Detecting the presence of injuries to the cervical spine is an important component of the initial assessment of patients sustaining blunt trauma. A small proportion of cervical spine injuries consists of ligamentous disruption. Accurate detection of ligamentous injury is essential as it may result in sequelae including radiculopathy, quadriplegia and death. Flexion-extension (FE) radiography has traditionally been utilised for the detection of ligamentous injury in patients who have been cleared of bony injury. There are controversies surrounding the use of FE for alert patients with neck pain. There are studies that call into question the diagnostic accuracy of FE, the high proportion of inadequate FE images due to muscle spasm and the adverse effects of prolonged cervical collar immobilisation while awaiting FE. Other literature indicates that FE provides no additional diagnostic information following a multi-detector helical computed tomography. This review evaluates the literature on the utility of FE for the detection of ligamentous injury and explores alternate strategies for clearing the cervical spine of ligamentous injury.

FER does not contribute additional diagnostic accuracy for the detection of ligamentous injury to the cervical spine following a normal CT of the cervical spine. We recommend FER be removed from cervical spine clearance protocols.

Background and Aim: Chronic heart failure (CHF) places a physical, psychosocial and financial burden on patients and carers. Provision of palliative care to CHF patients can support complex decision-making and significantly improve quality of life. This study describes characteristics of CHF patients at a tertiary referral hospital, including provision of palliative care, in the 12 months before death and during their terminal admission. Method: Retrospective medical review of 150 patients who died from CHF between Dec-2016 to May-2019 was performed. Data collection included patient and illness characteristics, palliative approach utilisation (e.g. symptom control, end-oflife management, goals of care (GOC)), and health service use. Results: Of 150 identified patients, 106 were eligible: 48 (45.3%) females and median age 84 (77.25-89) years. Commonest comorbidities were: ischemic heart disease (56.6%) and atrial fibrillation (57.5%). Referral to specialist palliative care (SPC) services occurred for 9 (8.5%) patients prior to, and 60 (56.6%) during the terminal admission. Inpatient SPC referrals occurred a median of 4 (1-8) days before death, mainly (96.6%) to manage active dying or physical symptoms. Palliative treatments included: opioids (97 patients, 92.4%) and benzodiazepines (81, 81.8%). Disease-directed medications on the day of death included: antiplatelets (18.9%) and statins (12.6%). Comfort/palliation GOC was documented in 9 (8.6%) patients on admission, and changed to this for 40 (37.7%) patients within 48 hours of subsequent death. Conclusion: Recognising and providing appropriate care for the active dying phase in CHF is both limited and challenging. New approaches to palliative care are required for CHF patients and their families.