Risk Categories:

High Risk: Needs imaging

• Age ≥ 65 years

• Dangerous mechanism of injury (e.g., fall >1 metre, axial load to the head, high-speed motor vehicle collision, rollover, ejection from vehicle, bicycle collision, horse riding accident)

• Paraesthesia in the upper or lower limbs

Low Risk: No imaging unless they unable to rotate neck 45 degrees left and right

• Minor rear-end motor vehicle collision

• Comfortable in a sitting position

• Ambulatory at any time since injury

• No midline cervical spine tenderness

• Delayed onset of neck pain

No Risk: No imaging

• Presence of a low-risk factor and ability to rotate neck 45 degrees left and right

Risk Indicators:

• Age ≥ 65 years with reported pain

• Dangerous mechanism of injury (e.g., fall >3 meters, axial load, high-speed collision, ejection from vehicle, etc.)

• Pre-existing spinal pathology or osteoporosis

• Suspected fracture in another spinal region

• Abnormal neurological symptoms or signs

• New deformity or bony midline tenderness

• Midline or spinal pain on coughing

• Pain or abnormal neurological symptoms upon mobilisation

Note: These rules are also challenging to apply to children and should consider developmental stages and communication abilities.

Cervical Spine

• High-Risk Adults: Perform CT based on the Canadian C-spine rule.

• Neurological Symptoms: Perform MRI following CT if there are definite neurological abnormalities.

• Children: Perform MRI if there is a suspicion of spinal cord injury or abnormal neurological signs. Consider plain X-rays if there is no suspicion of cord injury. See appendix for criteria for CT c-spine in children with head injuries.

Thoracic and Lumbar Spine

• Suspected Injury without Neurological Signs perform CT or MRI if available

• Confirmed Fracture: Image the entire spinal column.

Whole-Body CT

Recommended for major trauma patients with suspicion of injury in more than one body area.

• Imaging: Perform thin section CT from C0 to T4/5, or C0 to T1 if chest CT is performed.

• Thoracic and Lumbar Spine Clearance: Use CT reconstructions.

• Reporting: Immediate verbal report by a consultant radiologist during daytime; Out-of-hours service reports with continuation of spinal precautions until confirmed.

Agreement during TCDG meetings states that CT clearance is usually sufficient. If doubt remains, review CT with a neuroradiologist and consider MRI.

Patients with confirmed spinal cord injury, and open spinal fracture or a dislocated spine will need to be transferred to the MTC under the Automatic Acceptance Policy. Frimley Guidelines

Ensure an Asia Chart is completed and manage appropriately

For people under 16 who have sustained a head injury (including those with delayed presentation), only do a CT cervical spine scan if any of these risk factors apply:

• the GCS score is 12 or less on initial assessment

• the person has been intubated

• there are focal peripheral neurological signs

• there is paraesthesia in the upper or lower limbs

• a definitive diagnosis of a cervical spine injury is needed urgently (for example, if manipulation of the cervical spine is needed during surgery or anaesthesia)

• the person is having other body areas scanned for head injury or multisystem trauma, and there is clinical suspicion of a cervical spine injury

• there is strong clinical suspicion of injury despite normal X‑rays

• plain X‑rays are technically difficult or inadequate

• plain X‑rays identify a significant bony injury.

• Do the scan within 1 hour of the risk factor being identified.

For people under 16 who have sustained a head injury, and have neck pain or tenderness but no indications for a CT cervical spine scan, do 3‑view cervical spine X‑rays before assessing range of movement in the neck if any of these risk factors are identified:

National Institute for Health and Care Excellence [NICE] (2016) Spinal injury: assessment and initial management. NG41. Available at: https://www.nice.org.uk/guidance/ng41/ (Accessed: 05 September 2025).

Royal College of Radiologists (2024) Major paediatric trauma radiology guidance. Available at: https://www.rcr.ac.uk/our-services/all-our-publications/clinical-radiology-publications/major-paediatric-trauma-radiology-guidance/ (Accessed: 05 September 2025).

National Institute for Health and Care Excellence [NICE] (2023) Head injury: assessment and early management. NG232. Available at: https://www.nice.org.uk/guidance/ng232/ (Accessed: 05 September 2025).

Royal College of Radiologists (2024) Major adult trauma radiology guidance. Available at: https://www.rcr.ac.uk/our-services/all-our-publications/clinical-radiology-publications/major-adult-trauma-radiology-guidance/ (Accessed: 05 September 2025).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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