Original Contributions
Use of flexion-extension radiographs of the cervical spine in blunt trauma*,**,*

https://doi.org/10.1067/mem.2001.116810Get rights and content

Abstract

Study Objective: Flexion-extension (F/E) radiographs of the cervical spine are often used in patients with blunt trauma when the evaluating physician remains concerned about bony or ligamentous injuries despite negative or nondiagnostic standard radiographs. The use of this approach has never been addressed in a large prospective study. We sought to determine the clinical factors associated with ordering F/E views and the incidence of diagnostic F/E films in patients with a normal 3-view cervical spine series. Methods: Patients with blunt trauma selected for radiographic cervical spine imaging at 21 participating institutions in the National Emergency X-Radiography Utilization Study project underwent standard 3-view (cross-table lateral, anteroposterior, and odontoid views) series, as well as any other imaging deemed necessary by their physicians. Injuries detected by means of screening radiography were then compared with final injury status for each patient, as determined by review of all radiographic studies. Patients who underwent F/E views were analyzed separately. Results: Of 818 patients ultimately found to have cervical spine injury, 86 (10.5%) underwent F/E testing. Two patients sustained stable bony injuries detected only on F/E views. Four other patients had a subluxation detected only on F/E views, but all had other injuries apparent on routine cervical spine imaging. Conclusion: F/E imaging adds little to the acute evaluation of patients with blunt trauma. Other approaches, including magnetic resonance imaging, computed tomography, or delayed F/E, in the presence of specific clinical concerns would seem to provide a more reasonable approach to adjunctive imaging. [Pollack CV Jr, Hendey GW, Martin DR, Hoffman JR, Mower WR, for the NEXUS Group. Use of flexion-extension radiographs of the cervical spine in blunt trauma. Ann Emerg Med. July 2001;38:8-11.]

Introduction

Radiographic evaluation of the potentially injured cervical spine in the emergency department typically consists of a 3-view series supplemented by other imaging when there is continued concern about bony or ligamentous injuries, even after these views are found to be negative or nondiagnostic. Depending on the clinical circumstances, extended diagnostic evaluation might include swimmer’s views, static or dynamic flexion-extension (F/E) views, tomograms, computed tomographic (CT) scans, or magnetic resonance imaging (MRI).

F/E views are specifically recommended most often for patients with an acceleration-deceleration mechanism and patients with pain or tenderness.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 In such individuals, there is the potential for a ligamentous injury that may not be apparent in a static, neutral view of the cervical spine. Previous small studies have been unable to validate the utility of emergency F/E imaging. In this secondary analysis of the National Emergency X-Radiography Utilization Study (NEXUS) cohort, we attempted to determine the marginal benefit associated with ordering F/E views, as well as the incidence of positive F/E films among patients with a normal 3-view series.

Section snippets

Materials and methods

We performed a secondary analysis on the NEXUS relational database. A detailed description of this study and its methodology are included elsewhere, including a separate report in this issue.20, 21 Briefly, NEXUS was a prospective, observational study performed with institutional review board approval at 21 diverse emergency departments in the United States. The study included all patients with blunt trauma who underwent cervical spine radiography in the participating EDs at the discretion of

Results

Of 34,069 patients enrolled in the NEXUS database, radiographic studies demonstrated cervical spine injuries in 818 individuals (2.40%).21 F/E views were ordered in 86 (10.5%) of these injured patients, 6 of whom had no apparent injury on standard 3-view cervical spine imaging. In 2 of these 6 patients, no injuries were evident on any study other than F/E. The injuries seen on F/E but not plain radiographs were 4 spinous process fractures, 1 small avulsion fracture at C3, and a laminar fracture

Discussion

F/E views of the cervical spine are typically recommended for patients with persistent pain or tenderness in the absence of diagnostic findings on a standard 3-view series.2 Several small retrospective studies8, 15 have suggested that such an approach may provide diagnostic benefit in a few patients. On the other hand, F/E views require movement of the spine, which could theoretically provoke or exacerbate neurologic injury among patients who do have occult ligamentous instability.

Our data,

Acknowledgements

Author contributions: CVP, GWH, DRM, JRH, and WRM participated in the project development, data collection, interpretation, authorship, and critical review. WRM and JRH performed the interpretation and statistical analysis. WRM takes responsibility for the paper as a whole.

We thank Guy Merchant, NEXUS Project Coordinator, for his outstanding contributions to the project, as well as the house officers and attending physicians at each of the participating NEXUS sites, without whose cooperation

References (22)

  • T Highland et al.

    Spinal cord injuries

  • Cited by (0)

    *

    Author contributions are provided at the end of this article.

    **

    This work was funded by grant No. R01 HS08239 from the Agency for Healthcare Research and Quality, formerly the Agency for Health Care Policy and Research.

    *

    Address for reprints: Charles V. Pollack, Jr., MA, MD, PO Box 856, Bryn Mawr, PA 19010-0856;,fax 215-829-8044;,E-mail [email protected].

    View full text