The human cervical spine is a complex and relatively fragile structure, which is particularly exposed to trauma due to its exposed location and relatively poor ligamentous support mechanisms. Understanding the potential for occult injuries and looking for such injuries enhances chances for early diagnosis and thus impacts outcomes of treatment. At Harborview Medical Center surgeons have collected one of the largest number of patients who have survived an ‘internal decapitation’ (atlanto-occipital dissociation) type injury and present their outcomes. The current role of use of Halo-vest –immobilization, which remains the most powerful nonsurgical form of cervical spinal column immobilization, is reviewed based upon the largest to date clinical study on these devices. Finally the increasingly common occurrence of elderly patients presenting with fractures of their upper cervical spine and the difficulties in identifying the best possible treatment are outlined using the insights gained from an ongoing North American multi-center study. This review provides an update on currently pressing issues pertaining to injuries of the cervical spine facing patients and their treating physicians. From the Series:Seventh Annual Harborview Spine Symposium: Improving Outcomes of Spinal Injury