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The mission of the Harvey L. Neiman Health Policy Institute® is to establish foundational evidence for health policy and radiology practice that promotes the effective and efficient use of health care resources and improves patient care.

August 4, 2021

52% Increase in Emergency Department Cervical Spine Imaging from 2009 to 2018

Reston, VA – A new Harvey L. Neiman Health Policy Institute study found that cervical spine imaging per emergency department (ED) trauma encounter increased 52% between 2009 and 2018. This increase is largely attributable to the 10.5% annual increase in CT imaging for the large number of patients with minor injuries who have historically had lower utilization. This Journal of the American College of Radiology study was based on over 11.3 million ED trauma encounters for commercially insured patients using the IBM MarketScan Database, which includes data from over 300 insurance carriers. These encounters were then classified by injury severity using an International Classification of Disease code-derived Injury Severity Score algorithm. This is the first study to use this classification to assess imaging services.

This 52% increase in overall cervical spine imaging between 2009 and 2018 masks different modality-specific patterns. In 2009, radiography was the predominant imaging modality in these cases (14.6 per 1,000 ED trauma encounters) followed closely by CT (13.9 per 1,000 ED trauma encounters) with MRI accounting for a small share (0.3 per 1,000 ED trauma encounters). However, by 2018, CT was the predominant imaging modality followed distantly by radiography and MRI (32.8, 10.4, and 0.7 images per 1,000 ED trauma encounters, respectively). Hence, the use of CT had a 2.4-fold increase and radiography decreased by 29%. While the use of MRI had a 2.3-fold increase, it remained a small fraction of cervical spine imaging in these cases.

Noting these trends, Akram Khaja, MD, first author and current resident at the University of Florida said, “A better understanding of how and why this growth continues could inform ongoing efforts to ensure appropriate use of ED imaging, thus potentially improving patient throughput while simultaneously reducing both costs and radiation exposure.” Because the study was based on claims data, “Our analysis does not permit us to determine the reason for the observed changes in imaging ordering behavior, but we hope that our work will provide a foundation for future research to inform imaging ordering guidelines and to understand external influences on medical decision making, such as medical malpractice litigation concerns or increased access to imaging services.”

“Notably, we observed a reduction in what we consider potentially duplicative imaging, such as CT and the typically less sensitive radiography, performed during the same encounter” said senior author Richard Duszak, MD, FACR, Professor and Vice Chair for health policy and practice in the department of radiology and imaging sciences at Emory University and senior affiliate research fellow at the Neiman Institute. The study found that overall use of both CT and radiography during the same encounter decreased 64% between 2009 and 2018. When analyzed by the severity of the injury, this decrease was 58%, 72%, and 74% for minor, intermediate, and major injuries, respectively. “This suggests that the growth we observed in CT is more a phenomenon of its use as a replacement—rather than additive—modality.”


To obtain a copy of the study or to arrange an interview with a Neiman Institute spokesperson, contact Nichole Gay at (703) 648-1665 or


About the Harvey L. Neiman Health Policy Institute

The Harvey L. Neiman Health Policy Institute® is one of the nation’s leading medical imaging socioeconomic research organizations. The Neiman Institute studies the role and value of radiology and radiologists in evolving health care delivery and payment systems and the impact of medical imaging on the cost, quality, safety and efficiency of health care.Visit us at and follow us on Twitter, LinkedIn and Facebook.


Nichole Gay
Harvey L. Neiman Health Policy Institute