Utility of Flexion and Extension Radiographs of the Cervical Spine in the Acute Evaluation of Blunt Trauma

Insko, Erik K.; Gracias, Vicente H.; Gupta, Rajan; Goettler, Claudia E.; Gaieski, David F.; Dalinka, Murray K.

doi:10.1097/00005373-200209000-00005

Cited by 106 publications

(57 citation statements)

References 21 publications

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“…Two previous studies specifically address the utility of flexion extension films in awake, alert patients in the trauma setting. Insko et al [14] evaluated 106 patients and found that 30 % of patients had inadequate motion to make the examination significant or useful. The authors found that in those with adequate studies, F/E had a low false negative rate for ligamentous injuries.…”

Section: Discussionmentioning

confidence: 99%

“…Adequacy of F/E was defined as adequate visualization of the cervico-thoracic junction and at least 30°of motion from neutral [12,14]. Eighty percent of the F/E conducted in a 3-year period at our institution did not meet these criteria.…”

Section: Discussionmentioning

confidence: 99%

“…Those meeting these criteria were then measured for the degree of flexion and extension by measuring the angle from the posterior plate of C7 to the posterior plate of C2 (2nd cervical vertebra). A F/E was considered inadequate/limited if it did not include the C7/T1 junction or demonstrated less than 30°absolute change in motion from flexion to extension [14][15][16][17].…”

Section: Methodsmentioning

confidence: 99%

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

et al. 2013

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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

et al. 2013

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“…Although flexion/extension radiography is useful in the gauging of potential cervical spine instability, it can be difficult to perform in the setting of cervical spine trauma and has been shown to have low usefulness in the evaluation of potential diskoligamentous injury. [21][22][23][24][25] Normative data have been published regarding the upper limits of acceptable prevertebral soft tissue thickness on CT scan, 26 and spinous process widening on plain film 27 ; however, neither normative data regarding disk widening nor objective criteria for evaluation of potential ADL disruption have been published. Therefore, when evaluating the ADL on CT scan, radiologists are forced to rely on a subjective assessment of disk widening.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the Intervertebral Disk Angle for the Assessment of Anterior Cervical Diskoligamentous Injury

Alhilali

Fakhran

2013

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE:The anterior diskoligamentous complex is important for cervical spinal stability. Subjective widening of the disk space after trauma has been used to gauge disruption of the anterior diskoligamentous complex on CT scanning, but no quantitative CT measurements exist to evaluate injury. The purpose of our study was to evaluate if an increased intervertebral disk angle could serve as a more sensitive, reproducible indicator of disruption of the anterior diskoligamentous complex compared with subjective assessment.

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“…22,38 Although there is no official consensus in recently published guidelines, many authors consider MRI to be the gold standard for detecting cervical spine injuries. 13,24 Studies have shown flexion/extension radiographs to be suboptimal in the evaluation of obtunded trauma patients, 1,16 and current guidelines emphasize the use of MRI rather than dynamic radiographs in these patients. [32][33][34][35] It is our current practice to use MRI rather than flexion/extension radiographs in all patients in whom ligamentous injury is suspected.…”

Section: 42mentioning

confidence: 99%

Magnetic resonance imaging of traumatic injury to the craniovertebral junction: a case-based review

Roy¹,

Miller²,

Holland³

et al. 2015

FOC

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OBJECT The craniovertebral junction (CVJ) is unique in the spinal column regarding the degree of multiplanar mobility allowed by its bony articulations. A network of ligamentous attachments provides stability to this junction. Although ligamentous injury can be inferred on CT scans through the utilization of craniometric measurements, the disruption of these ligaments can only be visualized directly with MRI. Here, the authors review the current literature on MRI evaluation of the CVJ following trauma and present several illustrative cases to highlight the utility and limitations of craniometric measures in the context of ligamentous injury at the CVJ. METHODS A retrospective case review was conducted to identify patients with cervical spine trauma who underwent cervical MRI and subsequently required occipitocervical or atlantoaxial fusion. Craniometric measurements were performed on the CT images in these cases. An extensive PubMed/MEDLINE literature search was conducted to identify publications regarding the use of MRI in the evaluation of patients with CVJ trauma. RESULTS The authors identified 8 cases in which cervical MRI was performed prior to operative stabilization of the CVJ. Craniometric measures did not reliably rule out ligamentous injury, and there was significant heterogeneity in the reliability of different craniometric measurements. A review of the literature revealed several case series and descriptive studies addressing MRI in CVJ trauma. Three papers reported the inadequacy of the historical Traynelis system for identifying atlantooccipital dislocation and presented 3 alternative classification schemes with emphasis on MRI findings. CONCLUSIONS Recognition of ligamentous instability at the CVJ is critical in directing clinical decision making regarding surgical stabilization. Craniometric measures appear unreliable, and CT alone is unable to provide direct visualization of ligamentous injury. Therefore, while the decision to obtain MR images in CVJ trauma is largely based on clinical judgment with craniometric measures used as an adjunct, a high degree of suspicion is warranted in the care of these patients as a missed ligamentous injury can have devastating consequences.

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Utility of Flexion and Extension Radiographs of the Cervical Spine in the Acute Evaluation of Blunt Trauma

Cited by 106 publications

References 21 publications

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

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

Evaluation of the Intervertebral Disk Angle for the Assessment of Anterior Cervical Diskoligamentous Injury

Magnetic resonance imaging of traumatic injury to the craniovertebral junction: a case-based review

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