What is the most appropriate initial imaging for an elderly male with severe midline neck pain and bilateral paresthesias to arms after a high-speed motor vehicle accident (MVA) with normal mental status?

CT Cervical Spine Without IV Contrast

In an elderly male with severe midline neck pain and bilateral arm paresthesias following high-speed MVA, CT cervical spine without IV contrast is the most appropriate initial imaging study, regardless of normal mental status. 1

Rationale for CT as First-Line Imaging

Age and Trauma Mechanism Override Clinical Decision Rules

• Elderly patients (≥65 years) involved in high-speed MVA require cervical spine imaging even with normal mental status because the sensitivity of NEXUS criteria declines significantly in this population (66-89% sensitivity) 1

• Under Canadian C-Spine Rules (CCR), all blunt trauma patients >65 years of age should be considered for cervical spine imaging regardless of other clinical findings 1

• The presence of severe midline neck pain alone constitutes a "red flag" requiring imaging in the trauma setting 1

Bilateral Paresthesias Indicate High-Risk Injury

• Bilateral upper extremity paresthesias suggest potential spinal cord involvement or bilateral nerve root compression, which are unstable injuries requiring immediate detection 1, 2

• This neurologic finding elevates concern for ligamentous injury, fracture-dislocation, or central cord syndrome—all of which require urgent identification 1

CT Superiority in Acute Trauma

• CT is significantly more sensitive than radiographs for identifying cervical spine fractures, detecting approximately three times more fractures than plain films 1

• CT provides superior depiction of cortical bone, facet joints, and vertebral alignment critical for detecting unstable injuries 1

• Radiographs have been largely supplanted by CT for assessment of traumatic cervical spine injury in the acute setting 1

Why Not MRI Initially?

• While MRI is superior for soft tissue evaluation, CT remains the appropriate first-line study in acute trauma because it rapidly identifies fractures and unstable bony injuries that require immediate stabilization 1

• MRI should be obtained subsequently if CT shows abnormalities, if there is unexplained neurologic deficit, or if ligamentous injury is suspected based on CT findings 1

• In trauma patients with negative cervical spine CT, MRI identifies additional soft-tissue injuries in 5-24% of cases, but these rarely require surgical intervention if CT is negative and there is no clinical evidence of instability 1

Critical Pitfalls to Avoid

• Do not rely on clinical decision rules (NEXUS or CCR) to clear the cervical spine in elderly trauma patients—age >65 years is itself an indication for imaging 1

• Do not obtain plain radiographs first—they are inadequate in high-risk trauma and will delay definitive imaging, missing approximately two-thirds of fractures visible on CT 1

• Do not skip imaging based on normal mental status alone—the combination of elderly age, high-speed mechanism, severe pain, and bilateral neurologic symptoms mandates imaging 1

Subsequent Imaging Considerations

• If CT demonstrates fracture, malalignment, or soft tissue abnormalities, proceed immediately to MRI to evaluate for spinal cord injury, ligamentous disruption, and disc herniation 1

• If CT is negative but bilateral paresthesias persist, MRI is indicated to evaluate for central cord syndrome or ligamentous injury not visible on CT 1, 2

• Approximately 20% of patients with spine fractures at one level have noncontiguous injuries elsewhere, so consider imaging the entire spine if cervical injury is identified 1