Cervical Spine Imaging in Acute Traumatic Injury

Aka: Cervical Spine Imaging in Acute Traumatic Injury, Acute Cervical Spine Imaging

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II. Indications: C-Spine Imaging in Acute Traumatic Injury

  1. Decision Rules
    1. NEXUS Criteria
    2. Canadian Cervical Spine Rule
    3. PECARN C-Spine Imaging Rule (age <18 years)
  2. Strong indications
    1. Mental status less than alert or patient intoxicated
    2. Focal neurologic deficit
    3. Posterior midline neck tenderness
    4. Patient reports Neck Pain (especially if out of proportion to physical findings)
    5. Cancer (especially metastatic cancer)
    6. Advanced Arthritis or Degenerative Joint Disease
    7. Severe Osteoporosis
    8. Upper extremity Paresthesias
  3. Other indications
    1. Respiratory abnormality
    2. Neck spasm (immediately following injury)
      1. Paraspinous and trapezius Muscle spasm is expected following Whiplash and similar injuries
      2. However spasm should not be present immediately after injury (e.g. initial ED evaluation)
    3. Distracting injury (e.g. long bone extremity Fracture)
      1. See NEXUS for distracting injury criteria (and for controversy)
    4. Age over 65 years
      1. Advanced age is higher risk for Cervical Spine Injury (often occult)
        1. Cervical Spine imaging often accompanies head imaging for older adults with Closed Head Injury
        2. Canadian Cervical Spine Rule recommends C-Spine Imaging for all patients over age 65 years
      2. Consider not performing Cervical Spine imaging if all of the following criteria are met
        1. On exam, no external injury above the clavicles
        2. NO Altered Mental Status
        3. No Cervical Spine tenderness to palpation
        4. Williams (2022) Am J Emerg Med 53: 208-14 [PubMed]

III. Protocol: Imaging - Acute Traumatic Injury

  1. Precautions: Radiation risk
    1. CT Cervical Spine is associated with significant radiation exposure (especially to Thyroid Gland)
    2. CT Cervical Spine radiation dose at Thyroid averages 64 mSv in age <18 years
      1. Contrast with C-Spine XRay: <1 mSv
    3. CT Cervical Spine (contrast with 0.24-0.51% with C-Spine XRay) risk for Thyroid Cancer
      1. Thyroid Cancer excess Relative Risk is 13% for males and 25% for females
    4. Muchow (2012) J Trauma Acute Care Surg 72(2):403-9 [PubMed]
  2. Cervical Spine XRay Indications (inadequate in most cases where c-spine imaging is indicated)
    1. Non-severe mechanism of injury (see Cervical Spine CT for indications) and
    2. Adequate 3-view plain film C-Spine XRays can be obtained and
    3. Other CT imaging is not planned
  3. Cervical Spine CT Indications (first-line in most cases)
    1. See Cervical Spine CT for indications and findings
    2. Largely has replaced XRay in the U.S. for acute Trauma in adults
    3. Most severe Trauma cases warrant CT C-Spine if other CT imaging is obtained
      1. Examples: CT Head, chest/Abdomen/Pelvis
    4. Modern multidetector CT has excellent Test Sensitivity for Fractures and unstable spine injuries
      1. Multidetector CT rarely misses an unstable spine injury (Ligamentous Injury) that is identified on MRI
      2. Hale (2017) Childs Nerv Syst 33(11): 1977-83 [PubMed]
  4. MRI C-Spine Indications
    1. SCIWORA suspected (neurologic deficits with normal imaging) or
    2. Central Cord Syndrome suspected or
    3. Vascular neck injury suspected or
    4. Obtunded patients (or otherwise unreliable exams) or
    5. Pediatric patients (at some facilities if readily availability)
      1. Weigh risk of CT (radiation) with risk of MRI (delays, need for sedation)
  5. CT Neck Angiography
    1. Blunt neck injury may result in occult and initially masked major neck vascular injury
    2. Risk of Carotid Artery Dissection and thrombosis
    3. May be initially asymptomatic with subsequent vessel thrombosis and hemispheric stroke within 72 hours
    4. See Neck Vascular Injury in Blunt Force Trauma for CT Angiography criteria

IV. References

  1. Jang and Kaji (2013) Crit Dec Emerg Med 27(6): 2-9
  2. Hoffman (2000) N Engl J Med 343:94-9 [PubMed]
  3. Bagley (2006) Radiol Clin North Am 44(1): 1-12 [PubMed]

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