It is important to note that the low-risk criteria described earlier were created to apply to previously healthy people. There are a number of groups at significantly higher risk of spinal injury. Conditions known to predispose to CSI (eg, Down syndrome, Klippel-Feil syndrome, achondroplasia, mucopolysaccharidosis, Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta, Larsen syndrome, juvenile rheumatoid arthritis, juvenile ankylosing spondylitis, renal osteodystrophy, rickets, and a history of CSI or cervical spine surgery) represent special circumstances.3 These patients all require imaging if there is neck pain associated with trauma. As with other patients, plain radiography is the initial test, although it may be difficult to interpret with some of these conditions, and CT and/or MRI may be necessary to rule out significant injury. Such decisions should be made in consultation with neurosurgery or orthopedics.
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