There was variation in the rates of positive significant findings within all the imaging recommendations for cervical spine, with CT identifying a higher number of these positive findings as compared to X-rays. Inappropriate cervical spine imaging was associated with lack of positive significant findings. When imaging is considered inappropriate, imaging referral guidelines can effectively exclude clinically significant injury due to their high specificity. Furthermore, the analysis of patient dispositions suggests that we can omit most of this low-value imaging and still maintain safety and quality of care in the ED. It is therefore vital for imaging referral guidelines to be integrated into clinical practice in the ED, given that low-value imaging is preventable.