What type of imaging is recommended for a patient with cervical spine pain after a fall?

Imaging for Cervical Spine Pain After a Fall

CT of the cervical spine without IV contrast is the first-line imaging modality for evaluating cervical spine pain after a fall, as it has near 100% sensitivity and specificity for detecting clinically significant injuries and has completely supplanted plain radiographs. 1

Initial Decision: Who Needs Imaging?

Apply validated clinical decision rules to determine if imaging is warranted:

NEXUS Low-Risk Criteria (Image if ANY present):

• Altered level of consciousness 2
• Midline cervical tenderness on palpation 2
• Focal neurologic deficit 2
• Evidence of intoxication 2
• Painful distracting injury 2

Canadian C-Spine Rule (Image if ANY present):

• Age ≥65 years 2
• Dangerous mechanism of injury (fall from elevation >3 feet, axial load to head, high-speed motor vehicle collision) 2
• Paresthesias in extremities 2
• Inability to actively rotate neck 45° to left and right 2

Critical caveat: In patients >65 years, NEXUS criteria have reduced sensitivity (66-89%), so maintain a lower threshold for imaging in this population. 1, 2

First-Line Imaging: CT Cervical Spine Without Contrast

CT is the reference standard with 98-100% sensitivity for detecting cervical spine fractures. 1, 3 Modern multidetector CT with multiplanar reformations (sagittal and coronal) is sufficiently fast to avoid motion degradation and provides seamless high-quality visualization of all cervical vertebrae. 1

Why CT Over Plain Radiographs:

• Plain radiographs have only 36% sensitivity for identifying cervical injuries 1, 2, 3
• CT outperforms radiography across all risk stratifications and is sufficient to rule out clinically significant injuries 1
• Radiographs miss approximately 15% of cervical injuries that CT detects 4
• Do not obtain plain radiographs—they are inadequate and outdated for trauma evaluation 1, 2

IV Contrast Is Not Indicated:

There is no evidence supporting the addition of IV contrast to CT for detecting cervical spine injuries in acute blunt trauma. 1

When to Add MRI Cervical Spine

Obtain MRI after CT in these specific scenarios:

Absolute Indications:

• Neurologic deficits present despite negative CT 2, 5, 3
• Obtunded/unconscious patients with negative CT to evaluate for ligamentous injury 1, 2
• Persistent neck pain with negative CT when ligamentous injury is suspected 2, 5

Supporting Evidence:

• MRI detects soft-tissue injuries in 5-24% of trauma patients with negative cervical spine CT 1
• In a 2023 study, MRI identified 14 cases correctly diagnosed as injured that were missed by CT, with 88.5% sensitivity 3
• However, in older patients (≥65 years) with ground-level falls, normal neurologic exam, and normal CT, only 11.5% had abnormal MRI findings, with just one requiring operative intervention 6

MRI should not be used as first-line imaging—it is complementary to CT, not a replacement. 7, 3

Special Consideration: Vascular Injury Screening

If the fall mechanism involves high-energy transfer, anterior neck trauma (clothesline-type injury), or there are signs of blunt cerebrovascular injury (cervical bruit in patients <50 years, expanding hematoma, neurologic deficit inconsistent with imaging), add CTA head and neck with IV contrast to evaluate for vascular injury. 1, 4

Common Pitfalls to Avoid

• Never rely on plain radiographs alone—they miss two-thirds of fractures visible on CT 1, 2, 3
• Do not skip imaging in obtunded patients—clinical assessment is unreliable and CT is mandatory 2, 4
• Do not ignore persistent neck pain after negative CT—this may indicate ligamentous injury requiring MRI 2, 5
• Do not order MRA—there is no evidence supporting its use in acute cervical spine trauma 1
• Remember non-contiguous injuries—approximately 20% of patients with one spinal injury have injuries at other spinal levels 2

Practical Algorithm

1. Apply NEXUS or Canadian C-Spine Rule → If ANY criteria positive, proceed to step 2 2
2. Order CT cervical spine without contrast (1.5-2mm collimation with sagittal/coronal reconstructions) 1, 2, 4
3. If CT positive → Consult spine service; consider MRI for surgical planning 2
4. If CT negative BUT neurologic symptoms present → Order MRI cervical spine 2, 3
5. If CT negative BUT patient obtunded → Order MRI to evaluate ligamentous injury 1, 2
6. If CT negative AND patient alert with normal exam → Cervical spine is cleared 2