Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients

Abstract

Background Flexion and extension radiographs are often used in the setting of trauma to clear a cervical spine injury. The utility of such tests, however, remains to be determined. We hypothesized that in patients who underwent a negative computed tomography (CT) cervical spine scan, flexion and extension radiographs did not yield useful additional information. Methods We conducted a retrospective chart review of all patients admitted to a Level I trauma center who had a negative CT scan of the cervical spine and a subsequent cervical flexion-extension study for evaluation of potential cervical spine injury. All flexion-extension films were independently reviewed to determine adequacy as defined by C7/T1 visualization and 30°of change in the angle from flexion to extension. The independent reviews were compared to formal radiology readings and the influence of the flexion-extension studies on clinical decision making was also reviewed. Results One thousand patients met inclusion criteria for the study. Review of the flexion-extension radiographs revealed that 80 % of the films either did not adequately demonstrate the C7/T1 junction or had less than 30°range of motion. There was one missed injury that was also missed on magnetic resonance imaging. Results of the flexion-extension views had minimal effects on clinical decision making. Conclusion Adequate flexion extension films are difficult to obtain and are minimally helpful for clearance of the cervical spine in awake and alert trauma patients.

Subaxial cervical spine trauma

“…They found that 95 % of these studies were deemed inadequate as a result of either inability to visualize T1 or insufficient angulation (less than 30°) from neutral likely secondary from patient guarding [7]. Similar results were demonstrated by McCracken et al, who concluded that adequate flexion-extension films are difficult to obtain and therefore are minimally helpful in the acute setting for clearance of cervical spine trauma even in the awake and alert patient [8].…”

Diagnostic accuracy of flexion‐extension radiography for the detection of ligamentous cervical spine injury following a normal cervical spine computed tomography

“…We also found that despite almost all FER being inadequate when quantitative criteria were applied; the radiologist only reported a small fraction as inadequate. Other authors have reported similarly . This suggests that a large proportion of cervical spine clearance decisions were made on the basis of suboptimal imaging.…”

“…The use of FER is controversial. FER is inadequate in 30–95% . An adequate FER is defined as one, which visualises the entire cervical spine including the C7/T1 junction and demonstrates >30° of flexion and extension .…”

The Michel Benoist and Robert Mulholland Yearly European Spine Journal Review: a survey of the “surgical and research” articles in the European Spine Journal, 2013

“…Another paper which reduces radiation is that by McCracken et al [58] dealing with the value of flexion and extension lateral radiographs to detect instability in awake patients, with neck pain, when using CT there was no apparent injury to the neck. They retrospectively reviewed 1,000 patients, and found that adequate flexion extension films were difficult to obtain and minimally helpful in clearing the cervical spine in awake and alert trauma patients.…”