unstable craniocervical junction
      • Clearly documented indication for bony and soft tissue abnormality where assessment will change management (i.e., surgical approach) for the patient

For evaluation of suspected myelopathy
(ACR, 2015; Behrbalk, 2013; Davies, 2018; Sarbu, 2010; Vilaca, 2016)

  • Does NOT require conservative care
  • Progressive symptoms including hand clumsiness, worsening handwriting, difficulty with grasping and holding objects, diffuse numbness in the hands, pins and needles sensation, increasing difficulty with balance and ambulation
  • Any of the neurological deficits as noted above

For evaluation of known or suspected multiple sclerosis (MS)
(ACR, 2015; CSMS, 2018; Filippi, 2016; Kaunzner, 2017)

  • Evidence of MS on recent baseline Brain MRI
  • Suspected or known pediatric demyelinating diseases (MS/ADEM)
  • Suspected or known MS with new or changing symptoms consistent with cervical spinal cord disease (focal neurologic deficit or clinical sign, e.g., Lhermitte sign)
  • Combination studies MS (Barakat, 2015)
    • Cervical and/or Thoracic MRI for evaluation of suspected multiple sclerosis (MS) when Brain MRI does not fulfill diagnostic criteria (Filippi, 2016)
    • Cervical and/or Thoracic MRI with suspected transverse myelitis - with appropriate clinical symptoms (e.g., bilateral weakness, sensory disturbance, and autonomic dysfunction which typically evolve over hours or days)
    • Brain MRI with Cervical and/or Thoracic MRI for evaluation of neuromyelitis optica spectrum disorders (recurrent or bilateral optic neuritis; recurrent transverse myelitis) (Wingerchuk, 2015)
    • Known MS, entire CNS axis (Brain, and/or Cervical and/or Thoracic spine) is approvable prior to the initiation or change of disease modification treatments and assess disease burden (to establish a new baseline)
    • Follow-up scans, including brain and spine imaging if patients have known spine disease: 
        • 6 – 12 months after starting/changing treatment
        • Every 1 – 2 years while on disease-modifying therapy to assess for subclinical disease activity, less frequently when stable for 2 – 3 years

For evaluation of trauma or acute injury
(ACR, 2018)

  • Presents with any of the following neurological deficits noted above
  • With progression or worsening of symptoms during the course of conservative treatment*
  • History of underlying spinal abnormalities (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis), both MRI and CT are approvable (ACR, 2021; Koivikko, 2008; Taljanovic, 2009)
  • When the patient is clinically unevaluable or there are preliminary imaging findings (x-ray or CT) needing further evaluation
  • When office notes specify the patient meets NEXUS (National Emergency X-Radiography Utilization Study) or CCR (Canadian Cervical Rules) criteria for imaging:
    • CT for initial imaging
    • MRI when suspect spinal cord or nerve root injury or when patient is obtunded, and CT is negative
    • CT or MRI for treatment planning of unstable spine

("MRI and CT provide complementary information. When indicated it is appropriate to perform both examinations") (ACR, 2018)

For evaluation of known or new compression fractures with worsening neck pain
(ACR, 2018)

  • With history of malignancy
    • To aid in differentiation of benign osteoporotic fractures from metastatic disease
      • A follow-up MRI in 6 – 8 weeks after initial MRI when initial imaging cannot decipher (indeterminate) benign osteoporotic fracture from metastatic disease (Kumar, 2016)
  • With an associated new focal neurologic deficit as above (Alexandru, 2012)
  • Prior to a planned surgery/intervention or if the results of the MRI will change management 

For evaluation of tumor, cancer, or metastasis with any of the following (MRI is usually the preferred study, but CT may be needed to further characterize solitary indeterminate lesions seen on MRI)
(ACR, 2018; Kim, 2012; Roberts, 2010)

Primary tumor

  • Initial staging or re-staging of a known primary spinal tumor
  • Known spinal tumor with new signs or symptoms (e.g., new or increasing nontraumatic pain, physical, laboratory, and/or imaging findings)
  • With an associated new focal neurologic deficit as above (Alexandru, 2012)

Metastatic tumor

  • With evidence of metastasis on bone scan needing further clarification OR inconclusive findings on a prior imaging exam
  • Known malignancy with new signs or symptoms (e.g., new or increasing nontraumatic pain, physical, laboratory, and/or imaging findings) in a tumor that tends to metastasize to the spine
  • With an associated new focal neurologic deficit (Alexandru, 2012)
  • Initial imaging of new or increasing non-traumatic neck pain or radiculopathy or neck pain that occurs at night and wakes the patient from sleep with known active cancer and a tumor that tends to metastasize to the spine (ACR, 2018; Ziu, 2019)

For evaluation of inconclusive finding on prior imaging that requires further clarification

  • One follow-up exam to ensure no suspicious change has occurred in prior imaging finding. No further surveillance unless specified as highly suspicious or change was found on last follow-up exam (ACR, 2018)

Indication for combination studies for the initial pre-therapy staging of cancer, OR active monitoring for recurrence as clinically indicated, OR evaluation of suspected metastases

  • < 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine or Lumbar Spine

For evaluation of known or suspected infection/abscess
(ACR, 2018)

  • Infection
    • As evidenced by signs and/or symptoms, laboratory (i.e., abnormal white blood cell count, ESR and/or CRP) or prior imaging findings (Bond, 2016)
    • Follow-up imaging of infection
      • With worsening symptoms/laboratory values (i.e., white blood cell count, ESR/CRP) or radiographic findings (Berbari, 2015)

For evaluation of known or suspected inflammatory disease or atlantoaxial instability

  • In rheumatoid arthritis with neurologic signs/symptoms, or evidence of subluxation on radiographs (lateral radiograph in flexion and neutral should be the initial study) (Colebatch, 2013; Tehranzadeh, 2017)
    • Patients with negative radiographs but symptoms suggestive of cervical instability or in patients with neurologic deficits MRI is indicated (Gillick, 2015)
  • High-risk disorders affecting the atlantoaxial articulation, such as Down syndrome, Marfan syndrome with neurological signs/symptoms, abnormal neurological exam, or evidence of abnormal or inconclusive radiographs of the cervical spine (Henderson, 2017)
  • Spondyloarthropathies, known or suspected
    • Ankylosing Spondylitis/Spondyloarthropathies with non-diagnostic or indeterminate x-ray and appropriate rheumatology workup

For evaluation of spine abnormalities related to immune system suppression, e.g., HIV, chemotherapy, leukemia, or lymphoma
(ACR, 2015; Nagashima, 2010)

  • As evidenced by signs/symptoms, laboratory, or prior imaging findings

Other Indications for a Cervical Spine MRI
(Note- See combination requests, below, for initial advanced imaging assessment and pre-operatively)

  • Tethered cord or spinal dysraphism (known or suspected), based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata (AANS, 2019; Duz, 2008; Milhorat, 2009)
  • Known Arnold-Chiari syndrome (For initial imaging see combination below)
    • Known Chiari I malformation without syrinx or hydrocephalus, follow-up imaging after initial diagnosis with new or changing signs/symptoms or exam findings consistent with spinal cord pathology (Hitson, 2015)
    • Known Chiari II (Arnold-Chiari syndrome), III, or IV malformation
    • Achondroplasia (one Cervical Spine MRI to assess the craniocervical junction, as early as possible, even in asymptomatic cases)(Legare, 2020; White, 2016)
  • Syrinx or syringomyelia (known or suspected)
    • With neurologic findings and/or predisposing conditions (e.g., Chiari malformation, prior trauma, neoplasm, arachnoiditis, severe spondylosis (Timpone, 2015))
    • To further characterize a suspicious abnormality seen on prior imaging
    • Known syrinx with new/worsening symptoms
  • Toe walking in a child when associated with upper motor neuron signs, including hyperreflexia, spasticity; or orthopedic deformity with concern for spinal cord pathology (e.g., pes cavus, clawed toes, leg or foot length deformity [excluding tight heel cords])


Indications for combination studies: (ACR, 2017, 2019) - For approved indications as noted below and being performed in a child under 8 years of age who will need anesthesia for the procedure

Brain MRI/Cervical MRI

  • For evaluation of known Arnold-Chiari Malformation

Any combination of Cervical and/or Thoracic and/or Lumbar MRIs

  • Any combination of these studies for:
    • Scoliosis survey in infant/child with congenital scoliosis or juvenile idiopathic scoliosis under the age of 10 (ACR, 2018; SRS, 2019; Strahle, 2015)
    • In the presence of progressive spinal deformity or for preoperative planning (Trenga, 2016)
    • Neck pain and vertebral anomalies (hemivertebrae, hypoplasia, agenesis, butterfly, segmentation defect, bars, or congenital wedging) in a child on preliminary imaging
    • Scoliosis with any of the following (Ozturk, 2010):
      • Progressive spinal deformity;
      • Neurologic deficit;
      • Early onset;
      • Atypical curve (e.g., short segment, >30’ kyphosis, left thoracic curve, associated organ anomalies);
      • Pre-operative planning; OR
      • When office notes clearly document how imaging will change management
  • Arnold-Chiari II-IV
    • For initial evaluation and follow up as appropriate
  • Tethered cord, or spinal dysraphism (known or suspected) based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata (AANS, 2019; Duz, 2008; Milhorat, 2009), when anesthesia required for imaging (Hertzler, 2010)
  • Toe walking in a child when associated with upper motor neuron signs including hyperreflexia, spasticity; or orthopedic deformity with concern for spinal cord pathology (e.g., pes cavus, clawed toes, leg or foot length deformity (excluding tight heel cords))
  • Neck pain in a child with any of the following red flags (conservative care not required when red flags present):
    • Red flags that prompt imaging should include the presence of age 5 or younger, constant pain, pain lasting >4 weeks, abnormal neurologic examination, early morning stiffness and/or gelling; night pain that prevents or disrupts sleep; radicular pain; fever; weight loss; malaise; postural changes (e.g., kyphosis or scoliosis); and limp (or refusal to walk in a younger child <5yo) AND initial radiographs have been performed (Bernstein, 2007; Feldman, 2006)
  • Drop metastasis from brain or spine (imaging also includes brain)
  • Suspected leptomeningeal carcinomatosis (LC) (Shah, 2011)
  • Any combination of these for spinal survey in patient with metastases
  • Tumor evaluation and monitoring in neurocutaneous syndromes - See Background
  • CSF leak highly suspected and supported by patient history and/or physical exam findings (leak (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula))

Magnetic resonance imaging (MRI) produces high quality multiplanar images of organs and structures within the body without radiation. It is the preferred modality for evaluating the internal structure of the spinal cord, providing assessment of conditions such as degenerative disc pathology, osteomyelitis, and discitis.

*Conservative Therapy: (Spine) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections (epidural, facet, bursal, and/or joint, not including trigger point), and diathermy can be utilized. Active modalities may consist of physical therapy, a physician-supervised home exercise program**, and/or osteopathic manipulative medicine (OMT) or chiropractic care when considered safe and appropriate.

**Home Exercise Program - (HEP)/ Therapy: The following elements are required to meet guidelines for completion of conservative therapy (ACR, 2015; Last, 2009):

  • Information provided on exercise prescription/plan AND
  • Follow-up with member with documentation provided regarding lack of improvement (failed) after completion of HEP (after suitable 6-week period), or inability to complete HEP due to physical reason, i.e., increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without explanation does not constitute “inability to complete” HEP).
  • Dates and duration of failed PT, physician-supervised HEP, or chiropractic treatment should be documented in the original office notes or an addendum to the notes.

Cervical myelopathy: Symptom severity varies, and a high index of suspicion is essential for making the proper diagnosis in early cases. Symptoms of pain and radiculopathy may not be present. The natural history of myelopathy is characterized by neurological deterioration. The most frequently encountered symptom is gait abnormality (86%) followed by increased muscular reflexes (79.1%), pathological reflexes (65.1%), paresthesia of upper limb (69.8%), and pain (67.4%) (Vilaca, 2016).

Infection, Abscess, or Inflammatory disease

  • Infection:
    • Most common site is the lumbar spine (58%), followed by the thoracic spine (30%) and the cervical spine (11%) (Graeber, 2019)
    • High risk populations (indwelling hardware, history of endocarditis, IVDA, recent procedures) with appropriate signs/symptoms

Table 1: Gait and spine imaging



Work up/Imaging


Spastic unilateral, circumduction

Brain and/or, Cervical spine imaging based on associated symptoms


Spastic bilateral, circumduction

Brain, Cervical and Thoracic Spine imaging


Wide based, stiff, unsteady

Cervical and/or Thoracic spine MRI based on associated symptoms


Broad based, clumsy, staggering, lack of coordination, usually also with limb ataxia

Brain imaging


Magnetic, shuffling, difficulty initiating

Brain imaging


Stooped, small steps, rigid, turning en bloc, decreased arm swing

Brain Imaging


Irregular, jerky, involuntary movements

Medication review, consider brain imaging as per movement disorder Brain MR guidelines

Sensory ataxic

Cautious, stomping, worsening without visual input (ie + Romberg)

EMG, blood work, consider spinal (cervical or thoracic cord imaging) imaging based on EMG


Steppage, dragging of toes

EMGà foot drop Lumbar spine MRI
Pelvis MR appropriate evidence of plexopathy


Insecure, veer to one side, worse when eyes closed, vertigo

Consider Brain/IAC MRI as per GL

(References: Chhetri, 2014; Clinch, 2021; Gait, 2021; Haynes, 2018; Marshall, 2012; Pirker, 2017) 

MRI for Evaluation of DiscitisDiscitis is a known complication of cervical discography. Postoperative discitis in the cervical spine does not occur frequently but can result from accidental inoculation of bacteria into the disc space intra-operatively by a contaminated spinal needle being used as a radiological marker. There may be other causes for postoperative discitis, e.g., esophageal perforation, hematogenous spread, inoculation of bacteria during surgery. Patients with an alteration in the nature of their symptoms after cervical discectomy and fusion may have discitis. Symptoms may include complaints of mild paresthesia in extremities and neck pain. MRI may be performed to reveal feature of discitis with associated abscesses and may help to confirm the diagnosis and decide on further management.

MRI for Cervical RadiculopathyMRI is a useful test to evaluate the spine because it can show abnormal areas of the soft tissues around the spine; in addition to the bones, it can also show pictures of the nerves and discs and is used to find tumors, herniated discs, or other soft-tissue disorders. MRI has a role both in the pre-operative screening and post-operative assessment of radicular symptoms due to either disc or osteophyte.

Table 2: MRI and Cutaneous Stigmata (Dias, 2015) 

Risk Stratification for Various Cutaneous Markers

High Risk

Intermediate Risk

Low Risk

  • Hypertrichosis
  • Infantile hemangioma
  • Artretic meningocele
  • DST
  • Subcutaneous lipoma
  • Caudal appendage
  • Segmental hemangiomas in association with LUMBAR‡ syndrome
  • Capillary malformations (also referred to as NFS or salmon patch when pink and poorly defined or PWS when darker red and well-defined)
  • Coccygeal dimple
  • Light hair
  • Isolated café au lait spots
  • Mongolian spots
  • Hypo- and hypermelanotic macules or papules
  • Deviated or forked gluteal cleft
  • Nonmidline lesions

LUMBAR, lower body hemangioma and other cutaneous defects, urogenital abnormalities, ulcerations, myelopathy, bony defects, anorectal malformations, arterial anomalies, and renal anomalies.

MRI and Multiple Sclerosis (MS) MRI is a sensitive method of detecting the white matter lesions of MS. These plaques on MRI generally appear as multiple, well-demarcated, homogeneous, small ovoid lesions which often lack mass effect and are oriented perpendicular to the long axis of the lateral ventricles. Sometimes they present as large, space occupying lesions that may be misinterpreted as tumors, abscesses, or infarcts.

MRI and Neck Pain – Neck pain is common in the general population and usually relates to musculoskeletal causes, but it may also be caused by spinal cord tumors. When neck pain is accompanied by extremity weakness, abnormal gait, or asymmetric reflexes, spinal MRI may be performed to evaluate the cause of the pain. MRI may reveal areas of cystic expansion within the spinal cord. Enhancement with gadolinium contrast may suggest that the lesion is neoplastic.

Ossification Posterior Longitudinal Ligament (OPLL) (Choi, 2011)  – Most common in cervical spine (rare but more severe in thoracic spine)

Back Pain with Cancer History – Bone is the third most common site of metastases after the liver and the lungs, and approximately two-thirds of all osseous metastases occur in the spine. Approximately 60 70% of patients with systemic cancer will have spinal metastasis. Radiographic (x-ray) examination should be performed in cases of back pain when a patient has a cancer history, but without known active cancer or a tumor that tends to metastasize to the spine. This can make a diagnosis in many cases. This may occasionally allow for selection of bone scan in lieu of MRI in some cases. When radiographs do not answer the clinical question, then MRI may be appropriate after a consideration of conservative care.

Neoplasms causing VCF (vertebral compression fractures) include primary bone neoplasms, such as hemangioma or giant cell tumors, and tumor-like conditions causing bony and cellular remodeling, such as aneurysmal bone cysts, or Paget・s disease (osteitis deformans); infiltrative neoplasms, including and not limited to, multiple myeloma and lymphoma, and metastatic neoplasms (ACR, 2018).

Most common spine metastasis involving primary metastasis originate from the following tumors in descending order: breast (21%), lung (19%), prostate (7.5%), renal (5%), gastrointestinal (4.5%), and thyroid (2.5%). While all tumors can seed to the spine, the cancers mentioned above metastasize to the spinal column early in the disease process. Spinal metastasis is more commonly found in the thoracic region, followed by the lumbar region, while the cervical region is the least likely site of metastasis (Ziu, 2019). 

Cervical Spine Trauma Imaging (ACR, 2018): The National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian Cervical Rules (CCR) represent clinical criteria used to help determine the presence of significant cervical spine injury. Although the criteria are highly sensitive (99.6% for NEXUS), specificity is low (12.9% for Nexus).

A patient not meeting any of the NEXUS criteria of focal neurologic deficit, midline spinal tenderness, altered consciousness, intoxication, or distracting injury is unlikely to have a significant cervical spine injury. Imaging evaluation of the cervical spine in these patients is not necessary. In the CCR criteria, a patient without any high risk factors (Age >65 years, paresthesias in extremities, dangerous mechanism, falls from ≥3 feet/5 stairs, axial load to head, motor vehicle crash with high speed, rollover, or ejection, bicycle collision, motorized recreational vehicle accident) is next evaluated for low risk factors (Simple rear-end motor vehicle crash, patient in sitting position in emergency center, patient ambulatory at any time after trauma, delayed onset of neck pain, absence of midline cervical spine tenderness). If the patient meets a low-risk criteria, they are asked to move their head 45 degrees from midline in both directions. If the patient can accomplish this, the spine is cleared and imaging is not necessary

MRI and Neurocutaneous Syndromes

  • In NF-1, clinical evaluation appears to be more useful to detect complications than is screening imaging in asymptomatic patients. Imaging is indicated in evaluation of suspected tumors based on clinical evaluation and for follow-up of known intracranial tumors (Borofsky, 2013).
  • Conversely in NF-2, routine MR imaging screening is always indicated, given the high prevalence of CNS tumors, especially vestibular schwannomas. In patients with NF-2, routine screening brain/IAC imaging is indicated annually starting from age 10, if asymptomatic, or earlier with clinical signs/symptoms. Most individuals with NF2 eventually develop a spinal tumor, mostly commonly schwannomas, but meningioma and ependymomas are also seen. Spinal imaging at baseline and every 2 to 3 years is also advised with more frequent imaging, if warranted, based on sites of tumor involvement (Evans, 2017).
  • In patients with Tuberous Sclerosis, Brain MRI should be obtained every 1 – 3 years up until age 25 for surveillance for CNS abnormalities (Krueger, 2013).
  • In Von Hippel Lindau Syndrome, imaging of the brain and spinal cord for hemangioblastomas is recommended every 2 years (Varshney, 2017).
  • In Sturge Weber Syndrome, Brain MRI can rule out intracranial involvement after only age 1 and is recommended in patients <1 year old only if symptomatic (Comi, 2011).


  1. Acharya AB, Fowler JB. Chaddock Reflex. Updated 2019 Dec 15. In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing; 2020 Jan.
  2. AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal Spine. 2016.
  3. Alexandru D. Evaluation and management of vertebral compression fractures. Perm J. Published online October 30, 2012:46-51. doi:10.7812/TPP/12-037.
  4. Allegri M, Montella S, Salici F, et al. Mechanisms of low back pain: A guide for diagnosis and therapy v.2. F100Res. 2016; 5.
  5. American Association of Neurological Surgeons (AANS). Tethered spinal cord syndrome. 2019.
  6. American Association of Neurological Surgeons and Congress of Neurological Surgeons (AANSCNS). Choosing Wisely®. Released June 24, 2014.
  7. American College of Radiology (ACR). ACR Appropriateness Criteria®. 2015.
  8. American College of Radiology (ACR). ACR Appropriateness Criteria®. Cervical Neck Pain or Cervical Radiculopathy. Revised 2018.
  9. American College of Radiology (ACR). ACR Appropriateness Criteria®. Inflammatory Back Pain: Known or Suspected Axial Spondyloarthritis. Revised 2021.
  10. American College of Radiology (ACR). ACR Appropriateness Criteria®. Suspected Spine Trauma. 2018.
  11. Barakat N, Gorman MP, Benson L, Becerra L, Borsook D. Pain and spinal cord imaging measures in children with demyelinating disease. Neuroimage Clin. 2015;9:338-347. doi:10.1016/j.nicl.2015.08.019.
  12. Behrbalk E, Salame K, Regev GJ, et al. Delayed diagnosis of cervical spondylotic myelopathy by primary care physicians. Neurosurg Focus. July 2013; 35(1):E1.
  13. Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015 Sep 15; 61(6):e26–e46.
  14. Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. Am Fam Physician. 2007;76(11):1669-1676. 14— Cervical Spine MRI © 2019-2021 National Imaging Associates, Inc., All Rights Reserved
  15. Bond A, Manian FA. Spinal epidural abscess: A review with special emphasis on earlier diagnosis. Biomed Res Int. 2016; 2016:1614328.
  16. Borofsky S, Levy LM. Neurofibromatosis: Types 1 and 2. Am J Neuroradiol. 2013; 34(12):2250-2251.
  17. Braga-Baiak A, Shah A, Pietrobon R, et al. Intra- and inter-observer reliability of MRI examination of intervertebral disc abnormalities in patients with cervical myelopathy. [Published online ahead of print May 25, 2007]. Eur J Radiol. 2008; 65(1):91-98. doi:10.1016/j.ejrad.2007.04.014.
  18. Chhetri SK, Gow D, Shaunak S, Varma A. Clinical assessment of the sensory ataxias; diagnostic algorithm with illustrative cases. Pract Neurol. 2014;14(4):242-251. doi:10.1136/practneurol-2013-000764.
  19. Choi JH, Lee T, Kwon HH, et al. Outcome of ultrasonographic imaging in infants with sacral dimple. Korean J Pediatr. 2018 Jun; 61(6): 194–199.
  20. Choi BW, Song KJ, Chang H. Ossification of the posterior longitudinal ligament: A review of literature. Asian Spine J. 2011; 5(4):267–276. doi:10.4184/asj.2011.5.4.267.
  21. Clinch J, Wood M, Driscoll S. Evaluation of gait disorders in children. BMJ Best Practice. Published February 23, 2021. Accessed July 14, 2021.
  22. Colebatch AN, Edwards CJ, Østergaard M, et al. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Ann Rheum Dis. 2013 Jun; 72(6):804-14.
  23. Comi AM. Presentation, diagnosis, pathophysiology, and treatment of the neurological features of Sturge-Weber syndrome. Neurologist. 2011; 17(4):179.
  24. Consortium of Multiple Sclerosis Centers (CMSC). 2018 Revised guidelines of the consortium of MS centers MRI protocol for the diagnosis and follow-up of MS. 2018. Retrieved July 15, 2021.
  25. D’ Alessandro. Does This Sacral Dimple Need to be Evaluated?™. Iowa City, IA: July 20, 2009. Retrieved March 29, 2018.
  26. Davies BM, Smith EK. Degenerative cervical myelopathy. BMJ. 2018; 360 doi:
  27. Diab M, Landman Z, Lubicky J, et al. Use and outcome of MRI in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). April 15, 2011; 36(8):667-671. doi: 10.1097/BRS.0b013e3181da218c.
  28. Dias M, Partington M. Congenital brain and spinal cord malformations and their associated cutaneous markers. Pediatrics. 2015; 136(4):e1105-19.
  29. Dow G, Biggs N, Evans G, et al. Spinal tumors in neurofibromatosis type 2: Is emerging knowledge of genotype predictive of natural history? Neurosurg Spine. 2005; 2(5):574.
  30. Duz B, Gocmen S, Secer HI, et al. Tethered cord syndrome in adulthood. J Spinal Cord Med. 2008; 31(3):272-278. Retrieved March 29, 2018.
  31. Eubanks JD. Cervical radiculopathy: Nonoperative management of neck pain and radicular symptoms. Am Fam Physician. 2010 Jan 1; 81(1):33-40.
  32. Evans DGR, Salvador H, Chang VY, et al. Tuberous sclerosis complex surveillance and management: Recommendations of the 2012 International Tuberous Sclerosis Complex Consensus Conference. Clin Cancer Res. 2017; 23(12):e54.
  33. Feldman DS, Straight JJ, Badra MI, Mohaideen A, Madan SS. Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop. 2006;26(3):353-357. doi:10.1097/01.bpo.0000214928.25809.f9.
  34. Filippi M, Rocca MA, Ciccarelli O, et al. MRI criteria for the diagnosis of multiple sclerosis: MAGNIMS consensus guidelines. Lancet Neurol. March 2016; 15(3):292-303. doi: 10.1016/S1474-4422(15)00393-2. Retrieved May 8, 2018.
  35. Fisher BM, Cowles S, Matulich JR, et al. Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients? Am J Surg. 2013 Dec; 206(6):987-93; discussion 993-4. doi: 10.1016/j.amjsurg.2013.08.021. Epub 2013 Oct 10.
  36. Gait abnormalities. Stanford Medicine 25. Published 2021. Accessed July 14, 2021.
  37. Gillick JL, Wainwright J, Das K. Rheumatoid arthritis and the cervical spine: A review on the role of surgery. Int J Rheumatol. 2015; 2015:252456. Epub 2015 Aug 17.
  38. Goh C, Phal PM, Desmond PM. Neuroimaging in acute transverse myelitis. Neuroimaging Clin N Am. 2011 Nov; 21(4):951-73.
  39. Graeber A, Cecava ND. Vertebral Osteomyelitis. [Updated 2019 Jun 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.
  40. Haynes KB, Wimberly RL, VanPelt JM, Jo C-H, Riccio AI, Delgado MR. Toe walking: A neurological perspective after referral from pediatric orthopaedic surgeons. Journal of Pediatric Orthopaedics. 2018;38(3):152-156. doi:10.1097/BPO.0000000000001115.  
  41. Henderson FC, Austin C, Benzel E. Neurological and spinal manifestations of the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet. 2017 Mar; 175(1):195-211.
  42. Hertzler DA, DePowell JJ, Stevenson CB, Mangano FT. Tethered cord syndrome: A review of the literature from embryology to adult presentation. Neurosurg Focus. 2010;29(1):E1. doi:10.3171/2010.3.FOCUS1079.
  43. Hitson WJ, Lane JR, Bauer DF, et al. A prospective natural history study of nonoperatively managed Chiari I malformation: Does follow-up MRI surveillance alter surgical decision making? J Neurosurg Pediatr. 2015 Aug; 16(2):159-66.
  44. Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015; 313(11):1143-1153. doi: 10.1001/jama.2015.1871.
  45. Jensen AO, Jacobsen JB, Norgaard M, et al. Incidence of bone metastases and skeletal-related events in breast cancer patients: a population-based cohort study in Denmark. BMC Cancer. January 24, 2011; 11:29.
  46. Kaunzner UW, Gauthier SA. MRI in the assessment and monitoring of multiple sclerosis: An update on best practice. Ther Adv Neurol Disord. 2017;10(6):247-261. doi:10.1177/1756285617708911.
  47. Kim YS, Han IH, Lee IS, et al. Imaging findings of solitary spinal bony lesions and the differential diagnosis of benign and malignant lesions. J Korean Neurosurg Soc. August 2012; 52(2): 126-132. doi: 10.3340/jkns.2012.52.2. Retrieved March 29, 2018.
  48. Koivikko MP, Koskinen SK. MRI of cervical spine injuries complicating ankylosing spondylitis. Skeletal Radiol. 2008; 37(9):813-819. doi: 10.1007/s00256-008-0484-x.
  49. Krueger DA, Northrup H. Tuberous sclerosis complex surveillance and management: Recommendations of the 2012 International Tuberous Sclerosis Complex Consensus Conference. Pediatr Neurol. 2013; 49(4):255.
  50. Kumar Y, Hayashi D. Role of magnetic resonance imaging in acute spinal trauma: A pictorial review. BMC Musculoskelet Disord. 2016; 17:310.
  51. Last AR, Hulbert K. Chronic low back pain: Evaluation and management. Am Fam Physician. 2009; 79(12):1067-74.
  52. Legare JM. Achondroplasia. In: Adam MP, Ardinger HH, Pagon RA, et al., eds. GeneReviews®. University of Washington, Seattle; 1993. Accessed July 16, 2021. [Updated August 6, 2020].  
  53. Marshall FJ. Approach to the elderly patient with gait disturbance. Neurol Clin Pract. 2012;2(2):103-111. doi:10.1212/CPJ.0b013e31825a7823.
  54. Milhorat TH, Bolognese PA, Nishikawa M, et al. Association of Chiari malformation type I and tethered cord syndrome: Preliminary results of sectioning filum terminale. Surg Neurol. July 1, 2009. 72(1):20-35. Retrieved March 29, 2018.
  55. Nagashima H, Yamane K, Nishi T, et al. Recent trends in spinal infections: Retrospective analysis of patients treated during the past 50 years. Int Orthop. March 2010; 34(3):395-399. doi: 10.1007/s00264-009-0741-1. Retrieved May 8, 2018.
  56. North American Spine Society (NASS). Evidence-based Clinical Guidlines for Multidisciplinary Spine Care. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders. 2010 North American Spine Society.
  57. North American Spine Society (NASS). Clinician Lists. Choosing Wisely®. Released October 9, 2013.
  58. North American Spine Society (NASS). Five Things Physicians and Patients Should Question. 2014.
  59. Ozturk C, Karadereler S, Ornek I, Enercan M, Ganiyusufoglu K, Hamzaoglu A. The role of routine magnetic resonance imaging in the preoperative evaluation of adolescent idiopathic scoliosis. Int Orthop. 2010;34(4):543-546. doi:10.1007/s00264-009-0817-y.
  60. Pirker W, Katzenschlager R. Gait disorders in adults and the elderly: A clinical guide. Wien Klin Wochenschr. 2017;129(3-4):81-95. doi:10.1007/s00508-016-1096-4.
  61. Radic JAE, Cochrane DD. Choosing wisely canada: pediatric neurosurgery recommendations. Paediatr Child Health. 2018;23(6):383-387. doi:10.1093/pch/pxy012.
  62. Rao D, Scuderi G, Scuderi C, Grewal R, et al. The use of imaging in management of patients with low back pain. J Clin Imaging Sci. 2018 Aug 24; 8:30.
  63. Rednam SP, Erez A, Druker H, et al. Von Hippel-Lindau and Hereditary Pheochromocytoma/Paraganglioma syndromes: Clinical features, genetics, and surveillance recommendations in childhood. Clin Cancer Res. 2017; 23(12):e68.
  64. Roberts CC, Daffner RH, Weissman BN, et al. ACR Appropriateness Criteria® on metastatic bone disease. J Am Coll Radiol. 2010;7(6):400-409. doi:10.1016/j.jacr.2010.02.015.  
  65. Sarbu N, Lolli V, Smirniotopoulos JG. Magnetic resonance imaging in myelopathy: A pictorial review. Clin Imaging. 2019 Sep-Oct; 57:56-68. doi: 10.1016/j.clinimag.2019.05.002. Epub 2019 May 17.
  66. Scoliosis Research Society (SRS). Conditions and treatments: Juvenille scholiosis. 2019.
  67. Shah LM, Salzman KL. Imaging of spinal metastatic disease. Int J Surg Oncol. 2011; 2011:769753.
  68. Stolper K, Haug JC, Christensen CT, et al. Prevalence of thoracic spine lesions masquerading as cauda equina syndrome: Yield of a novel magnetic resonance imaging protocol. Intern Emerg Med. 2017 Dec; 12(8):1259-1264. doi: 10.1007/s11739-016-1565-9.
  69. Strahle J, Muraszko KM, Kapurch J, Bapuraj JR, Garton HJL, Maher CO. Chiari malformation Type I and syrinx in children undergoing magnetic resonance imaging. J Neurosurg Pediatr. 2011;8(2):205-213. doi:10.3171/2011.5.PEDS1121.
  70. Strahle J, Smith BW, Martinez M, et al. The association between Chiari malformation Type I, spinal syrinx, and scoliosis. J Neurosurg Pediatr. 2015; 15:607-611. Retrieved March 29, 2018.
  71. Taljanovic MS, Hunter TB, Wisneski RJ, et al. Imaging characteristics of diffuse idiopathic skeletal hyperostosis with an emphasis on acute spinal fractures: Review. AJR Am J Roentgenol. 2009;193(3 Suppl):S10-19, Quiz S20-24. doi:10.2214/AJR.07.7102.
  72. Tehranzadeh J, Ashikyan O, Dascalos J, et al. Cervical spine instability in the course of rheumatoid arthritis - imaging methods. Reumatologia. 2017; 55(4):201–207.
  73. Teoli D, Cabrero FR, Ghassemzadeh S. Lhermitte Sign. [Updated 2020 Oct 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
  74. Timpone V, Patel SH. MRI of a syrinx: Is contrast material always necessary? Am J Roentgenol. 2015; 204:1082-1085. 10.2214/AJR.14.13310.
  75. Trenga AP, Singla A, Feger MA, et al. Patterns of congenital bony spinal deformity and associated neural anomalies on X-ray and magnetic resonance imaging. J Child Orthop. August 2016; 10(4):343-352. doi: 10.1007/s11832-016-0752-6. Retrieved March 29, 2018.
  76. Varshney N, Kebede AA, Owusu-Dapaah H, Lather J, Kaushik M, Bhullar JS. A review of Von Hippel-Lindau Syndrome. J Kidney Cancer VHL. 2017;4(3):20-29. doi:10.15586/jkcvhl.2017.88.
  77. Vilaca C, Orsini M, Araujo Leite MA, et al. Cervical spondylotic myelopathy: What the neurologist should know. Neurol Int. 2016 Nov 2; 8(4): 6330. doi: 10.4081/ni.2016.6330.
  78. White KK, Bompadre V, Goldberg MJ, et al. Best practices in the evaluation and treatment of foramen magnum stenosis in achondroplasia during infancy. Am J Med Genet. 2016;170(1):42-51. doi:10.1002/ajmg.a.37394.
  79. Wingerchuk DM, Banwell B, Bennett JL, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology. 2015 Jul 14; 85(2).
  80. Ziu E, Mesfin FB. Cancer, Spinal Metastasis. StatPearls(Internet). April 23, 2019.  

Coding Section

Code Number Description
  72141 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material
  72142 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)
  72156 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2019 Forward     

11/04/2021  Annual reivew, modifying section on neurological deficits. Adding detail re: back pain in a child, gait table, tumor imaging, toe walking and achondroplasia. Also updating description and references. 
11/01/2020  Annual review, reformatting policy for clarity, updating references. 
11/26/2019 New Policy
Complementary Content