In a 37‑year‑old woman presenting with dizziness, visual changes, palpitations and nausea, when should I suspect missed skull or cervical spine fractures and what imaging is indicated?

Missed Skull and Cervical Spine Fractures in a 37-Year-Old Woman with Dizziness, Visual Changes, Palpitations, and Nausea

When to Suspect Missed Fractures

In this 37-year-old woman presenting with dizziness, visual changes, palpitations, and nausea, you must obtain a detailed trauma history immediately—even seemingly minor head or neck trauma within the past days to weeks can cause delayed presentation of cervical spine or skull fractures, and her symptoms may represent vertebrobasilar insufficiency from a missed cervical injury or intracranial pathology from an occult skull fracture. 1

Critical Red Flags Requiring Immediate Imaging

You should suspect missed cervical spine or skull fractures if any of the following are present:

• Recent trauma history (even if patient initially dismissed it as minor), particularly falls from ≥3 feet, motor vehicle collisions, bicycle accidents, or direct blows to the head/neck 2, 1

• Vertebrobasilar symptoms: Dizziness, visual changes, and nausea are classic signs of posterior circulation compromise, which can result from vertebral artery injury associated with cervical spine fractures involving C1-3 or the transverse foramen 2

• Focal neurologic deficits: Any weakness, numbness, paresthesias in extremities, or Horner syndrome 2, 1

• Midline cervical tenderness on palpation 2, 1

• Altered mental status or any period of loss of consciousness 2, 1

• Severe or persistent headache following trauma 2

Blunt Cerebrovascular Injury (BCVI) Warning Signs

The combination of dizziness and visual changes is particularly concerning for BCVI, which occurs in 3-4% of blunt trauma patients and can cause devastating stroke if missed 1. Specific signs include:

• Vertebrobasilar symptoms (dizziness, diplopia, ataxia, visual field defects) 2
• Cervical bruit in patients <50 years 2
• Horner syndrome (ptosis, miosis, anhidrosis) 2
• Neurologic deficits inconsistent with any identified head injury 2

Imaging Algorithm

Step 1: Initial Evaluation with CT

CT of the cervical spine is the gold standard initial imaging study and must be performed if any NEXUS or Canadian Cervical Rules criteria are met. 2, 1

• CT cervical spine is the first-line imaging modality with 98.5% sensitivity for clinically significant injury 2, 1
• CT detects fractures far better than plain radiographs, which miss up to 77% of cervical spine abnormalities 3, 4
• CT head should be performed concurrently if there is any concern for intracranial injury, as 3% of patients with normal skull radiographs have fractures visible on CT, and half of these develop epidural hematomas 2, 4

Step 2: Add MRI for Soft-Tissue and Vascular Injury

MRI cervical spine is mandatory if neurologic symptoms persist despite normal CT, as 5-24% of trauma patients with negative CT have significant soft-tissue injuries on MRI. 2, 3

MRI is superior for detecting:

• Ligamentous injuries (present in up to 25% of cervical spine injuries without fracture) 3
• Spinal cord contusions or edema 2, 3
• Epidural hematomas (13% have normal CT scans) 3
• Disc herniations causing cord compression 2, 5

Step 3: Vascular Imaging for BCVI Screening

CTA head and neck should be performed urgently if vertebrobasilar symptoms are present or if high-risk fracture patterns are identified on CT. 2, 1

High-risk fracture patterns mandating vascular imaging include:

• Cervical spine fractures at C1-3 or involving the transverse foramen at any level 2, 1
• Complex skull fractures or basilar skull fractures 2, 1
• Mandible fractures or displaced LeFort II/III fractures 2

Common Pitfalls to Avoid

Never Clear the Cervical Spine Based on Plain Radiographs Alone

Plain films are inadequate and miss significant injuries even with three views 1, 3, 6. One study showed that adding CT to the upper cervical spine during routine head CT identified four fractures completely invisible on plain films 4.

Do Not Assume Normal CT Excludes All Injury

Up to 23.6% of patients with negative cervical spine CT have abnormalities on MRI, including 16.6% with ligamentous injuries 2. In patients with persistent neck pain after normal CT, 30% have potentially unstable injuries detected only by MRI 5.

Recognize Delayed Presentation

Patients may present days after trauma with vague symptoms like dizziness or visual changes before catastrophic deterioration occurs 1. A high index of suspicion is essential, as approximately 3-4% of all blunt trauma patients sustain cervical spine injury 2, 1.

Screen for Noncontiguous Injuries

Twenty percent of spine trauma patients have injuries at multiple non-adjacent levels 3. If any cervical injury is found, image the entire spine 3.

Specific Recommendations for This Patient

Given her age (37 years, below the high-risk threshold of >65 years) and symptom constellation:

1. Obtain detailed trauma history focusing on any head/neck trauma in the preceding 2-4 weeks 1

2. Perform immediate CT cervical spine and CT head if any trauma history exists or if examination reveals midline tenderness, neurologic deficits, or altered consciousness 2, 1

3. Add MRI cervical spine if CT is negative but symptoms persist, as her vertebrobasilar symptoms may indicate ligamentous injury or cord pathology invisible on CT 2, 3

4. Perform CTA head and neck if any fracture is identified on CT or if clinical suspicion for BCVI remains high despite negative CT 2, 1

5. Do not delay imaging in obtunded or intoxicated patients, as prolonged collar use causes iatrogenic injury 1