Cervical spine clearance after blunt trauma

ACR AC Acute Spinal Trauma (2024); ACR AC Suspected Spine Trauma-Child; NEXUS/CCR; EAST obtunded cervical collar clearance (2015); EAST blunt cerebrovascular injury

A card with a genuine paediatric fork: in adults who fail a validated clinical decision rule the first study is CT, while in children the same failure usually leads to radiographs first, because the injury pattern and the radiation stakes are both different. The obtunded adult asks a third question — not "does this patient need a scan" but "can the collar come off after a normal one" — and EAST answers it with the CT alone.

Blunt trauma with neck pain, a distracting injury, intoxication, altered alertness or a neurological deficit, where the collar cannot be removed on clinical grounds alone.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Haemodynamic state

The fact that lets a pathway waive its own requirements. A crashing patient does not wait for a score.

GCS

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

CT Cervical Spine — Unenhanced, Thin Section

CT Cervical Spine

What we'd amend, and why

Radiographs miss a clinically significant proportion of adult cervical fractures, particularly at the craniocervical and cervicothoracic junctions where overlying structures defeat plain films and where a missed injury is most likely to be unstable. Thin-section CT with multiplanar reformats resolves those levels reliably and is fast enough to keep a collared patient moving through the department. The trade-off is dose, which is precisely why the decision rule that precedes the scan matters.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayadult — Adults
rulerule-paeds-dose — Child-sized technique and contrast dose; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(1)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

Child-sized technique and contrast dose
Confirm that a size- or weight-based protocol is selected — child-sized kV and mAs against size-based diagnostic reference ranges — and that contrast volume is calculated by weight rather than taken from an adult default. Weight-based iodinated contrast volumes of roughly 1.5–2.0 mL/kg are widely used in paediatric CT.
Radiographer at the scannerAt the scanner
Flags back if: No paediatric or size-based protocol exists on the scanner for the requested examination, or the requested coverage or number of phases exceeds what the clinical question needs — for example a multiphase study where a single phase answers it, or whole-body coverage for a focal question.

Worth asking the referrer (4)

None of these hold the request up. They sharpen the protocol or the plan that follows.

Can the patient be examined — alert, oriented, not intoxicated, no distracting injury and no neurological deficit?
It decides which question is being asked. A patient who can be examined and satisfies NEXUS or the Canadian C-Spine Rule needs no imaging at all; a patient who fails the rule needs the CT; an obtunded or intubated patient cannot be assessed by either rule, so the CT is performed by default and the real decision is what happens after it.
Has a high-quality cervical spine CT already been performed for this episode, and was it normal?
In the obtunded or unassessable patient this is the whole of the question. EAST recommends that the collar be removed after a negative high-quality CT alone, so a normal CT usually settles the matter without further imaging; where the CT has not been done, MRI is not the study to start with.
Is there a neurological deficit, a fracture on CT, or a specific clinical concern about instability?
These are what turn MRI from a routine adjunct into the right next study. Without one of them, MRI after a normal CT in an obtunded patient changes management in very few patients, and the collar time it costs carries its own harm.
Is there known ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis?
It changes both the threshold and the coverage: a trivial mechanism can produce an unstable transverse fracture, and non-contiguous injuries mean the whole spine rather than the neck alone is at risk.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Unassessable or unstable — no rule applies, CT by default

Role	Study & protocol	Why this answers the question
First line	CT Cervical Spine CT Cervical Spine — Unenhanced, Thin Section usually appropriate	Neither NEXUS nor the Canadian C-Spine Rule can be applied to a patient who cannot be examined, so the CT here is performed by default rather than by selection, and the paediatric preference for radiographs goes with it — a child who cannot be assessed, or who is being resuscitated, is one in whom radiographs cannot be interpreted against a clinical examination and a normal film clears nothing. This is also the point of the arm: it must not route an unstable or obtunded patient down a ladder that starts with a study that will have to be repeated. Where a trauma CT is already being performed, the cervical spine is part of that acquisition rather than a separate visit.
Second line	MRI Cervical Spine MRI Cervical Spine — degenerative and myelopathy	The real question in this patient is usually not whether to do the CT but what follows a normal one, and EAST answers it: in the obtunded adult blunt trauma patient a negative high-quality cervical CT is sufficient to remove the collar, and routine adjunct MRI to exclude ligamentous injury before removal changes management in very few patients while the collar time it costs causes pressure ulceration, raises intracranial pressure, increases aspiration risk and delays weaning. MRI stays the right study where there is a neurological deficit, a CT abnormality whose soft-tissue consequences must be defined before surgery, or a specific concern about instability — and it is slow and hard to deliver safely in a ventilated patient, so it never precedes the CT.

Resuscitation precedes imaging in an unstable patient. The collar stays on meanwhile, which is a decision that costs nothing while the bleeding is being found.

Children

Role	Study & protocol	Why this answers the question
First line	Spinal radiograph Spinal radiograph — AP and lateral usually appropriate	Paediatric cervical injuries are concentrated at the upper cervical levels and are frequently ligamentous rather than bony, so the incremental yield of CT over radiographs is smaller than in adults while the dose penalty to a growing thyroid and to the developing spinal cord is considerably larger. Radiographs answer the question in most children who need imaging at all, and CT is then reserved for the abnormal, inadequate or clinically discordant study.
Second line	CT Cervical Spine CT Cervical Spine — Unenhanced, Thin Section	Indicated where radiographs are abnormal, technically inadequate or discordant with a significant clinical concern, and as the first study in a child with a high-risk mechanism, a neurological deficit or an unassessable conscious level.
Problem solving	MRI Cervical Spine MRI Cervical Spine — degenerative and myelopathy	The study for the child with a neurological deficit and normal bony imaging, which is a recognised and specifically paediatric pattern. It is also what assesses the ligamentous complex when instability is suspected despite an unremarkable CT.

Adults

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	CT Cervical Spine CT Cervical Spine — Unenhanced, Thin Section usually appropriate	Radiographs miss a clinically significant proportion of adult cervical fractures, particularly at the craniocervical and cervicothoracic junctions where overlying structures defeat plain films and where a missed injury is most likely to be unstable. Thin-section CT with multiplanar reformats resolves those levels reliably and is fast enough to keep a collared patient moving through the department. The trade-off is dose, which is precisely why the decision rule that precedes the scan matters.
Second line	MRI Cervical Spine MRI Cervical Spine — degenerative and myelopathy	The study for cord, disc and ligamentous injury, which CT cannot show. It is indicated when there is a neurological deficit, when a fracture on CT needs its soft-tissue consequences defined before surgery, and when significant instability is suspected despite a normal CT. It is second-line rather than first because it answers a question that only arises once the CT is available: in the obtunded or unassessable adult, EAST concluded that a negative high-quality cervical CT is sufficient to remove the collar, and that routine adjunct MRI in that situation alters management in very few patients while the collar time it costs carries real morbidity. Where the CT has not been done, an MRI request is out of sequence rather than out of place — it is slow, it is hard to deliver safely in a ventilated patient, and it is poor at cortical bone.

Two distinct adult presentations share this arm. The first is the patient who can be examined and fails NEXUS or the Canadian C-Spine Rule: CT is the study, and the rule is what justified it. The second is the obtunded, intubated or otherwise unassessable patient, in whom no rule can be applied and CT is performed by default.
For the second group the request that reaches vetting is often for MRI after a normal CT. The EAST practice management guideline recommends removing the collar on the strength of a negative high-quality CT alone in that situation; routine adjunct MRI to exclude ligamentous injury before collar removal changes management in very few patients, and prolonged collar use causes pressure ulceration, raises intracranial pressure and delays weaning. MRI remains the right study where there is a neurological deficit, a CT abnormality needing its soft-tissue consequences defined, or a specific concern about instability — which is what the clarifying questions on this card are asking for.
The conscious level cannot be read from the request in this tool, so this fork is expressed as a question to the referrer rather than as a separate pathway. Where the answer is "obtunded, CT already normal, no deficit", the honest answer is usually that no further imaging is needed and the collar decision belongs to the trauma team.

Pitfalls

Reporting a CT as normal when the cervicothoracic junction is not visualised. Coverage to the top of T1 is a completeness criterion, not a preference.
Missing a fracture through an ankylosed segment, where the abnormality can be a subtle transverse lucency in fused bone.
Treating a normal CT as excluding cord injury. Spinal cord injury without radiographic abnormality is a real and predominantly paediatric entity.
Defaulting a child to CT because that is what the adult pathway does, which discards a substantially better dose profile for a small gain in bony sensitivity.
Scanning a patient who satisfies a validated clinical decision rule and needed no imaging at all.
Requesting MRI before the CT in an obtunded or unassessable patient. MRI is slow, difficult to deliver safely in a ventilated patient and poor at cortical bone; the CT comes first and usually answers the question.
Leaving a collar on an obtunded patient for days awaiting an MRI that will not change management. EAST supports collar removal after a negative high-quality CT alone, and prolonged collar use causes pressure ulceration, raises intracranial pressure, increases aspiration risk and delays weaning.
Reading "obtunded" as a reason to image more rather than as a reason to ask a different question. The absence of an examination changes who decides that the collar can come off, not how much imaging is needed.
Reporting a fracture through a transverse foramen, a facet subluxation or a C1 to C3 fracture without recommending CT angiography of the neck. Blunt cerebrovascular injury is silent at presentation and presents as a stroke days later; the screening criteria are met by the fracture itself, and the treatment that prevents the stroke depends on the diagnosis being made before it happens.
Clearing an elderly patient clinically after a low-energy fall. An odontoid fracture in an osteoporotic spine frequently produces little pain and no deficit, and both NEXUS and the Canadian C-Spine Rule treat age as a reason the examination cannot be relied on.

Priors — what to pull first

Degenerative change and old fusion make the spine both harder to read and more fragile; prior imaging separates chronic from acute.
In known ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis, review any prior study and image the whole spine, because non-contiguous fractures are common.

What makes a good request

NEXUS and the Canadian C-Spine Rule both exist to identify who does not need imaging. A patient who satisfies either rule needs no study at all, and that is the highest-value output of this pathway.
The ACR endorses NEXUS and the PECARN paediatric rule in children and recommends radiography as the preferred first modality in that group; older adolescents are generally assessed as adults.
The obtunded, intubated or otherwise unassessable adult is a different question from the patient who simply fails a decision rule, and it arrives at vetting as a different request. Neither rule can be applied at all, so CT is performed by default rather than by selection — and the request that then reaches vetting is usually not for the CT but for what should follow a normal one.
For that second question the EAST practice management guideline is explicit: in the obtunded adult blunt trauma patient with a negative high-quality cervical CT, the collar can be removed on the strength of that CT alone. Routine adjunct MRI to exclude ligamentous injury before collar removal changes management in very few patients, and prolonged collar use has its own morbidity — pressure ulceration, raised intracranial pressure, aspiration risk and delayed weaning. MRI stays the right study where there is a neurological deficit, a CT abnormality whose soft-tissue consequences must be defined, or a specific clinical concern about instability, and this card cannot tell those apart from the request alone.
Ankylosing spinal disease changes everything: a trivial mechanism can produce an unstable transverse fracture, radiographs are unreliable, and the whole spine rather than the neck alone is at risk.
The bony study is also the trigger for a vascular one. Blunt cerebrovascular injury — carotid or vertebral dissection — is clinically silent at presentation and declares itself as a stroke hours to days later, and it is preventable with antithrombotic treatment. Add CT angiography of the neck when the CT shows a fracture extending into a transverse foramen, a subluxation or dislocation, a fracture at C1 to C3, or a complex skull base fracture, and when the Denver-type clinical features are present: an unexplained neurological deficit, arterial neck haemorrhage, an expanding cervical haematoma, a cervical bruit in a patient under 50, a seat-belt or hanging mechanism, or a Le Fort II or III facial fracture. It is one extra acquisition in the same visit and it is the one finding on this card with a treatment that prevents a stroke.

Scoring this once it is done

The classification and risk tools this question ends in.

NEXUS Cervical Spine Criteria AO Spine Thoracolumbar Injury Classification SLICS — Subaxial Injury Classification & Severity Score Denis Three-Column Classification TLICS — Thoracolumbar Injury Classification & Severity Score ASIA Impairment Scale (AIS) with Frankel Mapping

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

CT Cervical Spine — Unenhanced, Thin Section MRI Cervical Spine — degenerative and myelopathy Spinal radiograph — AP and lateral

Confirm locally

CT Cervical Spine — Unenhanced, Thin Section: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.