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Practice Rational Imaging

Imaging after trauma to the neck

BMJ 2008; 336 doi: (Published 17 January 2008) Cite this as: BMJ 2008;336:154
  1. Bernard Wee, specialist registrar1,
  2. John H Reynolds, consultant radiologist1,
  3. Anthony Bleetman, consultant in emergency medicine2
  1. 1Department of Radiology, Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital, Birmingham, B9 5SS
  2. 2Department of Emergency Medicine, Heart of England NHS Foundation Trust
  1. Correspondence to: J H Reynolds john.reynolds{at}

    Plain radiography is often used to image the neck after trauma, but computed tomography and magnetic resonance imaging provide further useful information and should be considered

    The patient

    A 53 year old woman presented to the emergency department after falling down a flight of stairs several hours before. She had severe neck pain but was alert and orientated; she had a score of 15 on the Glasgow coma scale. A neurological and systemic examination identified no significant findings.

    What is the next investigation?

    Decisions about imaging should be based on careful clinical assessment of the patient and knowledge of the mechanism of injury. Two evidence based guidelines—the Canadian cervical spine rules1 2 (box 1) and the NEXUS (national emergency x radiography utilization study) rules3 (box 2; fig 1)—are useful decision making tools.

    Fig 1 The Canadian cervical spine rule

    Box 1 The Canadian cervical spine rule1

    High risk factors
    • Age ≥65 years, dangerous mechanism of injury, orparaesthesia in extremities

    A dangerous mechanism of injury is considered to be a fall from a height of at least a metre or five stairs; an axial load to the head (for example, during diving); a motor vehicle collision at high speed (>100 km/h) or with rollover or ejection; a collision involving a motorised recreational vehicle; or a bicycle collision

    Low risk factors
    • Simple rear end motor vehicle collision, able to sit rather than lie down in the emergency department, ambulatory at any time,delayed (not immediate) onset of neck pain, or absence of midline cervical spine tenderness

    A simple rear end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high speed vehicle.

    The Canadian cervical spine rule applies to trauma patients who are alert (Glasgow coma scale of 15) and stable. It has been shown to be safe and reliable, missing only one unstable …

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