What is the most appropriate initial cervical imaging test for a patient with severe neck pain and neurological symptoms after a high-speed rear-end collision?

CT Without Contrast is the Most Appropriate Initial Imaging

For an elderly patient with severe midline cervical neck pain, bilateral upper extremity paresthesias and weakness following high-speed motor vehicle trauma, CT cervical spine without IV contrast is the most appropriate initial imaging study. 1

Why CT is the Correct Initial Choice in This Trauma Setting

Age and Mechanism Mandate Imaging

• Elderly patients (≥65 years) involved in high-speed collisions require cervical spine imaging regardless of normal mental status, as the sensitivity of clinical decision rules like NEXUS declines significantly in this population (66-89% sensitivity). 1
• Under Canadian C-Spine Rules, all blunt trauma patients >65 years should be considered for cervical spine imaging regardless of other clinical findings. 1
• The high-speed mechanism (60 mph rear-end collision) combined with severe midline tenderness constitutes a "red flag" requiring immediate imaging. 1

Neurological Symptoms Indicate High-Risk Injury

• Bilateral upper extremity paresthesias and weakness suggest potential spinal cord involvement (central cord syndrome) or bilateral nerve root compression, which are unstable injuries requiring immediate detection. 1
• The presence of severe midline neck pain alone constitutes a "red flag" requiring imaging in the trauma setting. 1

CT Superiority Over Plain Radiographs in Acute Trauma

• CT is significantly more sensitive than plain radiographs for identifying cervical spine fractures, detecting approximately three times more fractures than plain films. 1, 2
• The pooled sensitivity for cervical spine plain radiography is only 52% compared to 98% for CT in detecting cervical spine injuries. 2
• CT provides superior depiction of cortical bone, facet joints, and vertebral alignment critical for detecting unstable injuries. 1
• Plain radiographs are inadequate in high-risk trauma and will delay definitive imaging, missing approximately two-thirds of fractures visible on CT. 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
• CT scanning in conjunction with clinical assessment can be used to clear cervical spines in trauma patients, with 100% sensitivity in detecting cervical spine injury in prospective studies. 3
• 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

Subsequent Imaging Algorithm

When to Proceed to MRI After Initial CT

• 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 and weakness persist, MRI is indicated to evaluate for central cord syndrome or ligamentous injury not visible on CT. 1
• CT may overlook ligamentous injury, and MRI is the optimal study for soft tissue and ligamentous evaluation in patients with persistent neurological deficits despite negative CT. 4

Extended Spine Evaluation

• 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

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 in this high-risk scenario—they are inadequate and will miss the majority of significant injuries. 1, 2
• Do not skip imaging based on normal mental status alone in elderly patients with high-speed trauma mechanisms. 1
• Do not delay CT imaging to obtain plain films first, as this provides no benefit and delays definitive diagnosis. 2