A 32-year-old man is brought in after a motorbike accident. He is alert, GCS 15, complaining of midline neck pain. No focal weakness or sensory loss. He was not wearing a helmet and has a visible forehead laceration. He is not intoxicated.
Examination: Midline cervical tenderness on palpation. Full power and sensation in all four limbs. No other distracting injury.
Does this patient need a C-spine CT, or can he be cleared clinically?
Why the Cervical Spine Matters So Much
The cervical spine protects the spinal cord at the level responsible for breathing (diaphragm innervation from C3–C5 — "C3, 4, 5 keep the diaphragm alive") and all four limbs. An unstable injury that goes unrecognised — because the patient was walking and talking on arrival — can convert a stable fracture into a permanent, devastating cord injury with a single unguarded movement. This is why cervical spine precautions are so aggressively maintained in trauma until injury is actively excluded, not just "unlikely."
Who Needs Imaging? The NEXUS Criteria
Not every patient with neck pain after trauma needs a scan. The NEXUS low-risk criteria let you clear the cervical spine clinically — without imaging — if all five of the following are true:
NEXUS: All 5 Must Be Present to Clear Clinically
- No midline cervical tenderness on palpation
- No focal neurological deficit
- Normal alertness (GCS 15, not intoxicated)
- No intoxication with drugs or alcohol
- No distracting injury (e.g. long bone fracture, visceral injury, severe pain elsewhere that could mask neck pain)
If even one of these is not met — as in our case, where the patient has midline tenderness — imaging is required. CT is now the standard first-line imaging in most trauma centres (far more sensitive than plain films for fractures), though the Canadian C-Spine Rule is a useful alternative decision tool, particularly for low-risk mechanisms where a simple range-of-motion test may avoid imaging altogether.
Immobilisation — Correctly Applied
A cervical collar alone does not provide adequate immobilisation. Full spinal precautions mean a well-fitted rigid collar plus head blocks or manual in-line stabilisation, on a firm surface, until the spine is cleared. Remove immobilisation as soon as clinically and radiologically cleared — prolonged unnecessary immobilisation causes pressure sores, aspiration risk, and raised ICP from collar-induced venous congestion in the head-injured patient.
SCIWORA — A Trap in Children
SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) is a paediatric phenomenon: children's spines are more elastic than their cords, so the vertebral column can stretch and recoil without fracturing — while the less elastic cord inside is still injured. A normal CT/X-ray in a child with neurological symptoms after trauma does NOT exclude cord injury. MRI is required if there is any neurological deficit, regardless of normal bony imaging.
If the Spine Is Unstable
Once instability or cord compression is confirmed, management depends on the level and type of injury, but the core principles are consistent:
Principles of Acute Management
- Maintain immobilisation until definitive stabilisation, log-roll technique for all repositioning
- Maintain spinal cord perfusion: target MAP ≥85mmHg in acute cord injury — hypotension worsens secondary cord ischaemia, just as it does in traumatic brain injury
- Neurogenic shock: high cervical/thoracic injuries can cause loss of sympathetic tone — hypotension WITH bradycardia (distinct from hypovolaemic shock, which causes tachycardia). Treat with fluids cautiously and vasopressors, not aggressive fluid resuscitation alone
- Early neurosurgical/orthopaedic spine input for operative vs conservative decision — unstable fractures, progressive deficit, or cord compression on imaging generally require surgical stabilisation/decompression
- Document a full neurological exam (ASIA/AIS grading if trained) as a baseline — repeat regularly to detect deterioration early
This patient failed NEXUS (midline tenderness present), so a CT cervical spine was performed — showing a stable C6 spinous process fracture with no canal compromise and no cord signal change. He was cleared for collar removal by the spine team after 48 hours of observation with serial exams remaining normal, and discharged with outpatient follow-up. No surgery was required.
Apply NEXUS — all 5 criteria must be met to skip imaging. CT is first-line imaging for at-risk patients. A collar alone is not full immobilisation. SCIWORA means a normal scan doesn't exclude cord injury in children with symptoms. Maintain MAP ≥85 in confirmed cord injury. Neurogenic shock = hypotension + bradycardia, not tachycardia.
References
- Hoffman JR et al. Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma (NEXUS). NEJM. 2000;343(2):94–99.
- Stiell IG et al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA. 2001;286(15):1841–1848.
- Ryken TC et al. The Acute Cardiopulmonary Management of Patients with Cervical Spinal Cord Injuries. Neurosurgery. 2013;72(Suppl 2):84–92.
