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Current Controversies-Initial Radiographic Imaging

On transport to the emergency room, the initial imaging modality to evaluate the cervical spine is plain-film radiography.

Both the NCAA and the Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete  have recommended that initial radiographs be obtained with the helmet and shoulder pads in place (but with the face mask removed). After the initial radiographic screening has been performed, the helmet and shoulder pads can be removed as described above. Standard anteroposterior, lateral, and odontoid views of the cervical spine are effective screening radiographs for patients with suspected cervical spine injury.

Helmets and shoulder pads, however, have been shown to interfere with adequate imaging of the cervical spine, particularly at the cervicothoracic junction. In a small study using volunteers, Davidson et al.It demonstrated that the upper cervical spine and the cervicothoracic junction were poorly depicted when radiographs were obtained with protective gear in place.

The designs of hockey and football helmets differ, however, such that the initial lateral cervical spine scout film may be adequate with the equipment in place for ice hockey players.

Given the problems with plain-film radiographs, several authors have suggested use of CT as the initial screening modality. Lateral CT scans have been used to effectively depict the entire cervical spine with protective equipment in place.

As CT technology improves, this modality may become the primary choice for initial radiographic screening of athletes with a cervical spine injury.

We recommend that initial screening radiographs be obtained with the protective equipment in place. If these films are inadequate, perform additional imaging. In the athlete with a high suspicion of a cervical spine injury (e.g., severe neck pain or a neurological deficit), we recommend proceeding directly to CT with the protective equipment in place.

If urgent CT is unavailable, remove the protective gear to obtain adequate films. In lower-risk cases, the helmet and shoulder pads can be carefully removed using the protocol described above; plain-film radiographs can then be obtained with the neck immobilized.

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