Diagnosing Cervical Ligament Injury

Clinical Assessment and Initial Imaging

The American College of Radiology recommends that initial evaluation of patients with suspected cervical ligament injury typically begins with standard radiographs, but these have limited sensitivity for ligamentous injuries 3
CT scanning is superior to radiographs for detecting bony injuries but has limited sensitivity for soft tissue injuries including ligamentous damage 4

The American College of Radiology considers CT scan of the cervical spine as the reference standard for evaluation of traumatic spine injury in adults, and recommends beginning with CT scan for patients with suspected cervical spine trauma 3
Standard radiographs alone are inadequate for excluding ligamentous injury, with sensitivity rates for detecting cervical spine abnormalities around 90% 5
If CT is negative but ligamentous injury is still suspected, the American College of Radiology recommends proceeding to MRI 6
MRI is the most sensitive test for detection of ligament injury and should be the next step when ligamentous injury is suspected despite negative CT 1, 7
MRI can identify cervical ligament injuries in 6-49% of patients with unreliable physical examination and negative CT 4

Flexion-extension radiographs in the acute setting are often inadequate and potentially dangerous, with 28-97% of flexion-extension studies being inadequate for evaluating ligament injury due to limited motion and inadequate visualization 2, 6
MRI has high sensitivity but lower specificity (64-77%) for soft-tissue injury, and a false-positive rate of 25-40% 1
Approximately 1% of patients with unreliable clinical examination and negative cervical spine CT will have an unstable cervical spine injury requiring surgical stabilization identified on MRI 3

In pediatric patients, the American College of Radiology recommends MRI as superior to CT and radiographs for craniocervical junction injuries to ligaments and the spinal cord, and fat-saturated T2 sequences are particularly useful for identifying soft tissue injuries in children 5