When is a cervical spine (Computed Tomography) CT scan recommended?

Cervical Spine CT Scan Recommendations

CT cervical spine without IV contrast is the preferred initial imaging modality for patients with suspected acute cervical spine trauma when imaging is indicated by NEXUS or Canadian C-Spine Rule (CCR) clinical criteria. 1, 2

When is Cervical Spine Imaging Indicated?

• Imaging is not recommended for patients 16-65 years of age with suspected acute blunt cervical spine trauma when they meet low-risk criteria according to NEXUS or CCR 2
• Imaging should be considered when patients meet any of the following NEXUS criteria:
  • Midline cervical tenderness
  • Focal neurologic deficit
  • Altered level of consciousness
  • Intoxication
  • Distracting injury 2
• Patients over 65 years of age should be considered for imaging even with lower-risk NEXUS criteria 2

Initial Imaging Modality Selection

• CT cervical spine without IV contrast is the gold standard for identification of cervical spine fractures 2, 1
• CT significantly outperforms radiographs, identifying approximately three times more fractures than plain films 2, 3
• CT without IV contrast provides detailed visualization of bony structures, alignment, and fractures without unnecessary contrast media exposure 1
• Multiplanar reconstructions from CT data allow comprehensive assessment in multiple planes 1, 4

When Additional Imaging is Needed After Initial CT

• MRI cervical spine without IV contrast is indicated in the following scenarios:

  • Confirmed or suspected cervical spinal cord or nerve root injury 2
  • Clinical or imaging findings suggesting ligamentous injury 2, 1
  • Obtunded patients with negative initial CT 2, 1
  • Persistent neck pain or tenderness despite negative CT 5
  • Upper extremity neurological deficits (highest positive predictive value for CT-occult injuries) 5

• MRI will identify soft-tissue injuries in 5-24% of blunt trauma patients with negative cervical spine CT 2

• Recent multicenter trials show that CT has 98.5% sensitivity for clinically significant injuries, but a small but significant incidence of missed injuries warrants MRI in select cases 2

Role of Other Imaging Modalities

• Plain radiographs have largely been supplanted by CT for assessment of traumatic cervical spine injury 2

  • May be useful as a problem-solving tool in case of motion artifacts on CT 2
  • A single lateral out-of-collar radiograph after negative CT may help assess for ligamentous instability in select cases 6

• CT myelography can assess traumatic spinal canal narrowing but is inferior to MRI for cord contusion, hemorrhage, and nerve root injuries 2

• CTA head and neck with IV contrast is appropriate only when there are clinical or imaging findings suggesting arterial injury 2, 1

Common Pitfalls to Avoid

• Relying solely on CT in patients with neurological symptoms - CT is inferior to MRI for identifying soft-tissue injuries such as epidural hematoma, cord contusion, and ligament sprains 2, 7
• Using contrast-enhanced CT when non-contrast CT would suffice, unnecessarily exposing patients to contrast media risks 1
• Overlooking the need for MRI in patients with persistent neck pain or neurological symptoms despite negative CT 5
• Failing to recognize that CT has limited sensitivity (32%) for isolated ligamentous injuries compared to MRI 7
• Overlooking C2 fractures on CT, which may be obscured by dental artifacts or occur in the horizontal plane of the scan 3