The guidelines established by the New York State Workers Compensation Board are intended to assist healthcare professionals in utilizing imaging and testing procedures for individuals with specific health conditions. These directives aim to support physicians and healthcare practitioners in determining the appropriateness and effectiveness of various diagnostic approaches as part of a comprehensive healthcare assessment.
Healthcare professionals specializing in the application of imaging and testing procedures can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable diagnostic techniques for their patients.
It is important to stress that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding imaging and testing procedures should involve collaboration between the patient and their healthcare provider.
Imaging
Clinical appropriateness guides the decision to obtain imaging of the cervical spine. Basic x-ray views, such as anteroposterior (AP), lateral, right and left obliques, swimmer’s, and odontoid, are considered, with lateral flexion and extension views employed for instability assessment. In certain cases, CT scans may be necessary for visualizing C7 and odontoid. MRI or CT is warranted when spinal cord injury is suspected, among other conditions discussed below. The request form for imaging should detail the mechanism of injury and specific indications to assist the radiologist and x-ray technician. Alert, non-intoxicated patients with isolated cervical complaints, lacking palpable midline cervical tenderness, neurologic findings, or other acute or distracting injuries elsewhere in the body, might not require imaging. Suggested indications for radiographic studies encompass:
– History of significant trauma, particularly high-impact motor vehicle accidents, rollovers, ejections, bicycle or recreational vehicle collisions, or falls from a height greater than one meter.
– Age over 65 years.
– Suspicion of fracture, dislocation, instability, or neurologic deficit – Quebec Classification Grade III and IV.
Unexplained or enduring cervical pain lasting a minimum of 6 weeks or pain exacerbated by rest. Additionally, indications for imaging include:
– Localized pain accompanied by fever, constitutional symptoms, suspected tumor, history of cancer, or suspected systemic illnesses like a rheumatic/rheumatoid disorder or endocrinopathy.
Laboratory Tests
Laboratory tests are seldom necessary during the initial evaluation unless there is a suspicion of systemic illness, infection, neoplasia, or an underlying rheumatologic or connective tissue disorder, as indicated by the patient’s history and/or physical examination. The following tests may be considered:
- Complete blood count (CBC) with differential: Recommended for patients with suspected infection, blood dyscrasias, or medication side effects.
- Erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), antinuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein (CRP): Recommended for detecting evidence of rheumatologic, infection, or connective tissue disorders.
- Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase: Recommended selectively for patients suspected of metabolic bone disease.
- Liver and kidney function: Recommended selectively for patients on prolonged anti-inflammatory use or other medications requiring monitoring.
- Serum Protein Electrophoresis: Recommended selectively in patients to evaluate for multiple myeloma, especially when imaging studies are inconclusive, such as a negative bone scan in the presence of an acute fracture.
Follow-Up Diagnostic Imaging and Testing Procedures
As extensively discussed in the General Principles section (A-13), the choice of diagnostic imaging studies is contingent upon the unique clinical presentation of the case, guided by clinical judgment. Moreover, there might be situations warranting a reconsideration or alternative diagnostic imaging. These situations encompass, but are not confined to, instances where a previous test lacks quality or fails to provide a diagnosis, when there are shifts in the clinical scenario (such as emergence or exacerbation of symptoms, preparation for surgery or therapeutic injections, etc.), or when monitoring clinical advancement (e.g., postoperatively) or deterioration over time is deemed necessary.
Making thoughtful decisions about the procedure(s) or the sequence in which multiple procedures are conducted is crucial for achieving the highest diagnostic accuracy, minimizing potential adverse effects on patients, and fostering clinical efficiency. Repeated procedures contribute to a rise in cumulative radiation exposure and the associated risks. Different diagnostic imaging procedures possess varying levels of sensitivity and specificity for any given diagnosis. The foundation for selecting and interpreting imaging studies should be established on clinical history, physical examination, and clinical judgment.
While plain X-rays often serve as a valuable starting point, they may not always suffice. Magnetic resonance imaging (MRI), myelography, or computed axial tomography (CT) scanning following myelography can offer valuable insights into various spinal disorders. It’s essential to acknowledge that repeat CT procedures escalate cumulative radiation exposure and associated risks. Under specific circumstances, as mentioned earlier, reconsideration or alternative imaging might be justified. The choice of one procedure over others typically hinges on multiple factors.
After the initial imaging, prompted by clinical indicators such as significant trauma or other “red flags” raising concerns about serious underlying conditions, and in the absence of a notable neurologic deficit, myelopathy, or progressive neurological changes, additional imaging is typically not necessary until conservative therapy has been attempted and proven unsuccessful. A treatment duration of at least four weeks, extending to six to eight weeks, is generally considered adequate before contemplating imaging procedures, but the clinician should exercise judgment in this matter. When diagnostic imaging findings don’t align with the clinical examination, priority should be given to objective clinical findings.
Research indicates that in the asymptomatic population over 40, the prevalence of disc degeneration exceeds 50%. Disc degeneration, evident as a loss of signal intensity on MRI, may stem from age-related changes, causing biochemical and structural alterations separate from traumatic injury, and may lack pathological significance. While disc bulging and posterior disc protrusion are not uncommon, they are more frequently symptomatic in the cervical spine than in the lumbar spine due to the smaller cervical spinal canal. In patients older than 40, mild reduction in the cross-sectional area of the spinal cord may be observed without myelopathy, requiring clinical correlation.
For further evaluation of neck injuries, the following studies can be employed based on the mechanism of injury, symptoms, and patient history. These studies are not presented in a specific order of preference, clinical indication, or utility, as these factors may vary depending on the specifics of each case.
