The guidelines established by the New York State Workers Compensation Board are designed to assist healthcare professionals in conducting diagnostic studies for individuals with specific health conditions. These directives aim to support physicians and healthcare practitioners in determining the appropriateness and effectiveness of various diagnostic procedures as part of a comprehensive healthcare assessment.

Healthcare professionals specializing in the application of diagnostic studies can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable diagnostic approaches for their patients.

It is crucial to emphasize that these guidelines are not meant to replace clinical judgment or professional expertise. The ultimate decision regarding diagnostic studies should involve collaboration between the patient and their healthcare provider.

Imaging Studies

X-Ray Imaging

It is advisable to perform X-ray imaging of the cervical spine as clinically indicated for assessing the bony anatomy of the cervical spine. This evaluation may include oblique views for the neural foramina and open-mouth views for the dens.

Additionally, flexion and extension views are recommended as clinically indicated to assess spinal instability and the position of the dens relative to the anterior aspect of the C1 ring vertebra. It is important to specify the mechanism of injury and provide specific indications for the imaging on the request to assist the radiologist and x-ray technician in their assessment.

Magnetic Resonance Imaging (MRI)

It is recommended to perform MRI in select patients with specific indications. These indications include suspected nerve root compression, myelopathy for evaluating the spinal cord, differentiation or ruling out masses, infections like epidural abscesses or disc space infection, bone marrow involvement by metastatic disease, and suspected disc herniation or cord compression/contusion following severe neck injury. Immediate MRI should be conducted if there is a question of infection or metastatic disease with cord compression.

However, MRI is contraindicated in patients with certain implanted devices. Generally, high-field conventional MRI provides the best resolution, but a lower field scan may be indicated for patients who cannot fit into a high-field scanner or experience claustrophobia despite sedation. The frequency is typically once, but inadequate resolution on the first scan may require a second MRI using a different technique.

A subsequent diagnostic MRI may be a repeat of the same procedure if the initial study was of inadequate quality. Patients should discuss any concerns or questions with the MRI center and/or radiologist. Note that the presence of ferrous material/metallic objects in the tissues may be a contraindication for MRI due to potential hazards caused by the magnetic field.

MRI With and Without Contrast

It is recommended to perform MRI with Gadolinium enhancement in specific cases, including patients who have undergone prior cervical surgery or have concerns for malignancy or infection. The use of Gadolinium enhancement for the MRI study may be necessary in these situations.

However, the request for Gadolinium-enhanced MRI should consider any underlying medical conditions that could contraindicate an enhanced MRI. This ensures that the imaging procedure is tailored to the individual’s health status and needs.

Specialized MRI Scans

It’s advisable to consider an MRI with 3-dimensional reconstruction for certain individuals. This can be particularly useful as a diagnostic step before surgery, providing precise details about the features, location, and spatial connections between soft tissues and bones.

On the other hand, dynamic-kinetic MRI of the spine is not recommended.

Computed Axial Tomography (CT)

It’s advisable for certain patients to consider Computed Axial Tomography (CT). CT is particularly effective in providing clear visuals of bones and is employed to further assess suspected fractures or bony masses that might not be clearly visible on regular X-rays. In some cases, CT can complement MRI scans, offering a more detailed view of bony osteophyte formation in the neural foramen. It’s commonly used when there’s suspicion of a cervical spine fracture, especially if plain films are inconclusive. CT scanning is also valuable for identifying congenital anomalies at the skull base and C1-2 levels.

However, it’s worth noting that CT scans may not be ideal for the C6-7 or C7-T1 levels due to potential shoulder artifacts. When there are ferrous or metallic materials present in the tissues, opting for CT is preferable over an MRI. It’s essential to bear in mind that CT examinations come with a significant radiation dose and associated risks. In cases where patients can’t tolerate an MRI, a CT scan might be used to assess the presence of cervical disc herniation and/or stenosis, with CT myelography providing enhanced clarity in these conditions.

Myelography

Myelography involves injecting a contrast material into the spinal subarachnoid space, followed by X-rays or a CT scan to illuminate the anatomy. In certain cases, it is suggested for specific individuals. This procedure can serve as a diagnostic step before surgery, offering precise details about the characteristics, location, and spatial relationships among soft tissue and bony structures.

It’s typically recommended for patients where the potential clinical benefits outweigh associated risks. Myelography might be considered when, due to case-specific circumstances, MRI (or the preferred alternative testing) is either unavailable, inconclusive, not clinically necessary, or poses clinical contraindications.

CT Myelography

CT Myelogram provides more intricate insights into the relationships between neural elements and surrounding anatomy. It is suggested for specific individuals, particularly those with a history of multiple prior operations or tumorous conditions, solely for pre-surgical testing purposes.

Myelography, including CT myelography, is recommended in unique patient-specific situations, such as the presence of implanted metal hindering MRI, ambiguous findings of disc herniation on MRI, spinal stenosis, or post-surgical scenarios necessitating myelography for patients unable to tolerate an MRI. However, using myelography (including CT and MRI myelography) as the primary diagnostic study for cervical root compromise is not advisable.

This testing might be considered for select patients where the clinical benefits outweigh the risks, especially in situations where MRI or the preferred alternative is unavailable, inconclusive, not clinically necessary, or clinically contraindicated. It’s essential to note that potential complications of this more invasive technique include pain, infection, and allergic reactions.

Bone Scan (Radioisotope Bone Scanning)

99M Technetium diphosphonate uptake is indicative of osteoblastic activity and can serve as a valuable tool in identifying metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory lesions. It is advised to utilize this method for assessing neoplasia, identifying hidden fractures, or detecting infections.

Bone scanning, employing this technique, proves to be a beneficial diagnostic test in specific situations that pertain to a minority of patients. It is particularly useful for diagnosing neoplasia, suspected metastases, infections like osteomyelitis, inflammatory arthropathies, and concealed fractures.

Dynamic (Digital) Fluoroscopy

Dynamic [Digital] Fluoroscopy of the cervical spine assesses the movement of intervertebral segments by utilizing a video fluoroscopy unit to record images while the individual engages in cervical flexion and extension. This process captures the anatomical motion of the spine and stores it in a computer. It is suggested to employ Dynamic Fluoroscopy in specialized trauma centers for the evaluation of the cervical spine, ensuring comprehensive visualization from C1 to T1 if the procedure is carried out.

Other Tests

Electrodiagnostic Studies (EDX)

Electrodiagnostic Studies (EDX) encompass needle EMG (Electromyogram), peripheral nerve conduction velocity studies (NCV), and motor and sensory evoked potentials. It is advised and preferable that EDX conducted in an outpatient setting be carried out and interpreted by physicians certified in Neurology or Physical Medicine and Rehabilitation. Generally, electrodiagnostic studies serve as a complement to imaging procedures like CT, MRI, and/or myelography. While X-ray, CT, and MRI indicate structural changes, electrodiagnostic studies provide insights into neurological functional status.

– It is recommended to use needle EMG to support the diagnosis of radiculopathy or spinal stenosis in individuals experiencing neck pain and/or upper extremity complaints. Needle EMG can also aid in determining whether radiculopathy is acute or chronic.
– NCV is recommended to help rule out other potential causes for the symptoms (co-morbidity or alternate diagnosis involving peripheral nerves) and to confirm radiculopathy.

Portable Automated Electrodiagnostic Device (also known as Surface EMG):

– Not advisable to use surface EMG for the diagnostic assessment of neck pain or neck injuries.

Somatosensory Evoked Potential (SSEP):

– It is recommended to employ SSEP in specific cases for assessing myelopathy, and it is commonly utilized during surgery.
– Not recommended for identifying radiculopathy.
– Indications: If significant radiating arm symptoms persist for more than four to six weeks after the injury onset, and there is no apparent level of nerve root dysfunction during examination, electrodiagnostic studies may be considered. These studies can also be helpful in determining the extent of injury in patients with an established level of injury.

Current Perception Threshold Evaluation (CPT):

– Not recommended as a diagnostic tool.

Injections – Diagnostic Atlanto-axial/atlanto-occipital:

– Not advised.

Provocative Discography:

– Not recommended.

Thermography: