II. Indications: C-Spine Imaging in Acute Traumatic Injury
- Decision Rules
- Strong indications
- Mental status less than alert or patient intoxicated
- Focal neurologic deficit
- Posterior midline neck tenderness
- Patient reports Neck Pain (especially if out of proportion to physical findings)
- Cancer (especially metastatic cancer)
- Advanced Arthritis or Degenerative Joint Disease
- Severe Osteoporosis
- Upper extremity Paresthesias
- Other indications
- Respiratory abnormality
- Neck spasm (immediately following injury)
- Paraspinous and trapezius muscle spasm is expected following Whiplash and similar injuries
- However spasm should not be present immediately after injury (e.g. initial ED evaluation)
- Distracting injury (e.g. long bone extremity Fracture)
- See NEXUS for distracting injury criteria (and for controversy)
III. Protocol: Imaging - Acute Traumatic Injury
- Precautions: Radiation risk
- CT Cervical Spine is associated with significant radiation exposure (especially to Thyroid Gland)
- CT Cervical Spine radiation dose at Thyroid averages 64 mSv in age <18 years
- Contrast with C-Spine XRay: <1 mSv
- CT Cervical Spine (contrast with 0.24-0.51% with C-Spine XRay) risk for Thyroid Cancer
- Thyroid Cancer excess Relative Risk is 13% for males and 25% for females
- Muchow (2012) J Trauma Acute Care Surg 72(2):403-9 [PubMed]
-
Cervical Spine XRay Indications (inadequate in most cases where c-spine imaging is indicated)
- Non-severe mechanism of injury (see Cervical Spine CT for indications) and
- Adequate 3-view plain film C-Spine XRays can be obtained and
- Other CT imaging is not planned
-
Cervical Spine CT Indications (first-line in most cases)
- See Cervical Spine CT for indications and findings
- Largely has replaced XRay in the U.S. for acute Trauma in adults
- Most severe Trauma cases warrant CT C-Spine if other CT imaging is obtained
-
MRI C-Spine Indications
- SCIWORA suspected (neurologic deficits with normal imaging) or
- Central Cord Syndrome suspected or
- Vascular neck injury suspected or
- Obtunded patients (or otherwise unreliable exams) or
- Pediatric patients (at some facilities if readily availability)
- Weigh risk of CT (radiation) with risk of MRI (delays, need for sedation)
- CT Neck Angiography
- Blunt neck injury may result in occult and initially masked major neck vascular injury
- Risk of Carotid Artery dissection and thrombosis
- May be initially asymptomatic with subsequent vessel thrombosis and hemispheric stroke within 72 hours
- See Neck Vascular Injury in Blunt Force Trauma for CT Angiography criteria
IV. References
- Jang and Kaji (2013) Crit Dec Emerg Med 27(6): 2-9
- Hoffman (2000) N Engl J Med 343:94-9 [PubMed]
- Bagley (2006) Radiol Clin North Am 44(1): 1-12 [PubMed]
