Mechanism of injury

• Fall from height >1 metre
• High-speed road traffic collision
• Diving injury
• Axial loading to the head or neck

Clinical features

• Neck pain or midline cervical tenderness
• Reduced range of movement
• Focal neurological deficit
• GCS <15
• Paraesthesia in the upper or lower limbs

• GCS <13 on initial assessment
• Patient has been intubated
• Focal neurological deficit
• Paraesthesia in the upper or lower limbs
• Dangerous mechanism of injury (fall from height >1 metre, axial loading, high-speed RTC)
• Age ≥65
• Multi-region trauma — CT already being performed for another indication
• Unable to actively rotate neck 45° left and right

Step 1 – Any high-risk factor?

• Age ≥65
• Dangerous mechanism
• Paraesthesia in extremities

If yes → CT indicated. If no, proceed to Step 2.

Step 2 – Any low-risk factor that allows safe assessment?

• Simple rear-end motor vehicle collision
• Sitting position in the ED
• Ambulatory at any time since injury
• Delayed onset of neck pain (not immediate)
• Absence of midline cervical tenderness

If no low-risk factor present → CT indicated. If at least one low-risk factor present, proceed to Step 3.

Step 3 – Can the patient actively rotate their neck 45° left and right?

If yes → no imaging required. If no → CT indicated.

• Children <10 years have a higher risk of upper C-spine injury (C1–C3) due to proportionally larger heads and weaker neck musculature
• SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) is more common in children under 8 — normal X-rays and CT do not exclude cord injury
• Pseudo-subluxation of C2/C3 is a normal variant in children and should not be mistaken for injury
• In children <16 years, plain X-rays are recommended as the first-line imaging modality for the C-spine (not CT), to reduce radiation exposure
• For thoracolumbar spine: X-ray is first-line. If a fracture is identified, image the rest of the spine to exclude non-contiguous injuries

• CT → shows fractures, dislocations, bony alignment
• MRI → shows spinal cord oedema, ligamentous injury, disc herniation, SCIWORA
• MRI is indicated after CT if there is neurological deficit with normal or equivocal CT findings
• MRI is also indicated if there is clinical suspicion of cord compression, even with a normal CT

When NOT to apply a cervical collar

• Ankylosing spondylitis — the spine is fused and rigid; a collar can worsen an unstable fracture by forcing the neck into an unnatural position
• Compromised airway — a collar can restrict access and worsen airway obstruction
• Penetrating neck trauma — a collar can obscure expanding haematoma and delay surgical access
• Combative patients — forced application can cause more harm than benefit

Alternatives to collars

• Manual in-line stabilisation (MILS)
• Head blocks with tape
• Sandbags (less commonly used now)

Spinal cord injury management

• Do NOT give methylprednisolone — NICE NG232 explicitly states it should not be used in acute spinal cord injury
• Do NOT give nimodipine
• Do NOT give naloxone (unless opioid overdose is suspected independently)

• NG41 (2016) was the original NICE spinal injury guideline
• NG232 (2023) updated and replaced NG41, incorporating the Canadian C-Spine Rule formally into NICE guidance
• The exam may reference either NG41 or NG232 — the clinical content is substantially the same, but NG232 is the current standard
• Key update in NG232: the Canadian C-Spine Rule is now the recommended clinical decision tool for C-spine imaging in adults

Fracture recognition on imaging

• Jefferson fracture — burst fracture of C1, lateral mass displacement on open-mouth peg view
• Hangman's fracture — bilateral fracture of C2 pedicles, hyperextension mechanism
• Odontoid (dens) fractures — Type I (tip, stable), Type II (base of dens, unstable, most common), Type III (extends into C2 body)
• Flexion teardrop fracture — highly unstable, anterior wedge fragment
• Clay shoveller's fracture — spinous process avulsion (C6/C7), stable

Management decisions

• Immediate vs definitive management — immobilisation first, then imaging, then specialist referral
• When to transfer to a spinal injuries unit — any confirmed or suspected unstable injury, any neurological deficit
• Complications to anticipate — neurogenic shock (bradycardia + hypotension, distinct from spinal shock), spinal cord syndromes (anterior cord, central cord, Brown-Séquard)