Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT

Several recent studies report the sensitivity of computed tomography (CT) to be far greater than that of traditional plain film radiographic studies for evaluation of cervical spine fractures and spinal cord pathology. Nevertheless, plain films continue to be the standard screening examination. CT is used only if fractures are demonstrated or suspected on plain film survey. Recently, three patients with significant head and neck trauma (all three patients had intracranial hemorrhage) had cervical spine evaluation by computed tomography and standard plain film views. CT demonstrated significant C1-C2 fractures, while plain films were completely normal in all three cases. Prospectively studying the next 50 patients with significant head trauma, we added a few more slices to the routine head scan protocol to cover the first three cervical vertebrae. This added very little time or cost to the procedure. The additional CT images demonstrated four upper cervical fractures that could not be seen on plain films, even in retrospect. Our findings suggest that routine inclusion of the upper cervical spine with head CT is appropriate in the evaluation of patients with significant head trauma as defined by intracranial hemorrhage or skull fracture.