Time-of-flight or phase-contrast sequences can be employed without the use of IV contrast for creation of virtual arteriograms. However, the use of IV contrast with 3-D time-of-flight imaging may greatly improve depiction of the vessels for identification of subtle stenosis or pseudoaneurysm formation. In addition, axial T1-weighted fat- suppressed images of the neck can greatly aid in the identification of intramural hematoma [71]. Three- dimensional magnetization-prepared rapid gradient-echo and diffusion-weighted imaging can also show mural thrombus related to dissection. Variant 6: Age greater than or equal to 16 years. Suspected acute cervical spine blunt trauma. Obtunded patient with no traumatic injury identified on cervical spine CT. Next imaging study after CT cervical spine without IV contrast. Radiography Cervical Spine There is no role for routine radiographs in assessment of an obtunded patient without traumatic injury identified on CT. Flexion-extension radiographs have been employed by some for exclusion of ligament injury. However, between 30% to 95% of dynamic flexion-extension radiographs have been found to be inadequate to exclude ligament injury because of limited motion and inadequate visualization of the lower cervical spine [35,74]. Even when flexion-extension radiographs adequately visualize the cervical spine, they rarely identify clinically significant cervical spine instability not apparent on CT, with reported positive predictive value as low as 0% [74- 76]. Flexion-extension radiographs have also been shown to identify fewer cervical ligament injuries compared with MRI. In a study of 48 patients with cervical spine trauma by Duane et al [75] in 2010 comparing flexion- extension radiographs with cervical spine MRI for diagnosing cervical spine ligament injury, none of the 8 Suspected Spine Trauma patients with ligament injury identified on MRI had an abnormality identified on flexion-extension radiographs.
Suspected Spine Trauma PCAs. Time-of-flight or phase-contrast sequences can be employed without the use of IV contrast for creation of virtual arteriograms. However, the use of IV contrast with 3-D time-of-flight imaging may greatly improve depiction of the vessels for identification of subtle stenosis or pseudoaneurysm formation. In addition, axial T1-weighted fat- suppressed images of the neck can greatly aid in the identification of intramural hematoma [71]. Three- dimensional magnetization-prepared rapid gradient-echo and diffusion-weighted imaging can also show mural thrombus related to dissection. Variant 6: Age greater than or equal to 16 years. Suspected acute cervical spine blunt trauma. Obtunded patient with no traumatic injury identified on cervical spine CT. Next imaging study after CT cervical spine without IV contrast. Radiography Cervical Spine There is no role for routine radiographs in assessment of an obtunded patient without traumatic injury identified on CT. Flexion-extension radiographs have been employed by some for exclusion of ligament injury. However, between 30% to 95% of dynamic flexion-extension radiographs have been found to be inadequate to exclude ligament injury because of limited motion and inadequate visualization of the lower cervical spine [35,74]. Even when flexion-extension radiographs adequately visualize the cervical spine, they rarely identify clinically significant cervical spine instability not apparent on CT, with reported positive predictive value as low as 0% [74- 76]. Flexion-extension radiographs have also been shown to identify fewer cervical ligament injuries compared with MRI. In a study of 48 patients with cervical spine trauma by Duane et al [75] in 2010 comparing flexion- extension radiographs with cervical spine MRI for diagnosing cervical spine ligament injury, none of the 8 Suspected Spine Trauma patients with ligament injury identified on MRI had an abnormality identified on flexion-extension radiographs.