423: Is Muscle Size or Fat Infiltration the Best Indicator of Neck Pain? A Systematic Review

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic primary musculoskeletal pain, Developing methodology/technology, Pain in Special Populations , Imaging (e.g. fMRI, PET, MRS)

Background and Aims: Muscle size and fat infiltration are commonly used markers of neck pain disorders, yet it remains unclear which specific measurements and cervical muscles provide the most reliable indicators. Some studies report more pronounced changes in superficial muscles, while others highlight alterations in deep cervical muscles. These inconsistencies may arise from differences in measurement techniques. For example, cross-sectional area (CSA) does not fully capture three-dimensional muscle morphology or the spatial distribution of fat, which can be assessed through volume measurements. This review aimed to determine which measurements, and which specific cervical muscles provide the most robust indicators of neck pain disorders.

Methods: A systematic search of four databases was conducted to June 2025. Case-control studies in adults with neck pain disorders compared to healthy controls were included. Outcome measures included were CSA and volume-based magnetic resonance imaging measures of muscle size and fat in cervical spine muscles. The Newcastle-Ottawa Scale was used to evaluate study quality. A quality effects model was used in the meta-analysis to calculate pooled weighted mean differences (WMDs) and 95% confidence intervals (95% CI).

Results: Twenty-eight studies involving 1013 patients and 831 controls were analyzed. Muscle fat measurements demonstrated a greater difference between individuals with neck pain disorders and healthy controls than muscle size. The most consistent differences in muscle fat CSA were observed in the deep cervical muscles, especially the multifidus (WMD=10.45; 95% CI= [6.68, 14.22] I²=94%), semispinalis cervicis (WMD=9.08; 95% CI= [5.44, 12.73] I²=95%), and splenius capitis (WMD=5.43; 95% CI= [2.43, 8.43] I²=93%). Muscle size findings were variable, with studies reporting enlargement, atrophy, or no change.

Conclusions: Muscle fat measures of the deep cervical extensor muscles represent a more consistent imaging biomarker than muscle size in predicting neck pain disorders.
These results indicate that evaluating myosteatosis with MRI could be more effective than measuring muscle size when studying muscle changes in neck disorders. Nevertheless, further research, including diagnostic accuracy and longitudinal studies, is necessary to clarify its clinical relevance. Developing standardized imaging protocols and segmentation techniques will be essential to improve consistency across studies and to allow future evaluation of both diagnostic and prognostic potential.

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Presenting Author: Roeya Eshaghimoghaddam
Submitting Author: Roeya Eshaghimoghaddam

Senior Author: Roeya Eshaghimoghaddam

IASP 2026 Global Year theme of Neuropathic Pain: No

• Roeya Eshaghimoghaddam: PhD student - Australian National University
• Alexandra Webb: Associate Professor - Australian National University
• Diana Perriman: Associate Professor - Australian National University
• Stephanie Woodely: Professor - University of Otago
• Martin Dobes: Associate Professor - Australian National University