D - DIAGNOSTIC IMAGING

We recommend that CT of the spine is acquired if:

1. Imaging for cervical spine injury is indicated by the Canadian C-spine rule; or,
2. There is a strong suspicion of thoracic or lumbosacral spine injury associated with abnormal neurological signs or symptoms.

For imaging in adults (16 or over) with a head injury and suspected cervical spine injury, follow the recommendations in section 1.5 of the NICE guideline on head injury:
Investigating injuries to the cervical spine:

1. Be aware that, as a minimum, CT should cover any areas of concern or uncertainty on X-ray or clinical grounds.
2. Ensure that facilities are available for multiplanar reformatting and interactive viewing of CT cervical spine scans.
3. MR imaging is indicated if there are neurological signs and symptoms referable to the cervical spine. If there is suspicion of vascular injury (for example, vertebral malalignment, a fracture involving the foramina transversaria or lateral processes, or a posterior circulation syndrome), CT or MRI angiography of the neck vessels may be performed to evaluate for this.
4. In CT, routinely review on 'bone windows' the occipital condyle region for patients who have sustained a head injury. Reconstruction of standard head images onto a high-resolution bony algorithm is readily achieved with modern CT scanners.
5. In patients who have sustained high-energy trauma or are showing signs of lower cranial nerve palsy, pay particular attention to the region of the foramen magnum. If necessary, perform additional high-resolution imaging for coronal and sagittal reformatting while the patient is on the scanner table.
6. Criteria for performing a CT cervical spine scan in adults:
   1. For adults who have sustained a head injury and have any of the following risk factors, perform a CT cervical spine scan within 1 hour of the risk factor being identified:
   2. GCS less than 13 on initial assessment.
   3. The patient has been intubated.
   4. Plain X-rays are technically inadequate (for example, the desired view is unavailable).
   5. Plain X-rays are suspicious or definitely abnormal.
   6. A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
   7. The patient is having other body areas scanned for head injury or multi-region trauma.
   8. The patient is alert and stable, there is clinical suspicion of cervical spine injury, and any of the following apply:
      1. age 65 years or older
      2. dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorized recreational vehicles; bicycle collision)
      3. focal peripheral neurological deficit
      4. paraesthesia in the upper or lower limbs.
   A provisional written radiology report should be made available within 1 hour of the scan being performed.
7. Assessing the range of movement in the neck:
   1. Be aware that in adults who have sustained a head injury and in whom there is clinical suspicion of cervical spine injury, range of movement in the neck can be assessed safely before imaging only if no high-risk factors (see recommendations 1.5.8, 1.5.11 and 1.5.12) and at least 1 of the following low-risk features apply. The patient:
      1. was involved in a simple rear-end motor vehicle collision
      2. is comfortable in a sitting position in the emergency department
      3. has been ambulatory at any time since injury
      4. has no midline cervical spine tenderness
      5. presents with delayed onset of neck pain.

Computed tomographic angiography (CTA) is recommended as a screening tool in selected patients after blunt cervical trauma who meet the modified Denver Screening Criteria for suspected vertebral artery injury (VAI).
Modified Denver Screening Criteria for blunt cerebrovascular injuries:
Lateralizing neurologic deficit (not explained by CT head)

1. Infarct on CT head scan
2. Cervical hematoma (nonexpanding)
3. Massive epistaxis
4. Anisocoria/Homer’s syndrome
5. Glasgow Coma Scale score <8 without significant CT findings
6. Cervical spine fracture
7. Basilar skull fracture
8. Severe facial fracture (LeForte II or III only)
9. Seatbelt sign above the clavicle
10. Cervical bruit or thrill

In the awake patient with neck pain or tenderness and normal high-quality CT imaging or normal 3-view cervical spine series (with supplemental CT if indicated), the following recommendations should be considered:

1. continue cervical immobilization until asymptomatic
2. discontinue cervical immobilization following normal and adequate dynamic flexion/extension radiographs
3. discontinue cervical immobilization following a normal magnetic resonance imaging (MRI) obtained within 48 hours of injury (limited and conflicting Class II and Class III medical evidence), or
4. discontinue cervical immobilization at the discretion of the treating physician.

In the obtunded or unevaluable patient with a normal high-quality CT or normal 3-view cervical spine series, the following recommendations should be considered:

1. continue cervical immobilization until asymptomatic
2. discontinue cervical immobilization following a normal MRI study obtained within 48 hours of injury (limited and conflicting Class II and Class III medical evidence), or
3. discontinue cervical immobilization at the discretion of the treating physician.