Written by Ketan Patel
Spoon Feed
A structured approach to cervical spine clearance using clinical decision rules, modern CT, and select use of MRI and x-ray in adult and pediatric patients allows us to avoid prolonged collar use, reduce ED crowding, and limit adverse collar effects for patients.
No to ifs… yes to CTs, CDRs and highly targeted MRIs
This review synthesizes a large foundation of traumatic cervical spine management, including clinical decision rules (NEXUS, Canadian C-Spine Rule, Pediatric exam +/- radiographs), modern multidetector CT use when indicated, and subsequent MRI use only when necessary to avoid prolonged collar use and delays in clearance, including those patients who are intoxicated or unconscious.
This systemic review (through October 2025) narratively synthesized thirty-three adult and eleven pediatric studies through a PubMed/MEDLINE search. In adults, modern multidetector CT scans showed 98–100% sensitivity and >99% negative predictive value for clinically significant/unstable injury. Subsequent MRI use only changed management in about 0.4–3% of patients. Pediatric protocols using exam and radiographs reduced CT use up to 70%, while maintaining high negative predictive values. MRI use was shown to be valuable for persistent symptoms or ligamentous concerns.
There is substantial heterogeneity in study designs, imaging technology/protocols, and clearance definitions. Data among geriatric and pediatric populations were also very sparse.
How will this change my practice?
This is an affirmation of how I currently manage these patients. Space in our standalone trauma center is a commodity. Keys are avoiding CT when possible, but if done, relying on the results, without over-reliance on subsequent MRI. I put clinical decisions rules first, but I’m glad for the donut of truth when I need it.
Source
Cervical Spine Clearance in Adult and Pediatric Trauma: A Systematic Review. J Emerg Med. 2026 Jun;85:95-113. doi: 10.1016/j.jemermed.2026.03.006. Epub 2026 Mar 13. PMID: 41955954.
