The American College of Surgery currently recommends routine performance of lateral cervical radiography of C-1 to C-7 for all patients admitted with a history of major blunt trauma. A survey of 125 North American hospitals with experience in acute trauma care revealed that 96% obtain cervical radiographs as a routine or protocol study on all patients who have suffered major blunt trauma. To ascertain the cost-benefit effect of this practice, a prospective study was conducted during a 19-month period to compare the results of admission bedside clinical assessment of the cervical spine and the outcome of cervical radiography and computed tomography (CT) performed on 408 patients admitted with a history of major blunt trauma. Among these patients, there were 138 (34%) who were judged to be mentally alert and without symptoms referable to cervical spine injury. CT was performed after cervical radiography to adequately visualize the lower cervical spine (132 patients) or to clarify uncertain radiographic findings (six patients). One nondisplaced transverse process fracture of C-7 was detected (a prevalence of less than 1% of asymptomatic patients). The combined cost of cervical radiography and CT for the 138 asymptomatic patients was $59,202. These results call into question both the cost and clinical efficacy of routine or protocol-driven cervical spine imaging for all patients who have sustained major blunt trauma and support the value of careful bedside clinical assessment of the cervical spine in mentally alert blunt-trauma victims.