What are the recommended X-ray views for evaluating cervical and thoracic spine injuries after a motor vehicle accident?

Recommended X-ray Views for Cervical and Thoracic Spine After Motor Vehicle Accident

CT scanning is the gold standard for evaluating cervical and thoracic spine injuries after motor vehicle accidents, as it significantly outperforms plain radiographs in identifying fractures. 1

Cervical Spine Imaging

Plain Radiographs (if CT unavailable)

If CT is not available, cervical spine radiographs should include at minimum:

• Anteroposterior (AP) view
• Lateral view (must include visualization of the cervicothoracic junction)
• Open-mouth odontoid view
• Additional "swimmer's lateral view" if the cervicothoracic junction is not visible on the conventional lateral radiograph

The sensitivity of an adequate cervical radiographic series ranges from 72% to >99%, but many studies evaluating this have been small or retrospective 1. The NEXUS study demonstrated that plain radiographs detected only 60.8% of patients with cervical spine injuries, with a functional sensitivity for an adequate series of only 89.4% 1.

Limitations of Plain Radiographs

• Radiographs identify only about one-third of fractures visible on CT 1
• The odontoid view is often compromised in unconscious trauma victims by artifacts from tubes and cervical collars 1
• Up to 49% of cases may have poor visualization of the cervicothoracic junction, where up to 60% of cervical injuries occur 1
• Flexion-extension views are rarely helpful in acute trauma and are often inadequate due to limited excursion or poor visualization 1

Thoracic Spine Imaging

For thoracic spine evaluation after MVA, if radiographs are used, they should include:

• Anteroposterior view
• Lateral view
• Additional "swimmer's lateral view" of the upper thoracic spine if obscured by shoulders 1

Current Best Practice Recommendations

1. CT is the imaging modality of choice for both cervical and thoracic spine trauma evaluation after MVA 1

   • CT has a reported sensitivity of 94-100% for identifying thoracolumbar spine fractures 1
   • CT significantly outperforms radiographs in all risk stratifications 1

2. MRI has a complementary role when:

   • Neurological symptoms are present
   • Soft tissue injuries are suspected
   • CT findings are equivocal
   • Patient has persistent pain despite normal CT 1

Common Pitfalls to Avoid

• Relying solely on a lateral cervical spine view (inadequate sensitivity)
• Failing to visualize the cervicothoracic junction
• Not obtaining adequate views of C1-C2 (craniocervical junction)
• Misinterpreting suboptimal radiographs (accounts for 50-90% of missed injuries) 1
• Clearing the cervical spine in unconscious patients based on radiographs alone

Special Considerations

• Approximately 20% of spine injuries will have a second associated spinal injury at a noncontiguous level, supporting the need for complete spine imaging 1
• Thoracolumbar fractures are challenging to identify clinically, with only 48-75% identified on clinical examination 1
• In elderly patients (>65 years), consider imaging even with lower-risk clinical criteria, as sensitivity of clinical assessment is reduced in this population 1

CT has revolutionized spine trauma imaging and should be the primary modality when available, with plain radiographs reserved for settings where CT is unavailable or as a problem-solving tool in specific circumstances.