|Year : 2018 | Volume
| Issue : 1 | Page : 29-32
Cervical Spine MRI findings in the evaluation of persistent neck pain in a Nigerian Tertiary Hospital
SA Olarinoye-Akorede, MZ Ibrahim, G Kajogbola
Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||23-Mar-2018|
Dr. S A Olarinoye-Akorede
Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Background: Neck pain is almost as common as low back pain; however, it is under reported especially among Nigerians. Neck pain has a diverse etiology, so it poses a diagnostic dilemma. Objective: To present the pattern of magnetic resonance imaging (MRI) findings in patients with persistent neck pain in resource poor setting. Materials and Methods: A two-year retrospective review of 130 patients (age range 13 to 78 years) who were referred for cervical MRI scan due to neck pain at the radiology department of Ahmadu Bello University Teaching Hospital, Zaria. All the patients were scanned using a single Siemens (Magneto Concerto) MRI scanner. Sagittal T1-weighted and T2-weighted fast spin echo images were acquired, and axial images and contrast-enhanced studies were done only when required. Results: This study included 96 males and 34 females with a mean age, at presentation, of 48.4 (±3.6 years) and modal age group of 41–50 years. Cervical spondylosis constituted the major finding 84 (64.6%). Other causes of neck pain were tuberculosis of the cervical spine (0.8%), vitamin B12 deficiency (0.8%), and spinal neoplasm (1.5%). Cervical cord compression was seen in 69 (53.1%) patients. In a few patients [5 (3.8%)], however, no abnormality was seen on MRI. Conclusion: Cervical spondylosis is the most common cause of neck pain in our environment. MRI obviates the need for a barrage of investigations and threshold should be lowered where the modality is available and in the appropriate clinical setting.
Keywords: Cervical spine, MRI, neck pain, Zaria
|How to cite this article:|
Olarinoye-Akorede S A, Ibrahim M Z, Kajogbola G. Cervical Spine MRI findings in the evaluation of persistent neck pain in a Nigerian Tertiary Hospital. Niger J Basic Clin Sci 2018;15:29-32
|How to cite this URL:|
Olarinoye-Akorede S A, Ibrahim M Z, Kajogbola G. Cervical Spine MRI findings in the evaluation of persistent neck pain in a Nigerian Tertiary Hospital. Niger J Basic Clin Sci [serial online] 2018 [cited 2021 Jun 16];15:29-32. Available from: https://www.njbcs.net/text.asp?2018/15/1/29/228366
| Introduction|| |
The cervical spine has a complex structure‒made up of seven vertebrae, disc elements, and synovial joints, all held together by ligaments and muscles. It does not bear the same weight burden as the lumbar spine; however, it has a greater mobility while compromising stability. The cervical spine is thus the most common spinal segment predisposed to compressive myelopathy. Neck pain is said to be almost as common as low back pain in the general population., In South West Nigeria, it is more common than low back pain, whereas among whites, it is the fourth leading cause of disability. Although most acute episodes resolve without treatment, nearly 50% will progress chronically, and it could be associated with distressful outcomes despite novel surgical techniques.
Neck pain has a diverse etiology, and until about two decades ago, there were no guidelines for treating neck pain. The major etiologies are degeneration and trauma. This is attributable to the erect posture of man coupled with increased mobility, that is, about 600 movements per hour.,
MRI has a superior ability over other imaging modalities in assessing the spinal soft tissue elements like the bone marrow, ligaments, disc elements, and the spinal cord in its entirety. It is therefore most suited for assessing the etiology of neck pain.
This study is presented to document the pattern of cervical MRI findings in patients with persistent neck pain in our locality.
| Materials and Methods|| |
A two-year retrospective study was conducted at Ahmadu Bello University Teaching Hospital. The study involved 130 patients who were referred to the radiology department for MRI scan with complaints of neck pain. Their MRI scans were extracted from our department's MRI database and clinical information was obtained from their hospital records.
All examinations were done using a single Siemens 0.2Tesla (magneto Concerto) scanner. The T1-weighted sagittal image (TR/TE = 345–478/13–15; field of view = 251 mm × 251 mm; section thickness = 4.5 mm) and T2-weighted sagittal image (TR/TE = 3500-4500/110–128; field of view = 253 mm × 253 mm; section thickness = 4.5 mm) were acquired using the fast spin echo sequence. When required, axial images (TR = 4520–7500, TE = 110–120, ST = 5.4 mm) and post gadolinium-enhanced T1-weighted contrast studies were employed.
The acquired images were reviewed and reported independently by 2 consultant radiologists (O-AS and IPO) with 8 years and 13 years of experience.
The statistical analysis was done by statistical package for social sciences SPSS version 20. (SPSS Inc., Chicago, IL, USA). Tables and charts were extracted for illustrations; we also employed simple descriptive statistics in form of means, frequencies, and percentages.
| Results|| |
Cervical MRI scans of 130 patients were reviewed for this study comprising 96 (73.8%) males and 34 (26.2%) females. The sex ratio (M: F) was 2.88: 1. The patients' ages ranged from 13 years to 78 years with a mean age of 48.4 (±3.6) years. The age group with the highest frequency of presentation for neck pain was 41–50 [Table 1].
The patients were engaged in various occupational activities as follows: 61 (46.9%) were civil servants, 23 (17.6%) were farmers, 13 (10%) were students, 12 (9.2%) were retired, 10 (7.7%) were artisans, 10 (7.7%) were housewives, and only 1 man (0.7%) was unemployed.
Associated with pain were one or more of the following additional complaints: radiculopathy 65 (50%), trauma 39 (30%), paraparesis 21 (16.1%), quadriparesis 3 (2.3%), neck stiffness 16 (12.3%), upper limb numbness 52 (40%), muscle (deltoid) wasting 4 (3.07%), and sphincteric dysfunction 3 (2.3%) [Table 2].
Degenerative changes (spondylosis) accounted for 64.6% of the radiologic findings whereas the nondegenerative changes were found in (35.4%) [Figure 1]. Males constituted 72% of patients with degenerative changes, whereas 28% occurred in females. The non-spondylotic findings include trauma (25.4%), infective (0.8%), metabolic (0.8%,) syringomyelia (3.1%), and neoplastic (1.5%).
In 5 (3.8%) of the patients, there was no radiologic abnormality documented. Overall, the specific radiological findings of spondylosis were distributed as follows: osteophytosis (72.3%), disc herniation (67.7%), disc dehydration (52.3%), exit foraminal stenosis (39.2%), disc space narrowing (24.6%), listhesis (14.6%), and cervical cord compression (53.1%) [Table 3] and [Figure 2]a, b]. The most prevalent disc level affected by spondylosis was C4/5 level and most patients were in the 5th decade.
|Figure 2a and b: T2Weighted mid sagittal MRI images (a) intervertebral disc dehydration from C2 to C7.Anterior and posterior marginal osteophytosis involving C4 to C7 vertebral bodies with irregularities of adjacent end plates. Disc elements are protruded centrally and anteriorly at these levels. (b) there is destruction with heterogeneous signal intensity of C5 vertebra from a thyroid metastatic disease. Compression and bowing or the spinal cord is seen and degenerative changes are also present|
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In this study, trauma was next in frequency of occurrence after spondylosis. Findings ranged from normal to vertebral collapse, spondylolisthesis, spinal cord compression, and cord injury (that is, signal change within the cord) that could represent edema, hematoma or cord infarction [Figure 3].
|Figure 3: (a) Severe degenerative changes with reversal of cervical curvature, disc space obliteration from C3 to C5. There is bowing of the cord (b) post traumatic retrolisthesis of C6 under C5 vertebral body with a focus of T2W hyperintensity within the cord, signifying severe cord injury.|
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Acute infection (meningitis) and chronic infection by tuberculosis and metabolic and neoplastic processes were less common causes.
Neck pain was associated with cord compression in 69 (53.1%) of the patients [Table 4]. Again, spondylosis was the most common cause of myelopathy in 42 (60.1%).
| Discussion|| |
Neck pain, when of musculoskeletal origin only, is usually self-limited. However, persistent neck pain should be evaluated irrespective of etiology. Our study shows a male preponderance across all age groups with an overall male to female ratio of 2.88:1. This gender difference was also documented in a similar studies in Nigeria , and Bangladesh. It was the reverse in a study in Finland, whereas there was no difference among the males and females that were studied in Iran. Also, perhaps the fact that in this part of the country, the working class consists of more males could also account for the gender disparity.
Apart from age and sex, occupation has been identified as one of the risk factors of neck pain and cervical spondylosis. In our study population, civil servants constituted the most (46.9%) patients affected, as with the other studies. This was followed by farmers 17.6% whereas 10% were students. It has been observed that work habits affect posture. Occupation would seem partly responsible for the low prevalence among housewives (7.7%) and unemployed men (0.7%) in our study.
Cervical spondylosis accounted for the commonest radiological finding in neck pain. The prevalent features of spondylosis were osteophytosis, disc herniation, disc dehydration, and compression of exit foramina. Disc space narrowing was not a common feature of spondylosis in our series. Cervical spondylosis also constituted 60.1% of all the cases of myelopathy. Our findings agree with both facts that cervical spondylosis is the commonest cause of neck pain and that spondylosis is the commonest cause of cervical cord dysfunction.,,,
Radiological findings of spondylosis can be found even in asymptomatic individuals, including children., The prevalence of cervical degenerative disease in a study was found to be 3% in 15-year olds and 100% in 65-year olds. In general, symptomatic patients could present no radiologic finding. Also, little correlation was found between radiological features and severity of disease and duration of symptoms. The pre-morbid dimension of the cervical canal is thought to be responsible for this discrepancy. We found no radiologic abnormality in 5 patients presenting with spondylotic symptoms. The few number of negative scans among symptomatic patients could be explained by cost. In our environment, the value of history and thorough clinical evaluation cannot be overemphasized, as the high cost of the examination would not permit unwarranted MRI requests.
The greatest cause of spinal cord dysfunction after 50 years of age is the spondylotic myelopathy., This is also supported by our findings. Our analysis revealed that more than half of the patients, 69 (53.1%), who complained of neck pain had associated myelopathy that ranged from mild compression, cord deformity, and hyperintense T2-weighted signal change within the cord. Thus, one in every two patients who underwent MRI for neck pain had some cord compromise.
Other less common causes of neck pain seen in our study included a 24-year-old female patient diagnosed with spinal TB. Tuberculosis is not uncommon in Zaria; however, it is rare in the cervical spine. Kovarsh et al. studied 100 cases of spinal tuberculosis and found 69% in the thoracolumbar spine and only 5% in the cervical spine. As with the common dorsolumbar disease, the findings were those of endplate destruction, vertebral collapse, gibbus, cord compression, and para vertebral abscess.
Out of the two patients with neoplastic disease, one had a primary tumor while the other had metastasis from thyroid carcinoma.
In the past before the acquisition of MRI, the diagnosis of spinal pathology rested on a combination of imaging methods: plain films, computed tomography, and myelography. More obsolete were discography and epidurography. MRI has exceeded the capacities of these methods in radiation safety, multiple imaging planes, and superior soft tissue resolution. It is the gold standard even in our environment despite low-field strength of the few available scanners.
The American College of Radiology (ACR) recommends an appropriateness criteria for the evaluation of patients with chronic neck pain irrespective of the etiology. They recommend 5 standard radiographic views (that is, anteroposterior, lateral, open-mouth, and both oblique views) as the initial imaging modality. This should suffice for patients with normal X-ray findings and no neurologic signs as well as for patients with radiographic evidence of spondylosis or trauma but no neurologic signs or symptoms. However, when neurologic signs or symptoms are present, MRI is the investigation of choice even with normal plain X-ray findings (if there are no contraindications to MRI).
| Conclusion|| |
A careful medical evaluation is mandatory in all patients presenting with chronic neck pain to not overlook a serious pathology or to over indulge a simple musculoskeletal pain. The early diagnosis of myelopathy in patients with neck pain would help reduce the burden of incapacitating morbidity.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]