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Home > Professional Reference > Plain Skull X-ray

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Plain Skull X-ray

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Synonym: SXR

Headache and head trauma are common presenting problems in both primary care and the Accident and Emergency department.

It is now well recognised that only in a small proportion of cases are plain skull X-ray films (plain skull films) appropriate and likely to aid management decisions. In light of the amounts of unnecessary radiation to which patients are exposed by the use of inappropriate X-rays, the Ionising Radiation (Medical Exposure) Regulation (IRMER) states that practitioners must ascertain that the net clinical benefit of each film justifies the risk involved in undergoing the procedure.

The majority of plain skull films are performed following trauma to the head and, in order to aid decisions as to which patients might benefit from these X-rays, several groups have audited past results from many radiology departments.1,2,3 From these and other studies it became clear that, whilst intracranial injury is more likely if there is a skull fracture, significant intracranial injury may also occur in the absence of a fracture,and a normal skull X-ray may give a false sense of reassurance.

There is also now useful literature on the prehospital management of head injury.4,5 Several guidelines have been produced in an attempt to aid the decision as to when a plain skull film may be helpful in both acute and non-acute situations.6,7

Indications for plain skull X-ray

When to request a skull X-ray?
Head injury or not
Clinical settings
Head injury
Glasgow Coma Scale (GCS) is 15/15 and CT scanning is not going to be carried out and one or more of the following present:7,8
  • Mechanism of the injury has not been trivial and/or has involved a fall from a significant height.
  • Consciousness has been lost.
  • Loss of memory.
  • Vomiting since the event.
  • Full thickness scalp laceration.
  • A boggy haematoma or scalp bruise is evident.
  • The child is under the age of 5 and non-accidental injury is suspected.
  • The history is inadequate.

CT is always the preferred investigation if available

Non-head injury cases6
  • Presence of a palpable vault abnormality which feels bony.
  • As part of an imaging protocol for specific clinical problems, e.g. skeletal survey for myeloma.
  • Facial views after trauma to facial skeleton, mandible or the orbit, or possibility of metallic foreign body.

Many departments might still opt for a CT scan in cases where a head-injury is involved and it is best to discuss the individual case with senior colleagues and radiologists, especially as a normal skull X-ray does not rule out intracranial injury. Similarly, it is still worth discussing the role of skull X-ray in non-head injury cases.

Skull films are not indicated routinely for the following indications:

  • Headache
  • Possible pituitary problems - (CT/MRI preferred)
  • Possible space-occupying lesion
  • Epilepsy
  • Dementia or memory loss
  • Middle or inner ear problems
  • Nasal trauma - coned views may be requested by appropriate specialist
  • Sinus disease - mucosal thickening is a common incidental finding and not diagnostic
  • Temporomandibular joint dysfunction - will not show disc abnormality which is the most common cause of dysfunction

Interpretation of skull films

Skull films should be interpreted wherever possible, by a doctor with specialist training and/or considerable experience in interpreting such films. In untrained hands approximately 10% of bony abnormalities are not recognised. The absence of a fracture on a skull film does not rule out the possibility of an operable intracranial haematoma in head injured patients. All such findings must be taken in the context of the clinical condition of the patient, e.g. patients with a GCS of 3-8 and no fracture still have a 1 in 27 risk of having an operable intracranial haematoma.9

Document references

  1. Simon SD, Dodds RD; The use of skull X-rays in the accident and emergency department. Ann R Coll Surg Engl. 2003 Mar;85(2):120-2. [abstract]
  2. Bartlett J, Kett-White R, Mendelow AD, et al; Recommendations from the Society of British Neurological Surgeons. Br J Neurosurg. 1998 Aug;12(4):349-52.
  3. No authors listed; A study of the utilisation of skull radiography in 9 accident-and-emergency units in the U.K. A national study by the Royal College of Radiologists. Lancet. 1980 Dec 6;2(8206):1234-6. [abstract]
  4. Early Management of Patients with a Head Injury, SIGN (May 2009)
  5. Hammell CL, Henning JD; Prehospital management of severe traumatic brain injury. BMJ. 2009 May 19;338:b1683. doi: 10.1136/bmj.b1683.
  6. Royal College of Radiologists .Making the best use of a department of clinical radiology. Guidelines for doctors, 4th ed.London:RCR;1998
  7. Triage - assessment - investigation and early management of head injury in infants, children and adults, NICE Clinical Guideline (September 2007).
  8. Johnson K, Williams SC, Balogun M, et al; Reducing unnecessary skull radiographs in children: a multidisciplinary audit. Clin Radiol. 2004 Jul;59(7):616-20. [abstract]
  9. Teasdale GM, Murray G, Anderson E, et al; Risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries. BMJ. 1990 Feb 10;300(6721):363-7. [abstract]

Internet and further reading

Acknowledgements

EMIS is grateful to Dr Gurvinder Rull for writing this article and to Dr Laurence Knott for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2011.
Document ID: 2618
Document Version: 25
Document Reference: bgp1571
Last Updated: 7 Sep 2009
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