Plain Skull X-ray

Authored by Dr Gurvinder Rull, 11 Feb 2014

Reviewed by:
Dr Adrian Bonsall, 11 Feb 2014

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Synonym: SXR

Headache and head trauma are common presenting problems in both primary care and the Accident and Emergency department. Plain skull X-ray films (plain skull films) have largely been superseded by CT scanning and/or MRI scans in the context of both headaches and head injuries.[1]This is also true in paediatric patients.[2]Skull X-rays are, however, still useful in children in whom non-accidental injury is suspected to detect previous injuries.[1]

There is also now useful literature on the pre-hospital management of head injury.[3, 4]

When to request a skull X-ray
Head injury or not
Clinical settings
Head injury
CT scanning is the recommended investigation and criteria for CT scanning are provided in the National Institute for Health and Care Excellence (NICE) guidance.[1]
Non-head injury cases
  • Presence of a palpable vault abnormality which feels bony.
  • As part of an imaging protocol for specific clinical problems - eg, skeletal survey for myeloma. Many centres now prefer bone scans for this purpose.
  • Facial views after trauma to the facial skeleton, mandible or orbit, or the possibility of a metallic foreign body.

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 the 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.

Skull films should be interpreted wherever possible by a doctor with specialised 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, which is why CT scanning is the investigation recommended in significant head injuries.[1]All such findings must be taken in the context of the clinical condition of the patient.

Further reading and references

  1. Head injury: assessment and early management; NICE Clinical Guideline (January 2014, updated June 2017)

  2. Kim YI, Cheong JW, Yoon SH; Clinical comparison of the predictive value of the simple skull x-ray and 3 dimensional computed tomography for skull fractures of children. J Korean Neurosurg Soc. 2012 Dec52(6):528-33. doi: 10.3340/jkns.2012.52.6.528. Epub 2012 Dec 31.

  3. Early Management of Patients with a Head Injury; Scottish Intercollegiate Guidelines Network - SIGN (May 2009)

  4. Hammell CL, Henning JD; Prehospital management of severe traumatic brain injury. BMJ. 2009 May 19338:b1683. doi: 10.1136/bmj.b1683.

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jonathan07898
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