Chronic Neck Pain and a Normal MRI

Chronic Neck Pain and a Normal MRI

Introduction

A patient with chronic neck pain (lasting more than 12 weeks) and a normal MRI often becomes a medical conundrum. However, there is a significant body of scientific evidence-based knowledge to accurately diagnose and treat this type of patient. In a personal injury case the proper application of this knowledge is essential in proving the extent of the patient’s injuries.

Normal cervical MRI

First, we should spend some time discussing what constitutes a normal cervical (neck) MRI. A normal cervical MRI is one with no evidence of fracture, dislocation, subluxation, disc protrusion (herniation) or other significant pathology like infection, tumor or spinal cord compression. Normal also means the presence of age related changes. These changes include bony spurs and disc bulges. While some may characterize these changes as “degenerative,” they are in fact normal changes and can be seen in teenagers. In older patients, normal may even mean rather significant “degenerative changes,” such as spurring that impinges upon the sac surrounding the spinal cord. In this instance, normal is interpreted in the context of whether or not the changes occur from normal wear and tear and whether or not the injured patient had pre-existing symptoms relatable to the MRI findings.

MRI and facet injury

While an MRI can display many types of findings, there are some that it cannot. Common among these is an injury to the cervical facet joints. These joints are located to the side of and just behind the disc. MRI may show a fracture, a dislocation and occasionally a contusion or bone swelling of these joints. MRI won’t show an injury to the joint capsule or internal components of the joint, unlike an MRI of the knee, hip or shoulder. The reason is that the joint is small and these injuries are beyond the resolving capacity of MRI. This has been espoused in guidelines statements of multiple spinal medical societies. It is accepted as fact by those in the medical profession with expertise in treating and diagnosing these injuries.

The lack of an ability to diagnose facet injury on MRI is of significance, given that the facet joint is the most common cause of chronic neck pain in the normal population and is also the most common cause of neck pain in the whiplash population. After automobile accidents facet injury may account for up to 80% of cases of chronic neck pain. Therefore, an accurate diagnosis is essential. 

Diagnosing facet injuries

The accurate diagnosis of cervical facet injury comes in the form of a diagnostic procedure called a medial branch block. The medial branch is a branch of a nerve that arises from the opening between vertebrae. This branch senses pain from the facet joint. There are 2 nerves per facet joint. To perform the procedure the physician inserts an x-ray guided needle up against the nerve and injects a small drop of anesthetic. The patient is then examined. If there is no pain the test is positive, and the offending joint is identified. The test is then repeated at a separate setting. The repetition of the test confirms the diagnosis with a very low false positive rate. This second test is considered prima facie evidence of cervical facet injury. Once the diagnosis is made, appropriate treatment, usually in the form of a medial branch rhizotomy is rendered.

Defense experts may purport that the medial branch block should never have been performed to begin with, due to the paucity of MRI findings. This is self-serving ignorance of MRI’s inability to detect the facet injury. In addition, the reliability of dual medial branch blocks to diagnose the facet injury is usually attacked without any substantive information to back up the claim. A properly prepared plaintiff expert will have no problem refuting the claim, as diagnostic medial branch blocks are among the most well studied procedures and diagnostic tests in spinal medicine.

Conclusion

The proper diagnosis of a cervical facet injury is important for the proper treatment of the injured patient with neck pain. It’s important to recognize that this injury co-exists with a normal or degenerative MRI and a diagnostic block must be performed to reliably diagnose the condition and prove injury.

D. Daneeka, MD

The views expressed are the personal views of the author and do not represent the views of George Rappard MD, George Rappard MD Inc, the Los Angeles Minimally Invasive Spine Institute, its partners, employees or its clients. Furthermore, the information provided by the author is not intended to be expert or legal advice.

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