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Difficulty: MediumOrdering Imaging Studies

A 38-year-old male is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. He was the restrained driver in a frontal impact where the airbag deployed. He was ambulatory at the scene but now complains of severe, continuous posterior neck pain. His temperature is 37.1°C (98.8°F), blood pressure is 135/85 mm Hg, pulse is 92/min, and respiratory rate is 16/min. His Glasgow Coma Scale score is 15. The patient arrives fully immobilized on a backboard with a rigid cervical collar in place. On physical examination, there is marked midline bony tenderness to palpation over the C4 and C5 spinous processes. Neurological examination reveals 5/5 motor strength in all upper and lower extremity muscle groups, intact sensation to light touch and pinprick bilaterally, and 2+ deep tendon reflexes. Which of the following is the most appropriate initial imaging study to evaluate this patient's cervical spine?

  1. Computed tomography of the cervical spine without intravenous contrastAnswer
  2. B
    Plain radiography of the cervical spine including anteroposterior, lateral, and open-mouth odontoid views
  3. C
    Magnetic resonance imaging of the cervical spine without intravenous contrast
  4. D
    Computed tomography angiography of the neck
  5. E
    Dynamic flexion-extension plain radiographs of the cervical spine

Answer

Computed tomography of the cervical spine without intravenous contrast
The correct answer is computed tomography (CT) of the cervical spine without intravenous contrast. According to the American College of Radiology (ACR) Appropriateness Criteria and advanced trauma life support (ATLS) guidelines, a non-contrast CT scan is the gold standard and initial imaging study of choice for evaluating the cervical spine in adult patients who have sustained blunt trauma and meet criteria for imaging. This patient requires imaging because he has marked midline cervical tenderness, which precludes clinical clearance using the NEXUS (National Emergency X-Radiography Utilization Study) criteria. CT is significantly more sensitive and specific than plain radiography for detecting cervical spine fractures and subluxations, and it is rapidly obtainable in the emergency department.

Step-by-Step Solution

1
Evaluate the mechanism of injury and patient's clinical stability.
The patient experienced a high-speed motor vehicle collision and is hemodynamically stable with a normal mental status (GCS 15).
This establishes the context of a high-risk blunt trauma where standard advanced trauma life support (ATLS) protocols apply.
2
Apply clinical decision rules (such as NEXUS criteria or the Canadian C-Spine Rule) to determine the need for imaging.
The patient has marked midline bony tenderness over the C4-C5 spinous processes, failing the NEXUS criteria.
Failing clinical clearance criteria mandates radiographic evaluation of the cervical spine.
3
Select the optimal initial imaging modality based on current evidence-based guidelines.
Non-contrast computed tomography (CT) of the cervical spine is selected.
According to the American College of Radiology (ACR) Appropriateness Criteria, non-contrast CT is the most sensitive and appropriate initial imaging test for adult blunt trauma patients requiring cervical spine evaluation.

Key Concept

In adult patients with high-risk mechanisms of injury or those who fail clinical decision rules (e.g., NEXUS criteria) for cervical spine clearance, non-contrast computed tomography (CT) is the initial imaging modality of choice.
Estimated Time:1m 0s
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Topics

Ordering Imaging Studies

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