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Difficulty: MediumOrdering Imaging Studies

Emergency medical services bring a 68-year-old retired teacher to the trauma bay following a high-velocity motor vehicle collision. The patient was the restrained driver of a sedan that struck a concrete barrier at highway speeds. He is awake, alert, and oriented, but reports severe posterior neck pain and a "pins and needles" sensation radiating down both arms. Vital signs include a heart rate of 94/min, blood pressure of 142/88 mmHg, respiratory rate of 16/min, and oxygen saturation of 99% on room air. Physical examination reveals midline cervical bony tenderness to palpation. Neurological assessment demonstrates 4/5 motor strength in bilateral elbow flexion and wrist extension, along with diminished sensation to light touch over the lateral forearms and thumbs. Lower extremity neurological findings are unremarkable. Which of the following is the most appropriate initial diagnostic imaging study for this patient?

  1. Computed tomography scan of the cervical spine without intravenous contrastAnswer
  2. B
    Magnetic resonance imaging of the cervical spine without intravenous contrast
  3. C
    Plain radiography of the cervical spine in three views
  4. D
    Flexion and extension plain radiographs of the cervical spine
  5. E
    Computed tomography angiography of the neck

Answer

The most appropriate initial imaging study is a computed tomography scan of the cervical spine without intravenous contrast.
This patient requires immediate evaluation for a cervical spine injury due to high-risk criteria (age over 65, high-speed mechanism, midline tenderness, and focal neurological deficits). In adult patients meeting criteria for cervical spine imaging, non-contrast computed tomography is the initial standard of care. It has significantly higher sensitivity for detecting cervical spine fractures compared to plain radiography and can rapidly identify unstable osseous injuries before further evaluation or intervention is pursued.

Step-by-Step Solution

1
Evaluate the patient's clinical presentation and mechanism of injury.
The patient is a 68-year-old male presenting with midline cervical tenderness and bilateral upper extremity neurological deficits following a high-speed motor vehicle collision.
Identifying high-risk features dictates the necessity and urgency of diagnostic imaging.
2
Apply evidence-based trauma imaging guidelines (e.g., NEXUS criteria or Canadian C-Spine Rule).
The patient meets multiple criteria mandating cervical spine imaging, including age over 65, dangerous mechanism, and focal neurological deficits.
Guidelines ensure appropriate utilization of imaging resources while minimizing the risk of missed unstable injuries.
3
Select the optimal initial imaging modality based on the clinical scenario.
A non-contrast computed tomography scan of the cervical spine is identified as the gold standard initial test.
Computed tomography offers rapid acquisition and significantly higher sensitivity and specificity for acute osseous injuries compared to alternative modalities.

Key Concept

Non-contrast computed tomography is the initial imaging modality of choice for evaluating the cervical spine in adult patients who have sustained high-energy blunt trauma or present with focal neurological deficits.
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Ordering Imaging Studies

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