Trauma constitutes a significant portion of emergency department practice. Such patients often have suspected cervical spine injury necessitating cervical spine radiographs. The importance of detecting cervical spine injury is obvious because failure to do so can lead to tragic consequences for patient and physician alike. Although most cervical spine radiographs are justified, poorly indicated and unnecessary examinations are unfortunately commonplace. Indiscriminate ordering of cervical spine examinations can easily exceed radiology resources assigned to the emergency department. Rational ordering practices are therefore essential for efficient patient management. A risk-tailored approach to performing these examinations, which can improve efficiency, is presented. Once obtained, cervical spine radiographs are presumed to detect injury with consistently high sensitivity. Prevailing conditions of emergency department practice that may lower the "sensitivity" of cervical spine radiographs are reviewed. Overreliance on the initial radiologic examination may lead to inappropriate haste in the evaluation of suspected cervical region injury as exemplified by the commonly voiced mandate to "clear the cervical spine" of injury. This approach is discouraged in patients with significant trauma in favor of a careful, progressive evaluation of the potentially injured cervical spine. Periodic review of these complex issues and close cooperation between clinical services are emphasized.