CT Indications for Cervical Spine After Motor Vehicle Collision

NEXUS Criteria for Cervical Spine Imaging

The American College of Radiology recommends CT cervical spine imaging if patients have an altered level of consciousness, presence of neck pain or tenderness on palpation, presence of focal neurologic deficit, evidence of intoxication, or presence of a painful distracting injury 1, 2, 3
CT cervical spine imaging is indicated if patients meet any of the NEXUS criteria, which have high sensitivity for detecting clinically significant cervical spine injuries 1, 2

The American College of Radiology recommends CT cervical spine imaging if patients are age ≥65 years, have a dangerous mechanism of injury, or have paresthesias in extremities 1, 2, 4
CT cervical spine imaging is indicated if patients have inability to actively rotate neck 45° to left and right 2

Older adults (age >65 years) should have a lower threshold for imaging as NEXUS criteria have reduced sensitivity (66-89%) in this population 4, 5
Obtunded patients should always obtain CT imaging as clinical assessment is unreliable 5, 6
High-risk mechanisms warrant CT imaging regardless of symptoms when the mechanism involves high-energy transfer 1
Neurological symptoms require CT imaging even with minimal neck pain 3

CT scan is the first-line imaging modality for suspected cervical spine injury after MVC due to its superior sensitivity (88.6-100%) compared to plain radiographs (36.4%) 3
Plain radiographs are inadequate for ruling out cervical spine injuries in trauma patients, identifying only about one-third of fractures visible on CT 3
MRI should be considered as a follow-up study when neurological deficits are present despite negative CT, ligamentous injury is suspected, or patient remains symptomatic with neck pain despite negative CT 6, 7

Relying solely on plain radiographs can miss significant injuries that CT can detect 3
Clearing the cervical spine in obtunded patients without imaging is unreliable 5, 6
Ignoring persistent neck pain can lead to missed ligamentous injuries that require MRI for detection 6, 7
Overlooking non-contiguous injuries can occur, as approximately 20% of patients with one spinal injury will have injuries at other levels of the spine 5, 8

Assess for NEXUS criteria or Canadian C-Spine Rules, and obtain CT cervical spine without contrast if ANY criteria are positive 1, 2, 8
If CT is positive, consult spine service and consider MRI for surgical planning 7, 8
If CT is negative but neurological symptoms are present, obtain MRI cervical spine 7
If CT is negative in an obtunded patient, MRI is recommended to evaluate for ligamentous injury 6, 8