What does an abnormal neck MRI mean? Unnecessary surgery for cervical stenosis? - (2024)

Ross A. Hauser, MD.

Are you getting cervical spine surgery for the wrong problem? Cervical radiculopathy mimics

Traditional pain management care involves trying to find the pain-producing structure and then doing something to it to calm the nerve impulses down.For the nerve to make it from the neck to the skin and muscles of the arm it has to travel through and by a lot of structures including muscles, fascia, and nearby joints such as the shoulder. Since the scalene muscles attach the transverse processes of the middle to lower cervical vertebrae to the first two ribs, instability in any of these joints would cause muscle spasms and potential hypertrophy of these muscles. This could, in turn, lead to compression of the nerves from the neck in the brachial plexus. In addition, shoulder instability can compress the brachial plexus nerves, as the nerves run just anterior to the shoulder joint. So knowing exactly where the joint instability is located is crucial to curing chronic neck pain and its sequelae and, as you will find out, static (non-motion) MRIs and x-rays are poor judges of this.

If you are like many of the patients we see, you went to your doctor and then were referred to a cervical spine specialist or a neurologist. Here at the specialist’s office, an MRI is ordered, and perhaps an Electromyogram (EMG) Test.

An April 2022 paper in the journal Muscle & Nerve (1) discusses the possible mimics that can cause a misdiagnosis of cervical radiculopathy.

“Musculoskeletal cervical radiculopathy mimics include: (1) head/neck pain, such as neck tension, cervicogenic headache, and temporomandibular disorder; (2) referred pain from shoulder pathology, such as rotator cuff tears/impingement; (3) elbow (problems such as elbow osteoarthritis, medial epicondylitis, and lateral epicondylitis; (4) wrist/hand conditions, such as DeQuervain’s tenosynovitis and intersection syndrome; (5) muscle connective tissue disorders, including myofascial trigger points; (6) conditions that have decreased range of motion, including frozen shoulder and rounded shoulders with tight pectoral/scalene muscles; (7) conditions with joint hyperlaxity and instability, as seen in post-stroke shoulder subluxation; (8) vascular conditions, such as thoracic outlet syndrome; and (9) autonomic controlled soft tissue changes associated with complex regional pain syndrome.”

In this image, we see the musculoskeletal interconnection between the shoulder and the cervical spine muscles and tendons. Here we see that shoulder instability can cause neck pain and equally neck instability can cause shoulder pain. If the shoulder is stable but painful, an examination of the upper cervical spine may reveal the answer to shoulder pain that did not appear on a shoulder MRI.

A January 2023 paper from an international team of doctors published in the journal Pain practice (2) used the common diagnostic aid of having a patient draw out where on their body their cervical radiculopathy was causing them pain to assess if the pain drawings and MRI findings could be brought into agreement about the affected levels of cervical radiculopathy and to see if clinicians could correctly interpret the drawings and match them to an MRI agreement. Finally, to see if the pain drawings correlated to common pain symptoms of pain distribution of people suffering with cervical radiculopathy (C4-C7). What the researchers found is that the patient drawings of pain distribution did not match what the MRI suggested. In fact it was “poor overall agreement with MRI.” The researchers suggested: “This study revealed a lack of agreement between the segmental level affected determined from the patient’s pain drawing and the affected level as identified on MRI.” Patients had a large overlap of pain and non-dermatomal distribution of pain (pain where it should not be in classical radiculopathy).

How the cervical spine MRI could be “read the wrong way”

The goal of a March 2019 study was to demonstrate that master’s chiropractic students could effectively and properly read an MRI of the cervical spine. What is important in this study from our point of view is that the researchers of this study published in the journal Chiropractic & Manual Therapies (3) made these observations about how MRI could be “read the wrong way,” and possibly send people to a surgery that would not be addressing the cause of their pain or radiculopathy issues.

• The most prevalent MRI findings were foraminal stenosis (77%), uncovertebral arthrosis (74%), and disc degeneration (67%) while the least prevalent finding was nerve root compromise (2%).

• The image above explains what foraminal stenosis is. The narrowing of the vertebral space where the nerves exit the spine.
• Uncovertebral arthrosis is disc degeneration and bone spur formation at the C3-C7 area at the “Luschka’s joint.”
• Cervical disc degeneration is the flattening and rupturing of the disc between the vertebrae. When this disc flattens, problems of foraminal stenosis become more apparent as the loss of disc space creates a narrowing without bone spurring.
  • Disc degeneration was categorized as:
    • 1) ‘normal’ (normal disc height and disc signal intensity),
    • 2) ‘mild disc degeneration (slightly reduced disc height and decreased disc signal intensity),
    • 3) ‘moderate disc degeneration’ (moderate reduced disc height) and
    • 4) ‘severe disc degeneration (collapsed disc space).

An October 2023 research paper lead by the University of Utah and published in The neuroradiology journal (4) suggests that changes in cervical stenosis may be present in cervical spine MRIs but that may be missed or misinterpreted. The researchers suggest that there is considerable variability among radiologists when grading spinal canal and foraminal stenosis on MRI. So to start with, MRI interpretations are varied. However, there is limited research to suggest if MRI interpretations also are varied when it comes to identifying degenerative changes.

Here are the clinical findings:

• There were 40 initial cervical MRI exams and 40 corresponding MRI follow-ups.
• While radiologists had high agreement when determining change in spinal canal and foraminal stenosis on follow-up cervical spine MRIs, it was difficult to determine the amount of change because the initial MRI interpretation may not have been accurate. This could give the impression that there was no or little change when there may have been more changes in the spine.

Researchers question the validity of diagnostic tools such as MRI and understand what these readings and other investigational tools provide the patient by way of treatments that help.

A February 2018 study published in the journal Musculoskeletal Science and Practice(5) helps to shed light on the challenges doctors and patients share in understanding cervical radiculopathy.

Here researchers from the University of Southampton made observations surrounding the validity of diagnostic tools such as MRI and understanding what these readings and other investigational tools provide the patient. Then the researchers asked the patients what did these MRIs and other investigational findings provide them?

Here are the bullet points from this study:

• “Clinical guidelines recommend that investigations, such as magnetic resonance imaging, are offered only when likely to change management. Meanwhile, the optimal process of diagnosing radiculopathy remains uncertain and, in clinical practice, differences of opinion can occur between patient and clinician regarding the perceived importance of investigations.”
  • COMMENT: In our experience, we have found most times, it is the patient who wants the MRI and it is the clinician who is trying to give them the realistic opinion that the MRI is not needed.
• “When investigations revealed potentially relevant findings, people experienced relief, validation, empowerment and decisive decision-making.”
  • COMMENT: In our experience, no matter what the MRI showed, if it showed any abnormality the patient was pleased. WHY? Because for many patients with cervical problems, many times they are not believed, their problems are considered “all in their head.” The MRI is validation.
• “Disappointment emerged, however, regarding treatment options and waiting times, and long-term prognosis.”
  • COMMENT: There is no comment here. If you are reading this article this probably describes you or a loved one. the MRI gave you validation, but not a game plan to help you.
• “When investigations failed to identify relevant findings, people were unable to make sense of their symptoms, relinquish their search to identify the cause, or to move forward in their management.”
  • COMMENT:Because the MRI did not correspond with the patient’s symptoms, the patient now feels hopeless. If you are reading this article this probably describes you or a loved one.

Does this sound like your path of treatment?

• You went to a specialist, you had an MRI.
• The MRI showed something.
• You were happy, now you have something to confirm why you suffered from a myriad of symptoms.
• BUT THEN, you were told of the treatment options, likely painkillers, physical therapy, and cortisone injections and if they did not work, then you would need surgery.

The MRI wants to show you a significantly herniated disc. We will show you that disc herniation may not be a factor at all.

Cervical radiculopathy is generally considered to result from pressure from aherniated disc, arthritis, or other injuries that increase pressure on these nerve roots. In 1998, German doctors writing in the journal Investigative Radiology(6) demonstrated that provocative movements such as flexion, extension, and rotation, rather than to the size of the herniated disc, worsened cervical radicular pain. Provocative movements are what we examine with the DMX.

In July 2023 study in the Global Spine Journal (7) doctors reviewed 242 patient case histories and could not suggest that degenerative spondylolisthesis truly a pain generator. Instead, degenerative spondylolisthesis appears to be a relatively frequent (found in 20% of the patients in this study) age-related condition reflecting radiographic (seen on an MRI), rather than necessarily clinical, disease. (It’s there but may not be cuaing any pain).

MRI and DMX a brief introduction explaining the difference and accuracy in understanding nerve compression

The concern presented above is that the MRI may present evidence for a surgery that is not needed. In our office, we utilize a different diagnostic tool, a DMX.

In the video below of a Digital Motion X-ray or DMX, the patient’s motion (in this case Dr. Hauser is the cervical radiculopathy patient) demonstrates that nerve compression can come and go with neck movement. This may explain why in the above research nerve root compromise was only seen in 2% of patients suffering from cervical radiculopathy. The MRI is a static picture taken of the patient in the “proper MRI position of “don’t move.” During the DMX the patient needs to move to show our doctors and clinicians at what point during the neck’s range of motion that nerve pinching is actually occurring.

In returning to the research reported in the journal Chiropractic & Manual Therapies, the researchers noted the prevailing medical research which agrees that:

• The use of Magnetic Resonance Imaging (MRI) in the search for biological causes of neck pain remains controversial as studies have shown that degenerative changes in the cervical spine are also common in healthy volunteers. In other words, people with pain and no pain can have the same-looking problems on MRI.
• There is no available evidence supporting MRI findings as predictive of treatment effects in people with neck pain. In other words, if the MRI is showing a problem, it does not recommend a treatment that will likely work.

Although some MRI findings seem to be more prevalent in symptomatic people compared to those without neck pain, the limitations of the studies described above prevent a clear conclusion. Also, as this is a cross-sectional study of a population with neck pain, the data cannot inform the association between MRI findings and the presence of symptoms, e.g. neck pain.

So it was not the size of the herniation that caused cervical radiculopathy issues, it was the unstable motion of the cervical vertebrae.

At the start of this article I wrote: “Narrowing of the bony cervical spine canal, or cervical spinal stenosis, may not be pathologic (symptom causing) itself. But when occurring in conjunction with cervical neck instability, it can impede neurological function. What is it I am saying here? It is that your MRI can reveal cervical stenosis, it can show boney overgrowth, but that in itself may not be creating the typical symptoms of cervical radiculopathy.”

Provocative movements such as flexion, extension, and rotation, cause pain by variation in the passage size of the neural foramen. This is the opening in the cervical spine vertebrae that allows the passage of spinal nerve roots to exit the spine.

As shown in the graphicsand the video below, various motions changed the foraminal size, nerve root motion, and cervical cord rotation. When arthritis or stenosis was present, the increased radicular pain was also related to the movement of the cervical spine as it narrowed the foraminal opening.

If the changes in foraminal size with motion cause an exacerbation in cervical radicular pain, it would follow that any instability in the cervical spine would exacerbate the radicular pain as well, since instability causes even more motion in the joint.

• The foraminal size will change as an individual carries out their normal daily activities, bending and rotating the neck.
• During these activities, the nerve root will get compressed intermittently as it exits the neural foramen.
• When the person assumes a different position, the nerve root contact may be relieved. In the study, movements such as flexion tended to relieve compression caused by cervical stenosis, and extension tended to produce more symptoms.
• Positional narrowing of the foramina or degenerative issues leading to radicular pain is exacerbated by the instability of the cervical spine.

In our experience, the instability of the spine is caused by injury to the cervical ligaments. Ligaments are connective structures that connect bone to bone and aid in the stabilization of the cervical vertebrae.

References

1Chiou‐Tan FY. Musculoskeletal mimics of cervical radiculopathy. Muscle & Nerve. 2022 Apr 24. [Google Scholar]
2 Marco B, Evans D, Symonds N, Peolsson A, Coppieters MW, Jull G, Löfgren H, Zsigmond P, Falla D. Determining the level of cervical radiculopathy: Agreement between visual inspection of pain drawings and magnetic resonance imaging. Pain Practice. 2023 Jan;23(1):32-40. [Google Scholar]
3 Jensen RK, Jensen TS, Grøn S, Frafjord E, Bundgaard U, Damsgaard AL, Mathiasen JM, Kjaer P. Prevalence of MRI findings in the cervical spine in patients with persistent neck pain based on quantification of narrative MRI reports. Chiropractic & manual therapies. 2019 Dec;27(1):13. [Google Scholar]
4 Costello JE, Shah LM, Peckham ME, Stilwill SE, Safazadeh G, Hutchins TA. Time for change? Radiologists highly concordant assessing change in stenoses on follow-up cervical spine MRI. The neuroradiology journal. 2023 Oct;36(5):588-92. [Google Scholar]
5 Ryan C, Roberts LC. Investigations for radiculopathy: The patient perspective. A qualitative, interpretative inquiry. Musculoskeletal Science and Practice. 2018 Feb 1;33:71-6. [Google Scholar]
6 Muhle C, Bischoff L, Weinert D, Lindner V, Falliner A, Maier C, Ahn JM, Heller M, Resnick D. Exacerbated pain in cervical radiculopathy at axial rotation, flexion, extension, and coupled motions of the cervical spine: evaluation by kinematic magnetic resonance imaging. Investigative radiology. 1998 May 1;33(5):279-88. [Google Scholar]
7 Kaye ID, Sebastian AS, Wagner SC, sem*nza N, Bowles D, Schroeder GD, Kepler CK, Woods BI, Radcliff KE, Kurd MF, Rihn J. No Difference in Neck Pain or Health-Related Quality Measures Between Patients With or Without Degenerative Cervical Spondylolisthesis. Global spine journal. 2023 Jul;13(6):1641-5. [Google Scholar]