What is the recommended initial imaging for a patient with neck and hip pain after a motor vehicle accident (MVA)?

Initial Imaging Recommendations for Neck and Hip Pain After Motor Vehicle Accident

For a patient with neck and hip pain after a motor vehicle accident (MVA), radiography is the recommended initial imaging modality for both the cervical spine and hip. 1

Hip Pain Imaging

Initial Imaging

• Standard hip radiographs should include an anteroposterior (AP) view with 15 degrees of internal hip rotation and a cross-table lateral view of the affected hip 1
• Many institutions include an AP view of the pelvis for assessment of hip symmetry, either as part of the standard trauma evaluation or in conjunction with the dedicated hip series 1
• Cross-table lateral view is preferred over the frog-leg lateral view due to potential risk for fracture displacement with frog-leg technique 1
• Radiographs can be performed portably in the trauma bay, allowing for rapid diagnosis without moving the patient 1

Follow-up Imaging (if radiographs are negative but clinical suspicion remains)

• CT without IV contrast is the recommended next step if radiographs are negative or indeterminate but clinical suspicion for hip fracture remains 1
• MRI may be necessary if CT is negative but clinical suspicion persists, as MRI has higher sensitivity for detecting occult fractures and soft tissue injuries 1

Cervical Spine Imaging

Initial Imaging

• Radiography of the cervical spine is the recommended initial imaging modality for patients with neck pain after MVA 1
• Standard cervical spine radiographs should include anteroposterior and lateral views 1
• Flexion-extension radiographs are often inadequate in the acute setting due to limited motion and inadequate visualization of the lower cervical spine 1

Follow-up Imaging (if radiographs are negative but clinical suspicion remains)

• CT of the cervical spine has higher sensitivity (88.6%) than radiography (36.4%) for detecting cervical spine injuries 2
• MRI should be considered if:
  • CT is negative but neurological symptoms persist
  • There is persistent neck pain despite normal CT
  • Patient remains unexaminable 2, 3
• MRI is superior for detecting soft tissue injuries while CT is better for detecting vertebral fractures 3

Important Clinical Considerations

High-Risk Features

• MVA is a significant risk factor for continuous neck pain (OR = 5.3) 4
• Up to 63% of MVA patients may experience continuous neck pain at follow-up compared to 40% in non-MVA neck pain 4
• Delays in diagnosis of hip fractures are associated with increased costs, complication rates, hospital length-of-stay, and mortality 1
• A surgical delay of >12 hours significantly increases the adjusted risk of 30-day mortality in hip fracture patients 1

Common Pitfalls to Avoid

• Relying solely on clinical examination to rule out hip or cervical spine fractures, as physical examination alone is insufficient 1
• Using frog-leg lateral view for hip imaging in acute trauma, which can potentially displace fractures 1
• Assuming that absence of visible deformity excludes injury 5
• Failing to obtain additional imaging when clinical suspicion remains high despite negative initial radiographs 1, 2

Imaging Algorithm

1. Initial Evaluation: Obtain standard radiographs of both cervical spine and hip 1
2. If radiographs are positive: Proceed with appropriate treatment
3. If radiographs are negative but clinical suspicion remains:
   • For hip: Proceed to CT without IV contrast 1
   • For cervical spine: Proceed to CT of cervical spine 2
4. If CT is negative but symptoms persist:
   • For hip: Obtain MRI without IV contrast 1
   • For cervical spine: Obtain MRI to evaluate for soft tissue injuries 3

This approach ensures timely diagnosis while minimizing radiation exposure and optimizing detection of both bony and soft tissue injuries that can significantly impact morbidity and mortality 1, 2.