From the Guidelines
Assessment for cervical spine ligamentous injury should involve a combination of clinical examination and imaging studies, with MRI being the gold standard for detecting ligamentous injuries, particularly in patients with neurological deficits, persistent neck pain despite normal CT, or those who cannot be clinically cleared due to altered mental status. The initial evaluation should include a thorough neurological examination, checking for midline cervical tenderness, altered mental status, focal neurological deficits, and distracting injuries. The NEXUS criteria or Canadian C-spine Rules can help determine if imaging is necessary [ 1 ].
Key Considerations
- Plain radiographs may be used initially, but CT scan is more sensitive for bony injuries [ 1 ].
- MRI is superior to CT in identifying cervical spine ligament injuries and should be performed when there is a high suspicion of ligamentous injury [ 1 ].
- Dynamic flexion-extension radiographs may be used in conscious patients with neck pain but no neurological deficits to assess stability, though these should be performed under medical supervision [ 1 ].
- Clinical clearance without imaging may be appropriate for low-risk patients who are alert, sober, have no midline tenderness, no neurological deficits, and no distracting injuries.
Imaging Modalities
- CT scan: sensitive for bony injuries but may not detect ligamentous injuries [ 1 ].
- MRI: gold standard for detecting ligamentous injuries, particularly in patients with neurological deficits or persistent neck pain despite normal CT [ 1 ].
- Dynamic flexion-extension radiographs: may be used to assess stability in conscious patients with neck pain but no neurological deficits [ 1 ].
Clinical Approach
- Initial evaluation should include a thorough neurological examination and assessment of midline cervical tenderness, altered mental status, focal neurological deficits, and distracting injuries.
- The NEXUS criteria or Canadian C-spine Rules can help determine if imaging is necessary.
- A comprehensive approach is necessary because ligamentous injuries can cause spinal instability leading to neurological damage if missed, even when bony structures appear intact on initial imaging.
From the Research
Assessment of Cervical Spine Ligamentous Injury
To assess for cervical spine (c-spine) ligamentous injury, the following methods are utilized:
- Computed Tomography (CT) scan to evaluate bony injury and basic soft tissue evaluation 2
- Magnetic Resonance Imaging (MRI) for complementary evaluation of neural structures and soft tissues, including ligaments 3, 4, 2
- Dynamic upright C-spine X-rays to evaluate ligamentous integrity and bony alignment 3, 5
- Out-of-collar lateral radiograph after a negative CT scan to assess for instability in neurologically intact and non-obtunded patients 5
- Physician-controlled stretch, flexion, and extension examination under fluoroscopy to screen for and evaluate ligamentous injuries 6
Imaging Techniques
The choice of imaging technique depends on the clinical presentation and the need for evaluation of soft tissues and ligaments.
- MRI is the optimal study for soft tissue and ligamentous evaluation 5
- CT is fast and accurate for evaluation of bony injury, but may overlook ligamentous injury 5, 2
- Advances in CT processing, imaging sequences, and techniques have improved the sensitivity for detection of pathology and decreased imaging and interpretation time 2
Clinical Relevance
The most important role of imaging is to provide information to help direct patient care, including diagnosis, next steps in treatment plan, and prognosis 2.