A 29-year-old woman sits rigidly on the stretcher after a low-speed rear-end collision, one hand pressed to the back of her neck. She is alert, speaking normally, and keeps asking whether she can go home; the only visible injury is a thin bruise from the shoulder belt. Her neurologic exam appears normal, but she reports midline tenderness when asked to look down. The question is whether the collar can come off—or whether the next move is imaging.

— What’s your move? Read on.

Before you read
  • When is CT enough, and when does MRI add value?
  • Which “normal” examination is not reliable enough to clear the spine?

When to Think of It

Consider cervical spine injury after blunt trauma with neck pain or midline tenderness, neurologic symptoms, distracting injury, intoxication, altered mental status, high-risk mechanism, or inability to actively rotate the neck. The key bedside question is whether the patient is awake, sober, neurologically reliable, and able to participate.

Sick or Not Sick

The decisive call is reliable clinical examination versus an unreliable or high-risk patient. A reliable, low-risk patient may be cleared clinically; everyone else generally needs imaging or specialist-directed clearance.

The First Fifteen Minutes

  • Maintain spinal motion restriction while assessing airway, breathing, circulation, and neurologic status; avoid forcing a neutral position if it worsens pain, resistance, or neurologic symptoms.
  • Severe pain limiting examination → fentanyl 25–50 mcg IV, repeated every 5 minutes to effect, usual maximum 200 mcg; it provides titratable analgesia without requiring movement for positioning. Monitor ventilation.
  • Hemodynamically stable patient needing additional analgesia → acetaminophen 1,000 mg PO or IV once; it reduces pain without respiratory depression. Maximum generally 4 g/day, or 3 g/day in older adults, liver disease, or heavy alcohol use.
  • Obtain thin-slice CT of the cervical spine with multiplanar reconstructions when clinical rules are positive or the examination is unreliable.
  • Do not administer steroids for traumatic spinal cord injury; routine high-dose methylprednisolone has no established ED benefit and causes harm.

Definitive Care & Disposition

For an alert, sober adult without midline tenderness, focal neurologic deficit, distracting injury, intoxication, or high-risk mechanism, apply NEXUS or the Canadian C-Spine Rule as appropriate; if low risk and able to rotate the neck 45° left and right, remove the collar. Canadian C-Spine Rule mandates imaging for age ≥65, dangerous mechanism, or paresthesias; NEXUS is more permissive but should not override clinical concern. CT is first-line imaging for most patients requiring imaging. A normal CT usually clears the spine in an awake, neurologically intact patient with no persistent midline tenderness; persistent pain, neurologic symptoms, severe degenerative disease, or suspected ligamentous injury warrants spine consultation and selective MRI. Unstable fracture, cord injury, or neurologic deficit requires trauma/spine admission and continued motion restriction.

How This One Kills

The dangerous error is treating a negative CT as permission to remove the collar in a patient with persistent neurologic deficit or an unreliable examination; CT can miss clinically important ligamentous or cord injury.
The Differential — What Else Looks Like This
  • Cervical muscle strain — diffuse paraspinal pain without midline tenderness or neurologic findings; confusing it with instability causes missed injury.
  • Cervical cord injury without fracture — neurologic deficit despite a normal CT; premature clearance can worsen secondary injury.
  • Distracting long-bone injury — the neck exam is unreliable because pain dominates attention; clinical clearance becomes falsely reassuring.
  • Cervical artery dissection — neck pain with headache, Horner syndrome, or focal deficit rather than mechanical midline tenderness; confusing the diagnoses delays vascular imaging and stroke prevention.

The Second-Day Story

Older adults may sustain unstable fractures after a ground-level fall, report little pain, and have severe spondylosis that makes CT interpretation difficult. Intoxicated or intubated patients cannot provide a meaningful examination, while patients with baseline neuropathy may not identify new symptoms. In these groups, mechanism, examination reliability, CT quality, alignment, and specialist review matter more than the patient’s subjective comfort.
Back to Our Patient
Back to our 29-year-old woman: she is alert, sober, hemodynamically stable, neurologically intact, and has midline tenderness, so she fails clinical clearance and receives CT rather than immediate collar removal. CT shows no fracture, malalignment, or prevertebral swelling; after analgesia she can rotate her neck 45° in both directions without neurologic symptoms. With a reliable examination and reassuring CT, the collar is removed, she receives return precautions for weakness, numbness, or worsening pain, and she is discharged with outpatient follow-up rather than admitted.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“This is a 29-year-old woman after a low-speed rear-end MVC with neck pain and midline cervical tenderness. She is alert, sober, hemodynamically stable, and denies weakness, numbness, paresthesias, loss of consciousness, or other distracting injury. Exam shows focal midline tenderness but normal strength, sensation, gait, and cranial nerves, without respiratory distress. She fails clinical clearance because of midline tenderness, so we obtained a high-quality CT cervical spine. CT shows no fracture, malalignment, or prevertebral swelling, and after analgesia she can actively rotate 45 degrees bilaterally without neurologic symptoms. I assess this as a cervical strain without evidence of unstable injury; I plan collar removal, symptomatic treatment, discharge precautions, and follow-up.”

Study Directive

  • Write the NEXUS criteria and Canadian C-Spine Rule from memory, then compare where each mandates imaging.
  • Practice three cases: alert low-risk patient, intoxicated patient, and awake patient with neurologic symptoms.
  • Review your institutional CT-to-collar-removal policy and identify when MRI or spine consultation is required.
  • Draw a one-page algorithm separating clinical clearance, CT clearance, and specialist-directed clearance.

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