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Role of flexion/extension radiography in paediatric neck injuries
  1. Elspeth Pitt, Specialist Registrar,
  2. Shobhan Thakore, A&E Consultant
  1. Emergency Medicine, Hope Hospital, Manchester, UK; s.carley1btinternet.com

    Abstract

    A short cut review was carried out to establish the potential utility of flexion/extension views of the cervical spine in children with neck injuries. Using the reported search, 51 papers were found, of which three presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

    Statistics from Altmetric.com

    Report by Elspeth Pitt, Specialist RegistrarChecked by Shobhan Thakore, A&E Consultant

    Clinical scenario

    A child attends the department; he has been involved in a high speed road traffic accident, complains of neck pain and midline neck spinal tenderness, but has no neurological signs/symptoms. Static cervical spine radiology (lateral, AP, and odontoid views) reveal no abnormality. You wonder if flexion/extension x rays would show any significant injury/instability.

    Three part question

    In [a neurologically intact child with neck pain following trauma but normal plain x rays] do [flexion/extension x rays] aid [diagnosis of ligamentous or soft tissue injury with instability]?

    Search strategy

    Medline 1966-11/04 and Embase 1988-11/04 using the Ovid interface.

    Medline: [exp neck injuries OR neck trauma.mp OR cervical spine trauma.mp OR exp spinal injuries OR exp spinal cord injuries OR exp spinal fractures OR exp fractures OR cervical spine injuries.mp OR exp dislocations OR exp cervical vertebrae OR cervical spinal cord trauma.mp OR exp spinal cord compression] AND [flexion-extension.ti OR dynamic cervical spine radiography.mp OR flexion-extension radiography.mp OR flexion-extension cervical spine radiography.mp OR flexion-extension radiographs.mp] AND [exp joint instability OR ligamentous injury.mp OR ligament injury.mp OR cervical vertebrae OR exp fractures OR ligamentous instability.mp OR exp soft tissue injuries OR soft tissue injury.mp] AND [BestBETs paediatric filter] LIMIT to human AND English language.

    Embase: [exp neck injuries OR neck trauma.mp OR cervical spine trauma.mp OR exp spinal injuries OR exp spinal cord injuries OR exp spinal fractures OR exp fractures OR cervical spine injuries.mp OR exp dislocations OR exp cervical vertebrae OR cervical spinal cord trauma.mp OR exp spinal cord compression] AND [flexion-extension.ti OR dynamic cervical spine radiography.mp OR flexion-extension radiography.mp OR flexion-extension cervical spine radiography.mp OR flexion-extension radiographs.mp] AND [exp joint instability OR ligamentous injury.mp OR ligament injury.mp OR cervical vertebrae OR exp fractures OR ligamentous instability.mp OR exp soft tissue injuries OR soft tissue injury.mp] AND [exp child OR child$.mp OR exp infant OR exp pediatrics OR pediatric$.mp OR paediatric$.mp] LIMIT to human AND English language.

    Search outcome

    Altogether 32 papers were found from Medline and 19 from Embase, of which three were relevant and are shown in the table.

    Comment(s)

    All studies are retrospective so the evidence base is limited. Flexion extension cervical spine radiography (FECSR) appears to have resulted in no permanent complications in these studies. However, the utility of FECSR in patients with normal static cervical spine radiography (SCSR) is low. In the current era of imaging modalities such as CT and MRI, the need for FECSR may decline.

    CLINICAL BOTTOM LINE

    If SCSR is normal, FECSR is unlikely to be abnormal. If SCSR is equivocal/abnormal, FECSR is still unlikely to be abnormal but may help may help to rule out injury in an alert child with no neurological signs complaining of pain and neck tenderness.

    Table 1

    Report by Elspeth Pitt, Specialist RegistrarChecked by Shobhan Thakore, A&E Consultant

    References

    View Abstract

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