Imaging Recommendations for Persistent Neck and Buttock Pain After Trauma

Cervical Spine Imaging Approach

The American College of Radiology recommends starting with plain radiographs (AP and lateral views) of the cervical spine as the initial imaging modality, though recognizing their significant limitations in detecting injury 1, 2.
Plain radiographs have low specificity and are frequently normal in the first 2-3 weeks after injury because 30-40% of bone destruction is needed before detection on radiographs 1, 2.
The sensitivity of plain cervical radiographs for detecting significant spinal injuries ranges from only 31-94%, with a pooled sensitivity of approximately 52% 3, 4.
If neck pain persists beyond the initial evaluation or if any neurological symptoms develop, proceed directly to MRI cervical spine without contrast 1, 2.
MRI is the imaging modality of choice for evaluating soft tissue injuries, ligamentous injury, disc abnormalities, and spinal cord pathology with sensitivity of 96% and specificity of 93% 1, 2.
Do not rely on negative plain radiographs alone to exclude significant cervical spine pathology in a patient with persistent symptoms 1, 2.

Obtain upright AP and lateral radiographs of the lumbar spine and coccyx as the initial imaging study 8.
Upright positioning is essential as it provides functional information about axial loading of the spine 8.
If radiographs are normal but buttock/coccyx pain persists, CT lumbar spine/coccyx without contrast provides superior bony detail for evaluating occult fractures, particularly of the coccyx which can be difficult to assess on plain films 6, 9, 8.
The American College of Physicians recommends prompt imaging with MRI or CT when progressive neurologic deficits are present or serious underlying conditions are suspected 5.
Do not obtain MRI of the lumbar spine unless radiographs show abnormalities or the patient develops radicular symptoms, as routine imaging does not improve outcomes in nonspecific low back pain 5.

At week 3 post-injury with persistent symptoms, obtain plain radiographs of cervical spine (AP/lateral) AND lumbar spine/coccyx (AP/lateral upright) 1, 2, 8.
If cervical radiographs are negative but neck pain persists, proceed to MRI cervical spine without contrast to evaluate for ligamentous injury, disc pathology, or soft tissue injury 1, 2.
If lumbar/coccyx radiographs are negative but buttock pain persists, consider CT lumbar spine/coccyx for better bony detail, particularly for coccyx fractures 6, 9, 8.
If radicular symptoms develop in either region, MRI is indicated for that spinal region 5, 6.

Do not assume negative plain radiographs exclude significant injury at this timeframe, especially for the cervical spine where ligamentous injuries may not be apparent 1, 2, 4.
Recognize that CT is superior to plain radiographs for bony injury detection but MRI is superior for soft tissue and ligamentous evaluation 3, 9, 4.