What is the protocol to clear a trauma patient from imaging?

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Last updated: November 23, 2025View editorial policy

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Clearing a Trauma Patient from Imaging

For alert, evaluable trauma patients, use clinical decision rules (NEXUS or Canadian C-Spine Rule) to determine if imaging is needed; for obtunded blunt trauma patients, multidetector CT (MDCT) of the entire spine with submillimeter cuts (<3mm) is the primary clearance modality, and MRI should be reserved only for patients with neurological deficits referable to the spine. 1, 2

Alert, Evaluable Patients

Clinical clearance without imaging is appropriate when ALL of the following preconditions are met: 1

  • GCS 15 and fully alert 1
  • No intoxicants present 1
  • No neck pain or tenderness 1
  • No distracting injuries 1
  • Moving all four limbs normally 1

If any precondition fails, proceed to imaging with MDCT of the entire spine. 1

Obtunded Blunt Trauma Patients (OBTPs)

Primary Imaging: MDCT Protocol

MDCT of the entire spine is the definitive clearance modality for obtunded patients, with sensitivity approaching 100% for detecting unstable bony injuries. 1, 2

Technical requirements for adequate MDCT: 2

  • Complete visualization from skull base through C7-T1 junction 2
  • Axial slice thickness <3mm (ideally 1.5-2mm) 2
  • Sagittal and coronal reconstructions mandatory 2

Critical pitfall: Plain radiographs are inadequate and dangerous, missing approximately 15% of cervical injuries, with the cervicothoracic junction not visualized in up to 49% of cases. 2

Thoracolumbar Spine Clearance

CT is superior to plain imaging for thoracolumbar spine with 100% sensitivity and 97% specificity versus 73% sensitivity for plain films. 1

  • If CT chest/abdomen/pelvis (CT-CAP) already performed, use reformats for thoracolumbar evaluation 1
  • Evaluate entire spine when any fracture identified, as 16% have non-contiguous fractures 1
  • Do not perform plain radiographs of thoracolumbar spine in obtunded patients 1

MRI Considerations: When and Why Not

MRI should be obtained ONLY in obtunded patients with neurological deficits referable to the spine (weakness, sensory changes, or myelopathy). 1

The case against routine MRI after normal CT: 1

  • MRI after normal CT detects additional findings in 7.5% of patients 1
  • Only 0.29% require operative intervention 1
  • 4.3% receive prolonged collar application 1
  • False positive rate is 25-40%, with many findings representing clinically insignificant variations 1
  • No established criteria exist to distinguish significant from inconsequential MRI abnormalities 1

The risk-benefit calculation: Isolated ligamentous injury in blunt polytrauma ranges from only 0.1-0.7% (consistently under 1%), while prolonged immobilization causes significant morbidity. 1, 2

Obsolete Modalities

Dynamic fluoroscopy and flexion-extension radiography should not be used: 1, 2

  • Ability to visualize relevant anatomy is poor (as low as 4%) 1
  • Low ability to detect injury 1
  • Number needed to treat is 295-500 to detect significant injuries 2
  • Highly resource and labor intensive 1

Morbidity of Prolonged Immobilization

Remove spinal precautions as soon as imaging clearance is achieved because complications escalate rapidly after 48-72 hours: 2

  • Pressure sores 2
  • Increased intracranial pressure 2
  • Life-threatening airway complications 2
  • Aspiration pneumonia 2
  • Thromboembolic events 2

Critical consideration: In a population where 95% have no actual spinal injury, the secondary morbidity and mortality from prolonged immobilization can rival the complication rates from missed injuries. 1

Practical Algorithm Summary

  1. Alert patient with GCS 15, no intoxicants, no neck signs, no distracting injuries: Clinical clearance without imaging 1

  2. Obtunded patient OR alert patient failing clinical criteria: MDCT entire spine with <3mm cuts and multiplanar reconstructions 1, 2

  3. Neurological deficit present in obtunded patient: Add MRI after MDCT 1

  4. Normal MDCT in obtunded patient without neurological deficit: Remove spinal precautions; do not obtain routine MRI 1

  5. Any fracture identified: Evaluate entire spine for non-contiguous injuries 1

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Cervical Spine Clearance Protocol

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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