The cervical spine is injured in 2-3% of major trauma patients. Over the past 15 years there have been dramatic changes in the approach to imaging acute cervical spine trauma. Radiographic clearance for injury must be provided efficiently and accurately. There are numerous choices for clearance that are now in clinical practice: plain radiographs, computed tomography (CT) with multiplanar reformations, and magnetic resonance imaging (MRI). This article reviews the literature on methods of C-spine clearance and emphasizes the pitfalls of each modality. The issue of clinical versus radiographic evaluation of low risk patient is also discussed. An algorithm for the use of advanced imaging in acute trauma situation is proposed.