A 22-year-old man comes to the emergency department after a motor vehicle collision. His car was stopped at a red light when another vehicle hit his car's rear end at approximately 16 kph (9.9 mph). The patient was restrained; however, on impact, his head moved suddenly backward then forward. He has mild neck soreness but no other pain. Temperature is 36.8 C (98.3 F), blood pressure is 128/74 mm Hg, pulse is 82/min, and respirations are 14/min. The patient does not appear intoxicated. Glasgow Coma Scale score is 15, and neurologic examination is normal. Palpation of the midline spine elicits no pain. The rest of the physical examination is unremarkable. Which of the following is the most appropriate imaging for evaluating this patient's cervical spine for injury?

Question

A 22-year-old man comes to the emergency department after a motor vehicle collision.  His car was stopped at a red light when another vehicle hit his car's rear end at approximately 16 kph (9.9 mph).  The patient was restrained; however, on impact, his head moved suddenly backward then forward.  He has mild neck soreness but no other pain.  Temperature is 36.8 C (98.3 F), blood pressure is 128/74 mm Hg, pulse is 82/min, and respirations are 14/min.  The patient does not appear intoxicated.  Glasgow Coma Scale score is 15, and neurologic examination is normal.  Palpation of the midline spine elicits no pain.  The rest of the physical examination is unremarkable.  Which of the following is the most appropriate imaging for evaluating this patient's cervical spine for injury?

Quizplus · Accepted Answer

Explanation: This patient, who was involved in a low-speed rear-end motor vehicle collision, experienced whiplash (ie, sudden, sequential extension and flexion of the neck), resulting in neck soreness. Whiplash most commonly causes cervical strain (ie, neck pain and/or stiffness of the cervical paraspinal muscles) without associated cervical spine fracture. However, validated clinical decision rules, such as the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria, are applied to determine whether cervical spine imaging should be obtained. Based on the NEXUS low-risk criteria, cervical spine imaging should be performed in any patient who has 1 or more of the following findings: Neurologic deficit Spinal tenderness Altered mental status Intoxication Distracting injury In adults age <60 who have none of the above findings, such as this patient, cervical spine imaging is not required because the likelihood of a clinically significant cervical spine fracture is extremely low (ie, negative predictive value of 99.9%). In contrast to this patient, those with any of the above findings should undergo cervical spine imaging. Noncontrast CT scan of the cervical spine is the preferred screening test in adults because it is significantly more sensitive for detecting fractures than plain radiography (ie, ~98% vs ~52% sensitivity) (Choice D). When CT scan is unavailable, multiple plain radiograph views (eg, lateral, anteroposterior, open-mouth) should be obtained (Choice A). A single-view (eg, portable lateral) radiograph is never adequate to exclude a fracture because it only detects 60%-80% of fractures seen with a complete radiographic series (Choice E). (Choice B) MRI of the cervical spine is not commonly performed as the primary screening test for cervical spine injury; rather, it is typically performed to better visualize the soft tissues when CT scan suggests ligamentous or spinal cord injury. In this patient, however, no imaging is necessary. Educational objective: Whiplash most commonly causes cervical strain without associated cervical spine fracture. Patients with cervical trauma should be evaluated using validated clinical decision rules (eg, National Emergency X-Radiography Utilization Study [NEXUS] low-risk criteria) to determine whether cervical spine imaging is needed. References: Emergency department evaluation and treatment of cervical spine injuries. (http://www.ncbi.nlm.nih.gov/pubmed/25892721) Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23048086)

A 22-Year-Old Man Comes to the Emergency Department After a Motor