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Role of flexion/extension radiography in neck injuries in adults
  1. Elspeth Pitt, Specialist Registrar,
  2. Shobhan Thakore, Consultant
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK;


    A short cut review was carried out to establish whether flexion-extension radiography is indicated in the investigation of a neurologically intact adult patient with midline neck tenderness and normal 3-view cervical spinal radiographs. Altogether 101 papers were found using the reported search, of which five 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.

    • radiography

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    Report by Elspeth Pitt,Specialist RegistrarChecked by Shobhan Thakore, Consultant

    Clinical scenario

    A man attends the emergency department having been involved in a high speed road traffic accident. He complains of neck pain and midline neck spinal tenderness but has no neurological signs or symptoms. Standard 3-view cervical spine radiology (lateral, anteroposterior, and odontoid views) shows no abnormality. You wonder if a flexion/extension radiograph would show any significant injury/instability.

    Three part question

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

    Search strategy

    Medline 1966-05/04 and Embase 1980-05/04 using the Ovid interface. [exp neck injuries/OR neck OR cervical spine OR exp spinal injuries/OR exp spinal cord injuries/Or exp spinal fractures/OR exp fractures/OR cervical spine injur$.mp OR exp dislocations/OR exp cervical vertebrae/OR cervical spinal cord OR exp spinal cord compression/] AND [flexion-extension.ti OR dynamic cervical spine radiograph$.mp OR flexion-extension radiograph$.mp OR flexion-extension cervical spine radiograph$.mp OR flexion-extension x-ray$.mp] AND [exp joint instability/OR ligamentous OR ligament OR cervical vertebrae/OR exp fractures/OR ligamentous OR exp soft tissue injuries/OR soft tissue] LIMIT to human AND English.

    Search outcome

    Altogether 101 papers from Medline and 79 from Embase were found of which five were relevant (see table 2).

    Table 2


    Most studies are retrospective so the evidence base is limited. Flexion-extension cervical spine radiography (FECSR) is safe in the properly selected patient. If the patient has adequate movement FECSR rarely adds to investigation if standard cervical spine radiography (SCSR) is normal. FECSR after an abnormal SCSR is of limited value because of the possibility of inadequate studies (because of pain or muscle spasm) and the risk of false negatives.


    In the acute setting FECSR adds little if CT/MR can be used to seek fractures or ligamentous instability.

    Report by Elspeth Pitt,Specialist RegistrarChecked by Shobhan Thakore, Consultant