We thank Drs Sundaram and Koteeswaran for their comments. With regard to the arguments in favour of whole C-spine CT, we agree with them entirely. We, too, believe that this method of imaging is more likely to identify injuries than plain radiography alone or in combination with ‘directed’ (that is, partial) CT. Indeed, we suggested as much in this journal some time ago [1]. Articles published in Anaesthesia since then suggest a slow acceptance that this approach offers the best chance of patients being liberated from immobilization when they do not need it. The Belfast group, for instance, in the last year have moved from suggesting that cervical collars be removed in the ICU but immobilization maintained [2, 3], to arguing for X-rays plus ‘directed’ CT as a means of terminating immobilization [3], to recommending X-rays plus entire C-spine CT in their review article [4] (a strategy they had previously described as‘prohibitive’[3]). As Drs Sundaram and Koteeswaran point out, helical CT is likely to offer even greater advantages than conventional CT, but we agree with them that the lack of a helical CT scanner should not preclude CT imaging of all of the C-spine, rather than parts of it. We note their recent reference from the radiology literature supporting this view [5]. Drs Sundaram and Koteeswaran also make a valid point about plain radiographs. A reliance on ‘adequate’ radiographs frequently requires repeat films, often without satisfactorily identifying or excluding an injury. There is also the additional problem of the time needed to acquire, develop and interpret each film. Since C-spine radiographs should not be allowed to delay definitive imaging of the brain, or definitive treatment for other life threatening injuries, the result is that unconscious trauma patients may have to be transferred back to the radiology department from the intensive care unit for plain radiographs to be taken. C-spine CT can, however, be undertaken easily at the same time as brain CT, thus avoiding a subsequent intrahospital transfer of a ventilated patient, with the attendant time, personnel and safety implications. We note that Drs Sundaram and Koteeswaran mention the intriguing concept of omitting the lateral C-spine radiograph altogether in these patients. Although we have never advocated such a step, it is not as controversial an idea as it might appear. Our hospital's experience in over 200 unconscious, intubated, blunt trauma patients suggests that when the lateral C-spine radiograph's performance was compared with that of whole C-spine CT, the radiograph did not identify any unstable injury that could not be seen on CT (data submitted for publication). On the other hand, the radiograph did miss several unstable C-spine injuries. It seems clear to us that the lateral C-spine radiograph is of limited value in diagnosing unstable injuries, and a normal film is equally limited for ‘clearing the spine’. Pointing out that whole C-spine CT is useful in clearing the spine [1] hardly constitutes a campaign to abandon plain radiography, but it is possible, apparently, to be misunderstood on this point [3]. We fully agree with Drs Sundaram and Koteeswaran that since all strategies entail some degree of risk, using CT as part of a protocol to clear the C-spine in unconscious patients is no exception. The question is how to minimise that risk to an acceptable level. Interestingly, the 1998 EAST guidelines [6] were cited recently to legitimise a protocol including ‘directed’ CT [7], even though those guidelines were changed several years ago as they were felt to be inadequate [8]. EAST suggested, of course, adding dynamic flexion-extension fluoroscopy, but if our survey is representative of the UK in general, fluoroscopy will be widely shunned (on safety grounds) as a means of excluding an unstable injury in the unconscious patient. It is possible that the data we have presented regarding the perceived dangers of dynamic fluoroscopy (derived from a national dataset) might be helpful for those involved in drawing up protocols at a local level.