| Lewis LM et al, 1991, USA | 141 consecutive adult trauma patients who had flexion extension cervical spine radiography (FECSR) after static cervical spine radiography (SCSR) series | Retrospective review | Radiological abnormality on SCSR | 11 of 141 instability on FECSR of which four had normal SCSR. Four had equivocal SCSR and three had fractures on SCSR | Retrospective |
| No comment on blinding or not of radiologist |
| | | Instability on FECSR | FECSR (compared with SCSR alone) increased the sensitivity and specificity for recognising injury from 71% to 99% and 89% to 93% respectively but this was not statistically significant because of small numbers | If abnormal SCSR, CT as well as FECSR done but sometimes before FECSR. Not clear if diagnosis made on CT or FECSR |
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| | | Neurological sequelae from performing radiographs | No neurological complications from FECSR | Adequacy of radiography not defined |
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| Wang JC et al 1999, USA | 290 patients after trauma—with neck pain, alert, neurologically intact had FECSR | Retrospective review | Instability on FECSR | 1 of 290 (0.34%) instability on FECSR | Retrospective |
| | | Adequacy of FECSR | 97 of 290 (33.45%) FECSR were inadequate and could not be assessed for instability so evaluated clinically later | Assessment of adequacy—qualitative |
| | | Neurological problems because of FECSR | No neurological changes during FECSR | SCSR not mentioned in study |
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| Brady WJ et al, 1999, USA | 451 patients over age 18 years with blunt trauma undergoing SCSR and FECSR | Retrospective descriptive review | Abnormality on FECSR | 372 (82.5%) normal SCSR of whom five (1.3%) had abnormal FECSR | Retrospective Convenience Sample—referral bias Clinical outcome of patients not really addressed |
| | | Complications of FECSR | Patients with blunt trauma and neck complaints and an abnormal SCSR are more likely to have abnormal FECSR showing cervical injury requiring stabilisation than if they had normal SCSR | No comment on adequacy of radiographs |
| | | | No complications from FECSR | |
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| Pollack CV Jr et al, 2001, USA | 86 patients who had FECSR with radiographically demonstrated cervical spine injury from blunt trauma from NEXUS database (patients also had SCSR and CT/MR as deemed necessary) | Subgroup analysis on prospective observational database | Incidence of diagnostic FECSR in patients with normal SCSR | 6 of 86 had normal SCSR but abnormal FECSR but none of these were deemed to be clinically significant | No statistics performed |
| No comment on adequacy of radiographs |
| Post hoc subgroup analysis |
| CT/MR used—confounding results |
| Small numbers |
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| Insko EK et al, 2002, USA | 106 cases aged 17–85, within 12 hours of blunt trauma, evaluated with FECSR—awake, had pain and normal SCSR | Retrospective review | Interpretation and adequacy of CSR radiographs. Clinical outcome on follow up | 9 of 106 patients had cervical spine injury (CSI) on basis of radiograph, clinical diagnosis, and follow up. 74 of 106 (70%) had adequate FECSR of whom five had CSI (no false negatives). 32 (30%) had inadequate FECSR of whom four (12.5%) had CSI subsequently found on CT or MRI | Retrospective No statistics performed Not all patients had the same imaging—varied number and types of plain radiography and CT/MR Excluded 228 patients because of inadequate follow up or radiograph taken after 12 hours |