It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Purpose
Computed tomography (CT) is performed for the evaluation of the cervical spine. CT may be used as the primary imaging modality, or it may complement other modalities. Primary indications for CT include conditions, e.g., traumatic, neoplastic, and infectious. CT is often used to study the cervical spine for conditions such as degenerative disc disease when MRI is contraindicated. CT provides excellent depiction of bone detail and is used in the evaluation of known fractures of the cervical spine and for evaluation of postoperative patients.
 

Policy

INDICATIONS FOR CERVICAL SPINE CT
Evaluation of Neurologic Deficits^1,2
When cervical spine MRI is contraindicated or inappropriate

• Extremity muscular weakness (and not likely caused by plexopathy or peripheral neuropathy)
• Pathologic (e.g., Babinski, Lhermitte's sign,³ Chaddock Sign,⁴ Hoffman’s and other upper motor neuron signs); OR abnormal deep tendon reflexes (and not likely caused by plexopathy, or peripheral neuropathy)
• Absent/decreased sensory changes along a particular cervical dermatome (nerve distribution): pin prick, touch, vibration, proprioception, or temperature (and not likely caused by plexopathy or peripheral neuropathy)
• Upper or lower extremity increase muscle tone/spasticity
• New onset bowel or bladder dysfunction (e.g., retention or incontinence)—not related to an inherent bowel or bladder process
• Gait abnormalities (see Table1 below for more details)
• Suspected cord compression with any neurological deficits as listed above

Evaluation of Neck Pain^5,6
With any of the following when cervical spine MRI is contraindicated

• 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 or weight loss or malaise,
• Postural changes (e.g., kyphosis or scoliosis)
• Limp (or refusal to walk in a younger child

Pre-Operative/Post-Operative/Procedural Evaluation
As part of initial pre-operative/post-operative/procedural evaluation (The best examinations are CT to assess for hardware complication, extent of fusion and pseudarthrosis and MRI for cord, nerve root compression, disc pathology, or post-op infection)¹⁰

Note: If ordered by Neurosurgeon or orthopedic surgeon for purposes of surgical planning, a contraindication to MRI is not required.

• For preoperative evaluation/planning
• CT discogram
• Evaluation of post operative pseudoarthrosis after initial X-rays (CT should not be done before 6 months after surgery)
• 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 -preferred exam CT myelogram])¹¹
• 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)
• Surgical infection as evidenced by signs/symptoms, laboratory, or prior imaging findings
• New or changing neurological deficits or symptoms post-operatively¹² (see neurological deficit section above).
• When combo requests (see ⁺) are submitted (i.e., 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)¹³
  • 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)¹⁴
  • 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 for the patient

Evaluation of Suspected Myelopathy^15,16
When cervical spine MRI is contraindicated

• 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

Evaluation of Trauma or Acute Injury¹⁷

• Presents with any of the following neurological deficits as above
• With progression or worsening of symptoms during the course of conservative treatment*
• History of underlying spinal abnormalities (i.e., ankylosing spondylitis) (Both MRI and CT are approvable)^18,19
• 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:¹⁷
  • 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
 

Evaluation of Known Fracture or New Compression Fractures^17,20
(With Worsening Neck Pain)

• To assess union of a fracture when physical examination, plain radiographs, or prior imaging suggest delayed or non-healing
• To determine the position of fracture fragments
• With history of malignancy (if MRI is contraindicated or cannot be performed)
• With an associated new focal neurologic deficit as above
• Prior to a planned surgery/intervention or if the results of the CT will change management

CT Myelogram^1,11
When MRI cannot be performed/contraindicated/surgeon preference

• When signs and symptoms inconsistent or not explained by the MRI findings
• Demonstration of the site of a CSF 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)
• Surgical planning, especially regarding to the nerve roots or evaluation of dural sac
• Evaluation of suspected brachial plexus or nerve root injury in the neonate

Evaluation of Tumor, Cancer, or Metastasis
With any of the following:
MRI is usually the preferred study (CT may be needed to further characterize solitary indeterminate lesions seen on MRI)^6,21,22

• With evidence of metastasis on bone scan needing further clarification OR inconclusive findings on a prior imaging exam
• With an associated new focal neurologic deficit¹⁷
• Known malignancy with new signs or symptoms (e.g., new or increasing nontraumatic pain, radiculopathy or neck pain that occurs at night and wakes the patient from sleep with known active cancer, physical, laboratory, and/or imaging findings) in a tumor that tends to metastasize to the spine^6,24

Further Evaluation of Indeterminate Findings
Unless follow-up is otherwise specified within the guideline

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification. When MRI cannot be performed, is contraindicated, or CT is preferred to characterize the finding⁶
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam). When MRI cannot be performed, is contraindicated, or CT is preferred to characterize the finding.⁶

Evaluation of Known or Suspected Infection/Abscess²⁵
When cervical spine MRI is contraindicated

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