Initial assessment of suspected cervical spine fracture in the emergency department: A contemporary narrative review.

Cervical spine fractures represent a potentially catastrophic consequence of blunt trauma. Early identification of unstable injuries is critical to prevent secondary neurological deterioration, yet over-imaging carries measurable risks including radiation exposure, resource burden, and immobilisation-related morbidity. This narrative review critically examines contemporary evidence guiding the initial assessment of suspected cervical spine fractures in the emergency department, with particular attention to clinical decision rules, imaging strategies, and special populations. Initial assessment remains grounded in Advanced Trauma Life Support principles, emphasising spinal protection while ensuring airway and haemodynamic stability. Study selection was guided by clinical relevance and applicability to modern trauma systems rather than predefined systematic criteria. Validated clinical decision rules-including the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-Spine Rule (CCR)-demonstrate high sensitivity for clinically significant injury but have recognised limitations in elderly and obtunded populations. Pooled data demonstrate CCR achieves superior specificity (∼40-50%) compared with NEXUS (∼36-37% pooled; ∼12-13% in the original derivation), with both tools approaching 99-100% sensitivity when applied appropriately. Multidetector computed tomography has become the cornerstone imaging modality, with sensitivity exceeding 98% for clinically significant bony injury and near-complete negative predictive value in obtunded patients. Magnetic resonance imaging plays a selective role, principally indicated for neurological deficit, suspected spinal cord injury without radiographic abnormality (SCIWORA), or concern for epidural haematoma in anticoagulated patients; routine adjunctive MRI following a normal CT is unlikely to be cost-effective in neurologically intact patients. The initial assessment of suspected cervical spine fracture requires integration of structured clinical evaluation, validated decision rules, and high-resolution imaging within a risk-calibrated framework. Future priorities include prospective validation of CT-alone clearance protocols across diverse trauma systems, development of age-adjusted decision tools for elderly patients, and exploration of artificial intelligence-assisted CT interpretation to improve diagnostic efficiency without compromising safety.