ED use of flexion-extension cervical spine radiography in the evaluation of blunt trauma

doi:10.1016/S0735-6757(99)90185-7

The American Journal of Emergency Medicine

Volume 17, Issue 6, October 1999, Pages 504-508

https://doi.org/10.1016/S0735-6757(99)90185-7 Get rights and content

Abstract

Dynamic cervical spine radiography (CSR) is used to detect ligamentous instability. We investigated the ED use of dynamic CSR through a retrospective descriptive review using a convenience sample study design at a university emergency department. Adult blunt trauma patients with static (lateral, AP, odontoid) and dynamic (flex, extend) CSR participated. 451 patients (52% male with mean age of 33.6 years) met entry criteria. Injury mechanisms were 74% MVA, 12% fall, 8% direct trauma, and 6% other. Indications for dynamic CSR were 100% traumatic mechanism, 86% neck pain, 70% midline neck tenderness, and 18% abnormal static CSR. Static CSR were normal in 372, 5 of which had abnormal dynamic CSR (5 cervical contour line disruption [CCLD], 2 posterior element abnormality [PEA]); of these 5 patients, none required invasive stabilization. Static CSR were abnormal in 79 patients (38 CCLD, 30 lordotic curve reversal, 17 PEA, 4 soft tissue swelling) of which 16 had abnormal dynamic CSR (9 increased CCLD, 4 PEA, and 4 fracture); of these 16 patients, 4 required invasive stabilization. Final diagnoses were 428 cervical soft tissue injury, 11 subluxation, 8 fracture, 2 fracture-subluxation, and 2 spinal cord injury without radiographic abnormality. Spine consultation was made in 12%. Stabilization therapy was required: 21 soft collar, 4 surgical, 3 halo-device, and 5 other. No complications of dynamic CSR were noted. The blunt trauma patient with neck complaints and an abnormal static CSR was more likely to have an abnormal dynamic CSR demonstrating a cervical injury requiring stabilization compared to patients with normal static CSR.

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Cited by (35)

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The subaxial cervical spine refers to cervical vertebrae located below the “axis” (C2) and is a critical distinction due to inherent biomechanical differences from vertebral levels more cephalad and caudad (Swartz et al., 2005). Responsible for the majority of cervical range of motion, vertebrae ranging from C3 to C7 contribute roughly 70 of flexion, 40 of extension, 30 of lateral bending, and 45 of rotation to either side (Tan et al., 2017). Furthermore, in the native cervical spine, C3–C7 (specifically, the facet joints) is responsible for about two-thirds of the total axial load imposed by the cranium. The remaining load is then distributed among cervical intervertebral discs (Tan et al., 2017). These relationships are held in a close equilibrium that is ultimately dependent upon a precise sagittal alignment, where the global cervical lordosis (i.e., C2–C7 curvature), sagittal vertical axis (SVA), T1 slope (T1S), and various other radiographic parameters cohesively interact (Jun et al., 2015; Park et al., 2013).
However, in the setting of various pathologies, these biomechanical relationships are frequently disrupted, often resulting in a redistribution of axial loading and diminished capacity to maintain native range of motion (Tan et al., 2017). Ultimately, these findings stress the importance of making appropriate radiographic measurements in the cervical spine, as the magnitude of radiographic disturbance is associated with disease prognosis and may help guide surgical management. As such, the present chapter will discuss the importance of critical subaxial radiographic measures, with particular emphasis placed on the clinical relevance and technique required to accurately perform these assessments.
C-spine clearance in poly-trauma patients: A narrative review
2021, Journal of Clinical Orthopaedics and Trauma
Citation Excerpt :
A flexion and extension of 30° from the neutral is considered adequate for diagnosing instability in the cervical spine. Various researchers have documented the adequacy of dynamic X-rays in acute trauma conditions to range from 31% to 70% of the patients.24–28 The limited mobility of cervical spine, therefore, limits the utility of this modality in an acute trauma scenario.
The incidence of cervical spine injury in patients with polytrauma is 3.7%. Early identification and management of cervical spine injuries in these patients play a crucial role in preventing secondary cervical spine and cord injuries. C-spine clearance assumes a pivotal role in reducing the morbidity and mortality associated with cervical spine injury. Despite the availability of various validated management algorithms and protocols for C-spine clearance, there are several controversies regarding C-spine clearance, such as the ideal protocol and imaging modality, clearance of obtunded patients and management of patients that lie out of the described protocols and rules. The current article aims to provide a comprehensive review of the relevant literature and address the prevalent controversies.
Imaging investigations in Spine Trauma: The value of commonly used imaging modalities and emerging imaging modalities
2017, Journal of Clinical Orthopaedics and Trauma
Citation Excerpt :
In the case of persistent discomfort from one week onwards after an injury there may be a role for elective flexion extension radiographs.72 CT can, though rarely, miss instability after cervical trauma and this may be demonstrated by flexion/extension views (Fig. 3).73,74 This may also be applied to paediatric patients.75
Traumatic spine injuries can be devastating for patients affected and for health care professionals if preventable neurological deterioration occurs. This review discusses the imaging options for the diagnosis of spinal trauma. It lays out when imaging is appropriate and when it is not. It discusses strength and weakness of available imaging modalities. Advanced techniques for spinal injury imaging will be explored. The review concludes with a review of imaging protocols adjusted to clinical circumstances.
ExpertDDx: Brain and Spine: A volume in ExpertDDx
2017, ExpertDDx: Brain and Spine
Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan?
2013, Journal of Surgical Research
Citation Excerpt :
To date, the data in the literature on FEF have been limited and conflicting. FEF have been reported to be valuable in CS clearance, particularly when only plain films of the cervical spine were obtained [12–14]. Nevertheless, even in the same setting, other studies have concluded that FEF adds little value to the evaluation of CS clearance [15,16] There is a paucity of studies to date that have specifically addressed the value of FEF after a negative CS CT.
There are variations in cervical spine (CS) clearance protocols in neurologically intact blunt trauma patients with negative radiological imaging but persistent neck pain. Current guidelines from the current Eastern Association for the Surgery of Trauma include options of maintaining the cervical collar or obtaining either magnetic resonance imaging (MRI) or flexion-extension films (FEF). We evaluated the utility of FEF in the current era of routine computerized tomography (CT) for imaging the CS in trauma.
All neurologically intact, awake, nonintoxicated patients who underwent FEF for persistent neck pain after negative CT scan of the CS at our level I trauma center over a 13-mo period were identified. Their charts were reviewed and demographic data obtained.
There were 354 patients (58.5% male) with negative cervical CS CT scans who had FEF for residual neck pain. Incidental degenerative changes were seen in 37%—which did not affect their acute management. FEF were positive for possible ligamentous injury in 5 patients (1.4%). Two of these patients had negative magnetic resonance images and the other three had collars removed within 3 wk as the findings were ultimately determined to be degenerative.
In the current era, where cervical CT has universally supplanted initial plain films, FEF appear to be of little value in the evaluation of persistent neck pain. Their use should be excluded from cervical spine clearance protocols in neurologically intact, awake patients.
Flexion/extension cervical spine views in blunt cervical trauma
2012, Chinese Journal of Traumatology - English Edition
To examine the contribution of flexion and extension radiographs in the evaluation of ligamentous injury in awake adults with acute blunt cervical spine trauma, who show loss of cervical lordosis and neck pain.
All patients who presented to our emergency department following blunt trauma were enrolled in this study, except those with schiwora, neurological deficits or fracture demonstrated on cross-table cervical spine X-rays, and those who were either obtunded or presented after cervical spine surgery. Adequacy of flexion and extension views was checked by the neurosurgery and radiology team members. All these patients underwent cross-table cervical spine view followed by flexion/extension views based on the loss of lordosis on cross-table imaging and the presence of neck pain.
A total of 200 cases were reviewed, of whom 90 (45%) underwent repeat X-rays because of either inadequate exposure or limited motion. None of the patients with loss of lordosis on cross-table view had positive flexion and extension views of cervical spine for instability.
Our results show that in patients who underwent acute radiographic evaluation of blunt cervical spine trauma, flexion and extension views of the cervical spine are unlikely to yield positive results in the presence of axial neck pain and/or loss of cervical lordosis. We can also hypothesize that performing flexion and extension views will be more useful once the acute neck pain has settled.

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^☆: Presented in part at the Society for Academic Emergency Medicine, New England Regional Meeting, Providence, RI, April 1997, the American College of Emergency Physicians Scientific Assembly and Research Forum, San Francisco, CA, October 1997, and Trauma Tactics, Orlando, FL, April 1998.

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Original contributionED use of flexion-extension cervical spine radiography in the evaluation of blunt trauma☆

Abstract

Ann Emerg Med

Ann Emerg Med

Am J Surg

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Rationale for ordering of cervical spine radiographs following trauma

Ann Emerg Med

Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical spine trauma

Ann Emerg Med

Flexion-extension cervical spine radiography in adult blunt trauma

Ann Emerg Med

Moderately severe whiplash injuries of the cervical spine and their roentgenologic diagnosis

Clin Orthop

Evaluation of the cervical spine in whiplash injuries

Radiology

Original contribution
ED use of flexion-extension cervical spine radiography in the evaluation of blunt trauma☆