Population Covered By The Guidance
This pathway provides guidance on the imaging of C-spine trauma
Lead Researcher: Dr Abhishta Bhandari, Dr Edward Henley
Experts & Contributors: Dr Daren Gibson
Date reviewed: November 2024
Date Published: May 2025
Cervical Spine Fracture
Cervical Spine Fracture
Cervical Spine Fracture
Cervical Spine Fracture
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This pathway applies to adult patients only.
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CT is considered superior to x-ray for the diagnosis of C-spine injury thus is recommended for initial assessment of C-spine injury. X-ray may miss undisplaced fractures as well as potential for disc or facet capsular injury under appreciating degree of subluxation and rotation.
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The Canadian C-spine rule has shown to be slightly superior to NEXUS criteria for the diagnosis of C-spine injuries, although NEXUS criteria are more easily implemented in the clinical setting.
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Ages greater than 65, ankylosing spondylitis, DISH may have fractures with low energy trauma thus it is recommended for CT in the first instance.
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CTA or time-of-flight MRA (which does not use contrast) can be used to diagnose vascular injury, however most vascular injuries require no treatment, thus the treating clinician should consider the utility of imaging in low risk patients.
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MRI is the imaging modality of choice for suspected disc, spinal cord and ligamentous injury.
Date of literature search: Nov 2023
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
References
- Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. Journal of Trauma and Acute Care Surgery. 2009;67(3):651-9 (Review article).
- Hale AT, Alvarado A, Bey AK, Pruthi S, Mencio GA, Bonfield CM, et al. X-ray vs. CT in identifying significant C-spine injuries in the pediatric population. Childs Nerv Syst. 2017;33(11):1977-83 (Level III evidence).
- Rutsch N, Amrein P, Exadaktylos AK, Benneker LM, Schmaranzer F, Müller M, et al. Cervical spine trauma – Evaluating the diagnostic power of CT, MRI, X-Ray and LODOX. Injury. 2023;54(7):110771 (Level III evidence).
- Douglas GP, McNickle AG, Jones SA, Dugan MC, Kuhls DA, Fraser DR, et al. A Pediatric Cervical Spine Clearance Guideline Leads to Fewer Unnecessary Computed Tomography Scans and Decreased Radiation Exposure. Pediatr Emerg Care. 2023;39(5):318-23 (Level III evidence).
- Ten Brinke JG, Slinger G, Slaar A, Saltzherr TP, Hogervorst M, Goslings JC. Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre. Eur J Trauma Emerg Surg. 2021;47(3):781-9 (Level III evidence).
- Baratloo A, Ahmadzadeh K, Forouzanfar M, Yousefifard M, Ranjbar MF, Hashemi B, et al. NEXUS vs. Canadian C-Spine Rule (CCR) in Predicting Cervical Spine Injuries; a Systematic Review and Metaanalysis. Archives of Academic Emergency Medicine. 2023;11(1):(Level II evidence).
- McCallum J, Eagles D, Ouyang YD, Vander Ende J, Vaillancourt C, Fehlmann C, et al. Cervical spine injuries in adults? 65 years after low-level falls-A systematic review and meta-analysis. AMERICAN JOURNAL OF EMERGENCY MEDICINE. 2023;67:144-55.
- Reinhold M, Knop C, Kneitz C, Disch A. Spine Fractures in Ankylosing Diseases: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine Journal. 2018;8(2_suppl):56S-68S (Review article).
- Dunn CJ, Changoor S, Issa K, Moore J, Moontasri NJ, Faloon MJ, et al. Cervical Computed Tomography Angiography Rarely Leads to Intervention in Patients With Cervical Spine Fractures. Global Spine J. 2020;10(8):992-7 (Level III evidence).
- Beckmann NM, West OC, Nunez D, Jr., Kirsch CFE, Aulino JM, Broder JS, et al. ACR Appropriateness Criteria(®) Suspected Spine Trauma. J Am Coll Radiol. 2019;16(5s):S264-s85 (Review).
- Rebehn KA, Place HM. Cervical angiograms in cervical spine trauma patients 5 years after the data: has practice changed? Journal of Hospital Management and Health Policy. 2019;3(July):(Review article).
- Fourman MS, Shaw JD, Vaudreuil NJ, Dombrowski ME, Wawrose RA, Boakye LAT, et al. Cervical Spine Fractures: Who Really Needs CT Angiography? Spine (Phila Pa 1976). 2019;44(23):1661-7 (Level III evidence).
- Hussain O, Kaushal M, Agarwal N, Kurpad S, Shabani S. The Role of Magnetic Resonance Imaging and Computed Tomography in Spinal Cord Injury. LIFE-BASEL. 2023;13(8):(Level II evidence).
- Onoue K, Farris C, Burley H, Sung E, Clement M, Abdalkader M, et al. Role of cervical spine MRI in the setting of negative cervical spine CT in blunt trauma: Critical additional information in the setting of clinical findings suggestive of occult injury. J Neuroradiol. 2021;48(3):164-9 (Level III evidence).
- Haefeli J, Mabray MC, Whetstone WD, Dhall SS, Pan JZ, Upadhyayula P, et al. Multivariate Analysis of MRI Biomarkers for Predicting Neurologic Impairment in Cervical Spinal Cord Injury. American Journal of Neuroradiology. 2017;38(3):648-55 (Level III evidence).
- Bozzo A, Marcoux J, Radhakrishna M, Pelletier J, Goulet B. The Role of Magnetic Resonance Imaging in the Management of Acute Spinal Cord Injury. Journal of Neurotrauma. 2010;28(8):1401-11 (Level II evidence).
- Cornelius RS. Imaging of acute cervical spine trauma. Semin Ultrasound CT MR. 2001;22(2):108-24 (Review article).
- Tomycz ND, Chew BG, Chang Y-F, Darby JM, Gunn SR, Nicholas DH, et al. MRI Is Unnecessary to Clear the Cervical Spine in Obtunded/Comatose Trauma Patients: The Four-Year Experience of a Level I Trauma Center. Journal of Trauma and Acute Care Surgery. 2008;64(5):(Level III evidence).
- Ekhator C, Nwankwo I, Nicol A, Ekhator C, Nicol AT. Implementation of National emergency X-radiography utilization study (NEXUS) criteria in pediatrics: A systematic review. Cureus. 2022;14(10):(Review article).
- Wu X, Malhotra A, Geng B, Kalra VB, Abbed K, Forman HP, et al. Cost-effectiveness of Magnetic Resonance Imaging in Cervical Clearance of Obtunded Blunt Trauma After a Normal Computed Tomographic Finding. JAMA Surg. 2018;153(7):625-32 (Level 1 evidence).
- Rutsch N, Amrein P, Exadaktylos AK, Benneker LM, Schmaranzer F, Müller M, et al. Cervical spine trauma–Evaluating the diagnostic power of CT, MRI, X-Ray and LODOX. Injury. 2023;54(7):110771 (Level II evidence).
- Mower WR, Hoffman JR, Pollack CV, Jr., Zucker MI, Browne BJ, Wolfson AB. Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med. 2001;38(1):1-7
(Level II evidence).
Pathway User Guide
Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.
White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).
Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.
Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Computed Tomography
Computed Tomography (CT)
Computed tomography is the imaging modality of choice and is preferred over x-ray due to its superior sensitivity and specificity.
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CT is considered first line in the evaluation of c-spine trauma in both paediatric and adult patients due to incidence of non-displaced fractures that can be missed.
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Numerous studies have been released demonstrating the superiority of CT over x-ray
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Adherence to C-spine clearance criterion such as the NEXUS and Canadian C-spine rule may reduce the rate of CT thus avoiding unnecessary radiation exposure
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The Canadian C-spine rule has been shown to have a slightly higher diagnostic test accuracy than NEXUS (AUC=>0.9 vs >0.8) in a recent meta-analysis, however NEXUS remains more easily implemented in clinical practice due to its simplicity. There is a paucity of evidence regarding the use of NEXUS and Canadian C-spine rule in paediatric patients
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A recent systematic review and meta-analysis found that adults ≥65 are at risk of C-spine injury even after low-level falls, thus there must be a lower threshold for imaging in this age group.
CT C-spine is recommended in patients with ankylosing spondylitis and DISH even in those with minor trauma due to the vulnerability of the spine. CT/MRI whole spine is recommended subsequently if there is a fracture on MRI or CT scan.
Magnetic Resonance Imaging
Magnetic Resonance Imaging (MRI)
Can be used where spinal cord injury is suspected (for e.g the patient has focal neurological deficits) and when CT is negative for fracture. Can also be used to evaluate for ligamentous injury.
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Magnetic resonance imaging is the modality of choice when spinal cord injury or ligamentous injury is suspected
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MRI has the added benefit over CT of revealing contusion/infarcts in the cord, bone contusions/fractures, haemorrhages and soft tissue injuries.
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Imaging sequences may differ between institutions due to MRI capabilities, but sequences recommended include T1-weighted imaging, T2-weighted imaging, T2 fat-suppressed imaging and T2*-weighted imaging. The most important sequences being short tau inversion recovery (STIR) and T2-weighted imaging due to their high sensitivity for injury and pathology.
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Indications
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Clinical evidence of spinal cord injury, especially incomplete injury
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Neurological deficits not explained by plain film or CT findings
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Patients with injuries requiring posterior stabilisation to exclude concomitant disc herniations that might alter the surgical approach
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MRI is not necessary for clearing the C-spine in patients without neurologic deficit, in a study of 690 comatose patients.
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Limitations
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Longer imaging time
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Inability to fully characterise vertebral fractures
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Technical difficulties in clinically unstable patients and patient risk during transport
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Potential delay in accessing the service after hours or if patient deteriorates and requires ICU or Anaesthetic support.
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An MRI may lead to a delay in surgery when urgent cord decompression is required, as determined by the spinal surgical team
CT angiography (CTA)
Computed Tomography Angiogram (CTA)
Can be used when a suspected vascular injury has occurred particularly when there is blunt force to the neck.
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CT angiography should be considered in those patients with blunt trauma with suspected vascular injury.
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This is particularly important in patients with upper cervical C1-3 fractures and new focal neurology..
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Magnetic resonance angiography is an appropriate alternative to CTA.
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Patients with vascular injury often do not receive surgical intervention or may not qualify for anticoagulants, thus prior to ordering angiography it may be worth considering whether the patient would benefit from imaging in the first instance.
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For further information please visit the suspected blunt cerebrovascular injury pathway: Suspected blunt cerebrovascular injury