We conducted a retrospective review of 124 consecutive patients who received all of the following studies between October 1998 and December 1999: three-view plain films (3VPF), full CT survey (CTS), and MRI of the cervical spine. We compared the EAST guidelines for 1) patients with persistent neck pain, 2) those with neurologic deficits (NDs), and 3) those who were obtunded in our study group to determine whether EAST recommendations would risk a significant missed injury rate. The average age was 28 years (range 5 months-78 years). There were 94 males and 30 females. The mean Injury Severity Score (ISS) was 16.8 and the mean Glasgow Coma Score (GCS) 10.87. The most common mechanism of injury was motor vehicle crash (58%) followed by falling (15%), auto versus pedestrian (9%), all-terrain vehicle accident (4%), assault (3%) and other (11%). For comparisons we identified a group of 33 patients with normal mental status and normal 3VPF. Twenty patients had MRI for persistent neck pain. Eleven of 20 had normal MRI. The nine abnormal MRIs showed: six ligamentous injuries, two cord compressions, and one nonligamentous soft-tissue injury. Thirteen of the 33 patients had MRI for ND. Six had normal MRI and all these NDs resolved. The remaining seven MRIs showed: two disc herniations, two cord contusions, one cord edema, one lumbar fracture, and one brachial plexus avulsion. We also examined a group of 51 obtunded patients with normal 3VPF. Thirty-six of 51 had normal CTS and MRI. Ten patients had an abnormal MRI, two an abnormal CTS, and three abnormal MRI and CTS. No obtunded patient with an adequate 3VPF had an injury identified below C2 using CTS and MRI. In the 10 patients with abnormal MRI the mean age was 28.4 years, the mean GCS 6.6 (P = 0.0025), and the mean ISS 24.3 (P = 0.03) (Wilcoxson two-sample test). The injuries identified by MRI were four disc herniations, two ligamentous injuries, two soft-tissue traumas, one meningeal tear, and one cord transection. Thirty per cent of patients with persistent neck pain had potentially unstable injuries not detected by 3VPF or CTS. Fifty-four per cent of patients with ND had abnormal MRI. Twenty-two per cent of obtunded patients with normal 3VPF and CTS had an abnormal MRI. These patients have a significantly lower GCS and a higher ISS. Six per cent of these injuries were potentially unstable. Our data support EAST guidelines for patients with persistent neck pain and ND. The guidelines for obtunded patients appear safe in detecting bony injury but may not be sensitive enough for unstable ligamentous injury and significant disc herniations.