Normal Cervical Spine CT Report Template (Trauma)
Normal trauma cervical spine CT report template: alignment, prevertebral soft tissues and craniocervical junction, with notes on ligamentous injury wording.
EXAMINATION: CT cervical spine without intravenous contrast. CLINICAL HISTORY: [indication] COMPARISON: None available. TECHNIQUE: Axial helical images through the cervical spine without intravenous contrast, with coronal and sagittal reformats. FINDINGS: Alignment: Normal cervical lordosis. The anterior vertebral, posterior vertebral and spinolaminar lines are maintained. No subluxation. Craniocervical junction: Normal atlantoaxial and atlanto-occipital relationships. No widening of the atlantodental interval. Vertebrae: Normal heights. No acute fracture. Disc spaces: Preserved. No significant degenerative change. Facet joints: Aligned bilaterally at all levels. No perched or jumped facet. Prevertebral soft tissues: Normal thickness. No prevertebral swelling. Visualized lung apices: Clear. Visualized skull base and thyroid: Unremarkable. IMPRESSION: 1. No acute fracture or malalignment of the cervical spine.
Dictation notes
- Prevertebral soft tissue swelling can be the only sign of an anterior column injury — say explicitly that it is normal.
- A negative CT does not exclude ligamentous injury; in the obtunded or persistently symptomatic patient, the impression should offer MRI rather than stay silent.
- Check the facets on sagittal reformats level by level — a perched facet is the classic axial-only miss.
Frequently asked questions
What should a normal trauma cervical spine CT report include?
A trauma cervical spine CT report covers alignment — the anterior vertebral, posterior vertebral and spinolaminar lines — the craniocervical junction including the atlantodental interval, vertebral body heights, disc spaces, facet joint alignment at every level, and the prevertebral soft tissues. The visualized lung apices, skull base and thyroid are also addressed. The normal impression reads 'No acute fracture or malalignment of the cervical spine.'
Does a negative cervical spine CT exclude ligamentous injury?
No. CT demonstrates fractures and malalignment but can be normal despite significant ligamentous injury. In the obtunded patient or one with persistent midline tenderness or neurologic symptoms, the report should explicitly offer MRI rather than stay silent — MRI evaluates the ligaments, cord and soft tissues directly. Prevertebral soft tissue swelling can be the only CT sign of an anterior column injury, so stating that it is normal matters.
Why are facet joints checked on sagittal reformats?
A perched or jumped facet is the classic finding missed on axial images alone, because the facet surfaces lie roughly in the axial plane and subluxation displaces them along it. Reviewing the facets level by level on sagittal reformats shows the normal shingled alignment directly and makes a perched facet obvious. The report should state that the facets are aligned bilaterally at all levels.
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