Unstable Cervical Spine Fracture with Normal Computed Tomography Imaging

The disposition for neurologically intact and alert patients complaining of persistent symptoms despite negative computed tomography (CT) imaging is controversial. Computed tomography has excellent sensitivity for osseous injuries but is insensitive for ligamentous injuries. Some advocate that these patients undergo early magnetic resonance imaging (MRI) because, although it is insensitive for osseous injury, it is highly sensitive for ligamentous and spinal cord injuries. We present the case of an alert and neurologically intact 84-year-old patient presenting with neck pain after a mechanical fall. Computed tomography demonstrated no acute osseous pathology. The patient was discharged home with persistent neck pain and advised to return to care within 2 days if his symptoms did not resolve. In 2 days, the patient returned to the emergency department and repeat CT imaging was negative. Magnetic resonance imaging demonstrated an unstable type 2 odontoid fracture. The patient was admitted, underwent cervical collar immobilization for 3 and a half months without neurologic sequelae at which time repeat imaging demonstrated no instability, and the collar was discontinued. We searched the peer-reviewed literature and identified 2 prior patients with CT-negative cervical spine fractures detected on MRI and requiring cervical collar immobilization. However, in neither case was the indication for immobilization documented to be an unstable fracture (vs associated ligamentous injuries). Our unique case adds to the growing literature suggesting a significant prevalence of actionable cervical spine injuries in patients with blunt trauma with persistent symptoms after negative CT imaging. Emergency physicians should consider early MRI for these patients instead of discharge with cervical collar.