Can an X-ray Miss a Spinal Fracture Charlotte NC | Imaging-Credentialed DC | Clear Life Scoliosis

By Dr. Justin M. Dick, DC, CNMT, ARRT(N)(CT) | Clear Life Scoliosis and Chiropractic Center, Charlotte, NC | Published October 26, 2026

Yes. In trauma patients who need neck imaging, plain X-rays miss a large share of fractures that CT finds. That is why the American College of Radiology prefers CT for the initial assessment of spine trauma. A normal X-ray after a high-risk crash does not clear the spine, and patients in Charlotte who were X-rayed instead of scanned should know that.

How Often X-rays Miss Fractures

A prospective study at a Miami trauma center imaged 667 consecutive trauma patients with both three-view cervical X-rays and multislice CT. Nearly half of the injuries came from motor vehicle collisions. Sixty patients, 9%, had acute cervical spine injuries. CT had a sensitivity of 100%. Plain X-rays had a sensitivity of 45%, and they missed 15 of 27 clinically significant injuries, 55.5% (Mathen, J Trauma 2007). The authors concluded that plain films added no clinically relevant information to CT.

A meta-analysis of seven studies found the same pattern: pooled sensitivity of 52% for cervical radiographs and 98% for CT (Holmes and Akkinepalli, J Trauma 2005).

What the Guidelines Say

The American College of Radiology Appropriateness Criteria for suspected spine trauma state that CT is preferred to radiographs for the initial assessment of spine trauma (Beckmann, J Am Coll Radiol 2019). The same document notes that cervical spine injuries occur in 3% to 4% of blunt trauma patients in the emergency department.

Who Needs Imaging at All

Not every crash patient needs CT. The NEXUS criteria and the Canadian C-Spine Rule identify patients at low enough risk to skip imaging. NEXUS requires all five criteria: no midline tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful distracting injury (Hoffman, N Engl J Med 2000). In a direct comparison, the Canadian rule was more sensitive, 99.4% versus 90.7% (Stiell, N Engl J Med 2003). The question is not X-ray or CT for everyone. It is whether imaging is needed, and if so, CT.

Where X-rays Still Fit

The meta-analysis authors recommended CT first for high-risk patients and found the evidence insufficient to replace X-rays with CT in lower-risk patients who still need imaging (Holmes and Akkinepalli, J Trauma 2005). X-rays also answer questions CT is not used for. A standing X-ray shows alignment under load, and flexion and extension X-rays measure motion between vertebrae, which the AMA Guides accept for rating ligament laxity. Those are follow-up questions, asked after fracture has been excluded.

What CT Does Not Show

CT shows bone. A ligament can be injured without a fracture. In surgical cervical trauma cases, MRI found ligament injuries confirmed at surgery, with sensitivity from 67% to 100% depending on the ligament (Goradia, AJNR 2007). A CT read as "no acute fracture" answers the fracture question and leaves the ligament question open.

In my office, a patient with high-risk findings who has had only X-rays goes for CT before anything else is done. Midline tenderness, new numbness or weakness, tingling in the arms or legs, or age 65 or older after a crash are enough.

For an example of how post-collision imaging findings and outcomes are documented in the peer-reviewed literature, read Dr. Justin Dick's published case report on refractory lumbar pain following a motor vehicle accident in a geriatric patient.

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Frequently Asked Questions

Can an X-ray miss a broken neck?

Yes. In a prospective study of 667 trauma patients, plain X-rays had 45% sensitivity for cervical spine injury and missed 55.5% of clinically significant injuries that CT found (Mathen, J Trauma 2007).

Is CT better than X-ray for spinal fractures?

Yes, when imaging is needed after trauma. The American College of Radiology prefers CT to radiographs for initial assessment of spine trauma (Beckmann, J Am Coll Radiol 2019).

Do I need a CT scan after a car accident if my X-ray was normal?

If you had high-risk findings, such as midline tenderness, neurologic symptoms, or age 65 or older, a normal X-ray does not clear the spine. Dr. Justin Dick in Charlotte, NC refers those patients for CT.

Does everyone need imaging after a car accident?

No. The NEXUS criteria and Canadian C-Spine Rule identify low-risk patients who do not need imaging. The Canadian rule was more sensitive in a direct comparison (Stiell, N Engl J Med 2003).

Can a CT scan miss a spinal injury?

CT is very sensitive for fractures but shows bone. Ligament injuries without fracture need MRI or, for laxity, flexion and extension X-rays.

Where can I get evaluated for a missed spinal fracture in Charlotte, NC?

Dr. Justin Dick, DC, CNMT, ARRT(N)(CT), reviews post-accident imaging and refers for CT when indicated at Clear Life Scoliosis and Chiropractic Center, 8814 Rachel Freeman Way, Suite 103, Charlotte, NC 28278, phone 980-368-0766. Personal injury patients are treated on a lien basis, with no out-of-pocket payment at the time of care.

Sources and Evidence Tiers

1. Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma. 2007;62(6):1427-1431. PMID 17563660. LinkEvidence tier: Prospective comparative cohort (667 patients)
2. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma. 2005;58(5):902-905. PMID 15920400. LinkEvidence tier: Meta-analysis of observational studies (no RCTs)
3. Beckmann NM, West OC, Nunez D, et al. ACR Appropriateness Criteria: Suspected Spine Trauma. J Am Coll Radiol. 2019;16(5S):S264-S285. PMID 31054754. LinkEvidence tier: Evidence-based guideline with expert panel rating (RAND/UCLA and GRADE)
4. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-99. PMID 10891516. LinkEvidence tier: Prospective multicenter cohort
5. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-2518. PMID 14695411. LinkEvidence tier: Prospective comparative cohort
6. Goradia D, Linnau KF, Cohen WA, Mirza S, Hallam DK, Blackmore CC. Correlation of MR imaging findings with intraoperative findings after cervical spine trauma. AJNR Am J Neuroradiol. 2007;28(2):209-215. PMID 17296981. LinkEvidence tier: Diagnostic accuracy cohort (31 surgical patients)

Service Area

Clear Life Scoliosis and Chiropractic Center sees personal injury and spinal imaging patients from Charlotte NC, Huntersville NC, Ballantyne NC, Matthews NC, Concord NC, Mooresville NC, Rock Hill SC, and Fort Mill SC.

Related Pages

• Personal injury and car accident spinal care in Charlotte
• Dr. Justin Dick's research
• Case report: refractory lumbar pain after a motor vehicle accident
• Research and evidence at Clear Life
• Questions and answers
• Our team
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• Contact Clear Life

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This article is educational and is not a diagnosis. Imaging decisions depend on an in-person examination.