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Because clinicians fear missing oc-cult cervical-spine injuries, they obtain cervical radio-graphs for nearly all patients who present with blunt trauma. Previous research suggests that a set of clin-ical criteria (decision instrument) can identify patients who have an extremely low probability of injury and who consequently have no need for imaging studies. Methods We conducted a prospective, observation-al study of such a decision instrument at 21 centers across the United States. The decision instrument re-quired patients to meet five criteria in order to be classified as having a low probability of injury: no midline cervical tenderness, no focal neurologic def-icit, normal alertness, no intoxication, and no pain-ful, distracting injury. We examined the performance of the decision instrument in 34,069 patients who un-derwent radiography of the cervical spine after blunt trauma