Cervical Spine Trauma CT Report Template: Normal and Injury Examples

Scope and normal report example

This framework is for reporting an adult cervical spine CT after blunt trauma when imaging has been obtained. It does not determine whether a patient needs imaging or whether a cervical collar can be removed; those are clinical decisions using an appropriate pathway. Pediatric trauma requires a pediatric-specific approach.

The example assumes noncontrast multidetector CT with coverage from the occiput through T1 and sagittal and coronal reformations. State the actual coverage and technique.

Examination: CT of the cervical spine without intravenous contrast.

Technique: Noncontrast multidetector CT was performed from the occiput through T1 with sagittal and coronal reformations.

Comparison: [Date and examination / None available].

Findings: Cervical alignment is maintained. The craniocervical and atlantoaxial relationships are preserved. Vertebral body heights are maintained. No acute fracture or traumatic malalignment is identified from the occiput through T1. No significant prevertebral soft-tissue swelling is present. The included lung apices are clear.

Impression: No acute cervical spine fracture or traumatic malalignment identified.

Use this wording only when the relevant anatomy is covered and diagnostic. A negative CT should not be phrased as excluding every ligamentous, spinal cord, nerve-root, or vascular injury.

A systematic trauma review

1. Confirm coverage and image quality

Check the full requested region, including the craniocervical junction and cervicothoracic junction. Review axial images and sagittal and coronal reformations. Note motion, streak artifact, incomplete coverage, or any factor that limits evaluation. If T1 or the occiput is not adequately shown, say so.

2. Review alignment and the craniocervical junction

Assess occipital condyles, atlanto-occipital joints, C1 ring, dens, atlantoaxial alignment, and the remaining vertebral alignment. Look for translation, rotation, facet malalignment, interspinous widening, or abnormal disc-space widening. Do not use “alignment is normal” without reviewing the junctions and facets.

3. Search for osseous injury

Inspect vertebral bodies, endplates, pedicles, laminae, spinous and transverse processes, and facet joints at every level. For a fracture, report the exact level and side, the involved component, displacement or angulation if present, extension into the canal or neural foramen, and any retropulsed fragment. If there are multiple fractures, list each and avoid an impression that obscures the most consequential injury.

4. Assess the canal and visible soft tissues

Describe bony canal compromise and visible prevertebral swelling or hematoma. CT has limited assessment of the spinal cord, nerve roots, and ligamentous structures. Do not infer that these structures are intact from a normal CT. Review the included lung apices and other imaged structures without extending the conclusion beyond the field of view.

Selected injury wording

Use descriptive morphology. Do not assign a fracture classification unless the full criteria are met and the classification is useful to the clinical team.

Nondisplaced posterior-element fracture

There is a nondisplaced fracture through the right C6 lamina extending to the inferior articular process. No facet malalignment, vertebral translation, or significant osseous canal narrowing is identified.

Vertebral body compression fracture

There is mild anterior height loss of the C5 vertebral body with a fracture line through the superior endplate. No posterior wall retropulsion or significant osseous canal narrowing is identified.

Facet malalignment

There is traumatic malalignment of the [right/left] C5-C6 facet joint with [describe the observed subluxation/dislocation]. State associated fractures, translation, canal compromise, and any additional injury separately. This finding requires prompt communication according to local policy.

These modules describe imaging. They do not label an injury stable or prescribe management.

Fictional worked example with urgent communication

The following case is fictional. It demonstrates a complete report for a fracture with facet involvement; the details are illustrative.

Examination: CT of the cervical spine without intravenous contrast.

Technique: Noncontrast multidetector CT was performed from the occiput through T1. Sagittal and coronal reformations were reviewed.

Comparison: None available.

Findings: Cervical alignment is maintained. There is a fracture through the right C6 lamina extending into the inferior articular process, with approximately 2 mm separation of the fracture fragments. The right C5-C6 facet remains aligned. No vertebral body fracture, traumatic translation, or significant osseous canal narrowing is identified. No large prevertebral hematoma is seen. The included lung apices are clear.

Impression:
1. Acute right C6 lamina fracture extending into the inferior articular process, without facet malalignment or significant osseous canal narrowing.

Communication: The finding was communicated by [method] to [name/role] at [time] on [date], in accordance with local critical-result policy.

The communication line is a documentation field, not a substitute for completing the communication. Record the actual recipient, method, and time; do not leave an unverified placeholder in a signed report.

Limited or negative examinations

If motion, hardware, incomplete coverage, or another artifact prevents confident assessment, identify the affected level or structure and state whether repeat or alternative imaging should be considered through the treating team. Avoid a blanket “no acute injury” impression when a segment is not diagnostic.

When no fracture or traumatic malalignment is identified, state that directly. Avoid “no cervical injury,” which implies exclusion of soft-tissue, ligamentous, cord, nerve-root, and vascular injury that a routine noncontrast CT may not assess. CT angiography is a separate examination for a separate clinical question.

Final checklist

• Adult blunt-trauma context and correct study
• Coverage includes occiput through T1 or limitation explicitly named
• Axial images and multiplanar reformations reviewed
• Craniocervical junction, C1-C2, facets, and cervicothoracic junction checked
• Every fracture described by level, side, component, displacement, and canal/facet effect
• Alignment, posterior wall, retropulsion, and bony canal assessed
• Soft-tissue statements limited to what CT shows
• Impression names the most consequential injury
• Time-sensitive findings communicated and documentation completed per local policy

For patients in whom imaging is indicated, the ACR Appropriateness Criteria® for Acute Spinal Trauma (opens in a new tab) identify noncontrast cervical CT as usually appropriate initial imaging for adults meeting the specified clinical criteria. This reporting guide does not replace those criteria, local trauma pathways, or the treating team’s clinical assessment.

For a practical framework on communicating and documenting urgent findings, see Communicating and Documenting Critical Radiology Findings.

References

• American College of Radiology. ACR Appropriateness Criteria®: Acute Spinal Trauma (opens in a new tab), revised 2024.
• American College of Surgeons. Best Practices Guidelines: Spine Injury (opens in a new tab), 2022.
• American College of Radiology. Practice Parameter for Communication of Diagnostic Imaging Findings (opens in a new tab).

This educational framework does not replace patient-specific interpretation, the current local trauma protocol, or clinical judgment.