Assessment of Cervical Spine in Occipital Soreness Without Trauma History
In a patient with occipital soreness and no history of injury, clinical examination alone is sufficient to determine if imaging is needed—specifically, if the patient has no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no distracting injury, then no imaging is required. 1
Clinical Decision Algorithm
Step 1: Apply NEXUS Criteria for Imaging Decision
The patient does NOT require imaging if ALL of the following are present: 1
- No midline cervical tenderness
- No focal neurologic deficit
- Normal alertness/consciousness
- No intoxication
- No distracting injury
If any single criterion is positive, proceed to imaging. 1
Step 2: Focused Physical Examination
When evaluating for potential cervical pathology, assess: 2
- Motor strength testing: Evaluate all major muscle groups bilaterally, documenting any asymmetry 2
- Sensory examination: Test for paresthesias in extremities, as this mandates imaging regardless of other factors 1
- Sacral function: Assess perianal sensation and rectal tone to exclude cauda equina involvement 2
- Reflexes: Document patellar and Achilles reflexes bilaterally, as hyperreflexia suggests upper motor neuron pathology 2
Step 3: Imaging Selection When Indicated
If imaging is warranted, CT cervical spine without contrast is the initial study of choice. 3, 4
- CT is the reference standard for traumatic cervical spine evaluation, with significantly higher sensitivity than radiographs for detecting fractures 3, 4
- Plain radiographs have been supplanted by CT, identifying only about one-third of fractures visible on CT 3
Step 4: When to Proceed to MRI
MRI should be obtained if: 4
- CT is negative but ligamentous injury is still suspected clinically 4
- Patient has neurological symptoms or deficits 5, 6
- Patient has advanced cervical degenerative disease (higher risk for acute disc and ligamentous injury) 5
MRI identifies cervical ligament injuries in 6-49% of patients with negative CT, though approximately 1% will have unstable injury requiring surgical stabilization 4
Critical Pitfalls to Avoid
Do NOT perform flexion-extension radiographs in the acute setting. 4
- These studies are inadequate in 28-97% of cases due to limited motion and poor visualization 4
- They carry real danger of producing neurologic injury 3
- They have a positive predictive value as low as 0% for identifying instability not apparent on CT 3
Do NOT rely on plain radiographs alone to exclude cervical pathology, as sensitivity is only approximately 90% for detecting abnormalities 4
Do NOT skip sacral examination in any patient with suspected neurological involvement, as sacral sparing versus involvement fundamentally changes prognosis and management urgency 2
Special Considerations for Non-Traumatic Presentation
In patients presenting with occipital soreness without clear trauma history: 7
- Upper cervical injuries can be easily overlooked, particularly when patients have altered consciousness or when obtaining accurate history is complicated 7
- Complex regional anatomy makes plain radiographic interpretation difficult 7
- Delayed recognition can result in significant disability, making thorough clinical assessment critical 7
MRI has particular clinical significance in revealing injuries not recognized by CT in symptomatic patients, correctly diagnosing injuries missed by CT in documented cases 6