What is the best initial radiology imaging for cervical (c) spine pathology?

Best Initial Imaging for Cervical Spine Pathology

CT of the cervical spine without IV contrast is the gold standard for initial imaging of suspected cervical spine trauma in patients who meet clinical screening criteria (NEXUS or Canadian C-Spine Rule). 1

Clinical Decision Framework

Step 1: Determine if Imaging is Needed

• Do NOT image patients 16-65 years old who fail to meet NEXUS or Canadian C-Spine Rule (CCR) criteria—these clinical decision rules have sensitivities of 81-100% for detecting significant cervical spine injury 1
• Image immediately if patient meets NEXUS or CCR criteria, which include: altered mental status, midline cervical tenderness, focal neurologic deficit, intoxication, or distracting injury 1

Step 2: Choose Initial Imaging Modality

CT cervical spine without contrast is the definitive first-line study for the following reasons:

• CT detects 3 times more fractures than plain radiographs—radiographs identify only about one-third of fractures visible on CT 1
• CT has 88.6-89.8% sensitivity and 99% specificity for cervical spine injuries 2
• CT is considered the gold standard for identifying bony cervical spine fractures across all risk stratifications 1

Plain radiographs have been largely supplanted and should not be used as the primary screening tool—they miss too many injuries and add no value when CT is available 1

Step 3: Determine if Additional MRI is Needed

MRI cervical spine without contrast is indicated as a follow-up study in specific scenarios:

Mandatory MRI Indications:

• Any neurologic symptoms or signs (cord injury, nerve root injury, myelopathy)—CT alone is inadequate for excluding soft-tissue pathology causing neurologic deficits 1
• Suspected or confirmed ligamentous injury—MRI is the gold standard for discoligamentous complex assessment 1
• Preoperative planning for unstable spine—MRI complements CT by evaluating disc herniation, epidural hematoma, and cord contusion 1

Selective MRI Indications (More Controversial):

• Obtunded patients with negative CT: Recent evidence suggests CT alone may be sufficient, as MRI rarely changes management and prolongs collar time without improving outcomes 1. However, the ReCONECT trial found MRI abnormalities in 23.6% of patients with negative CT (including 16.6% with ligamentous injury), with 11 patients requiring surgery 1
• Alert patients with persistent neck pain and negative CT: MRI detects soft-tissue injuries in 5-24% of cases with negative CT 1, though clinical significance is debated. A 2015 study showed most alert patients with tenderness can be cleared clinically without additional imaging 3

Key Performance Characteristics

CT Advantages:

• Superior for bony fractures (gold standard) 1
• Rapid acquisition in trauma setting 4
• 50.2% sensitivity for all injuries but 76.6% specificity 5

MRI Advantages:

• Superior for soft-tissue injuries: ligaments, cord contusion, epidural hematoma, disc herniation 1
• Detects injuries missed by CT in 5-24% of trauma patients 1
• 88.5% sensitivity with 96.9% specificity, identifying 14 cases correctly that CT missed 2
• Essential for detecting ligamentous instability in <1% of unexaminable patients not visible on CT 1

Critical Pitfalls to Avoid

• Never rely on plain radiographs alone—they miss 67% of fractures detected by CT and have only 36.4% sensitivity 1, 2
• Do not use LODOX for cervical spine clearance—it has only 5.3% sensitivity despite 100% specificity 2
• Do not add IV contrast to CT—it provides no benefit for detecting spinal injury and may obscure subtle fractures 1
• Do not skip MRI in neurologically symptomatic patients—CT misses critical soft-tissue injuries requiring surgical intervention 1
• Avoid flexion-extension views—they rarely demonstrate instability not already identified on standard imaging and are often inadequate 1

Special Populations

Children:

• CT remains superior to radiographs for high-risk pediatric patients 1
• Consider sedation risks versus imaging benefits, particularly when radiographs are normal 1
• Normal variants in children <8 years (pseudosubluxation, widened atlantodental interval) can complicate CT interpretation 1

Obtunded Patients:

• CT alone is increasingly accepted for cervical spine clearance in obtunded patients without neurologic findings—this approach reduces ICU stay, collar-related morbidity, and ventilator time without increasing missed injuries or mortality 1
• MRI adds diagnostic findings but often does not change management and prolongs collar immobilization 1