investigation of a neck injury

Last edited 05/2023 and last reviewed 08/2023

Investigation of neck injuries

• be aware that, as a minimum, CT should cover any areas of concern or uncertainty on X-ray or clinical grounds
  
  
• ensure that facilities are available for multiplanar reformatting and interactive viewing of CT cervical spine scans
  
  
• 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
  
  
• be aware that MRI may add important information about soft tissue injuries associated with bony injuries demonstrated by X-ray and/or CT
  
  
• MRI has a role in the assessment of ligamentous and disc injuries suggested by X-ray, CT or clinical findings
  
  
• 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
  
  
• 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

Assessing range of movement in the neck

• be aware that in adults and children 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 and at least 1 of the following low-risk features apply. The patient:
  
  
  • was involved in a simple rear-end motor vehicle collision
    
    
  • is comfortable in a sitting position in the emergency department
    
    
  • has been ambulatory at any time since injury
    
    
  • has no midline cervical spine tenderness
    
    
  • presents with delayed onset of neck pain

Criteria for performing a CT cervical spine scan in adults

• 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:
  
  
  • GCS less than 12 on initial assessment
    
    
  • the patient has been intubated
    
    
  • plain X-rays are technically inadequate (for example, the desired view is unavailable)
    
    
  • plain X-rays are suspicious or definitely abnormal
    
    
  • a definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery)
    
    
  • the patient is having other body areas scanned for head injury or multi-region trauma
    
    
  • the patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply:
    • age 65 years or older
    • 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 motorised recreational vehicles; bicycle collision)
    • focal peripheral neurological deficit
    • paraesthesia in the upper or lower limbs
      
      
  • a provisional written radiology report should be made available within 1 hour of the scan being performed
    
    
• for people 16 and over who have sustained a head injury, and have neck pain or tenderness but no high-risk indications for a CT cervical spine scan, do a CT cervical spine scan within 1 hour for any of these risk factors:
  • it is not thought to be safe to assess the range of movement in the neck
  • safe assessment of range of neck movement shows that the person cannot actively rotate their neck 45 degrees to the left and right
  • the person has a condition predisposing them to a higher risk of injury to the cervical spine (for example, axial spondyloarthritis)
    

Criteria for performing a CT cervical spine scan in children (people under 16)

• for children who have sustained a head injury, perform a CT cervical spine scan only if any of the following apply (because of the increased risk to the thyroid gland from ionising radiation and the generally lower risk of significant spinal injury):
  • GCS less than 12 on initial assessment
  • the patient has been intubated
  • focal peripheral neurological signs
  • paraesthesia in the upper or lower limbs
  • a definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery)
  • the patient is having other body areas scanned for head injury or multi-region trauma
  • there is strong clinical suspicion of injury despite normal X-rays
  • plain X-rays are technically difficult or inadequate
  • plain X-rays identify a significant bony injury
• scan should be performed within 1 hour of the risk factor being identified

For children who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan, perform 3-view cervical spine X-rays before assessing range of movement in the neck if either of these risk factors are identified:

• dangerous mechanism of injury (that is, 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 motorised recreational vehicles; bicycle collision)
• safe assessment of range of movement in the neck is not possible
• the person has a condition that predisposes them to a higher risk of injury to the cervical spine (for example, collagen vascular disease, osteogenesis imperfecta, axial spondyloarthritis

The X-rays should be carried out within 1 hour of the risk factor being identified and reviewed by a clinician trained in their interpretation.

If range of neck movement can be assessed safely in a child who has sustained a head injury and has neck pain or tenderness but no indications for a CT cervical spine scan, perform 3-view cervical spine X-rays if the child cannot actively rotate their neck 45 degrees to the left and right

• when the person is unable to understand commands or open their mouth, a peg view may be omitted
  
  
• the X-rays should be carried out within 1 hour of this being identified and reviewed by a clinician trained in their interpretation

Reference:

• NICE (May 2023). Head injury - Triage, assessment, investigation and early management of head injury in children, young people and adults