The initial evaluation and management of cervical spine injuries is of critical importance because of the impact of early treatment and management on the patient's eventual outcome. The devastation and cost of missing even one unstable cervical spine fracture is tremendous. The existence of patients with an unsuspected cervical spine fracture who have few, if any, symptoms and/or signs of an injury to the cervical spine is a valid concern and a dilemma for the practicing physician. Thus the principle of the occult unstable cervical spine fracture, which has been established as the standard of care, has major significance and implications. Recently, however, the concept of the occult cervical spine fracture has been challenged. Does the entity of an occult cervical spine fracture exist? If so, how should this affect our indications for obtaining cervical spine radiographs? The author presents the case of an unstable occult cervical spine fracture and a review of the literature.