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Cervical spine evaluation after blunt trauma: Are Flexion/Extension radiographs needed to clear the cervical spine when multi-detector row CT scan is normal? 2007

General Spine

Brett A Christian, MD
Pradeep Jacob, MD, Non ASSR Member

Scientific Paper

Purpose

To retrospectively determine the contribution of flexion/extension radiographs (FER) in excluding unstable cervical spine injury when preliminary multi-detector row computed tomography (CT) of the entire cervical spine (including routine coronal and sagittal multiplanar reformations) findings are normal.

Methods & Materials

IRB approval was obtained and HIPAA compliance was maintained for the study. Patients presenting to a level I trauma center who underwent preliminary CT examination of the neck for evaluation of suspected blunt trauma to the neck were considered in the study. From January 2006 to October 2006, 251 consecutive patients (164 Male [65%] and 89 Female [35%]; age range, 3-86 years; mean age, 38.8 years) suspected of blunt trauma to the neck underwent flexion/extension radiology to rule out ligamentous injury (LI) after preliminary CT evaluation was read by the interpreting radiologist as negative for acute injury. Electronic chart review was performed to determine if the patients were ultimately diagnosed with or treated for LI of the neck. Review was performed on the immediate and subsequent hospital visits/admissions.

Results

Average time to FER was 15.3 hours [range, 1hr - 23days]. FER examination was adequate and negative for fracture or LI in 102 (41%) patients. 142 (56%) of examinations were limited secondary to either incomplete visualization of the complete cervical spine [non-visualized C7/T1 (77 patients, 31%), non-visualized C6/C7 (32 patients, 13%), Non-visualized C5/C6 or more superior (10 patients, 4%)], or inadequate excursion in flexion or extension (16 patients, 6%). 7 patients (3%) had FER examinations limited by both incomplete visualization to T1 and inadequate range of motion. Of the limited examinations, repeat FER was done in 2 patients and was negative for LI. MRI was negative in 11 patients (6 had limited FER. 5 had negative CT and FER). Chart review of all negative and limited examinations found no documented evidence for unstable LI. Review of subsequent visits, if any, were also negative for sequelae of LI.

In 7 patients (3%), injury was suspected (Image 1). MRI was suggested and performed in 6 patients and was negative for acute injury in 5 patients. Chart review in the patients with negative MRI did not reveal any evidence of LI.

The only positive MRI confirmed acute disruption of the Ligamentum Flavum, supraspinous, interspinous, and posterior longitudinal ligaments. Retrospect analysis of the CT examination on this patient revealed and epidural hematoma at C4-C5, the site of LI (Image 2). At the time of CT, alignment remained intact, likely due to immobilization collar (Image 3). FER imaging was also markedly suggestive of LI at C4-C5 despite limited ROM (Image 4). The patient subsequently underwent anterior decompression and fusion for unstable LI.

Conclusion

Evaluation with flexion/extension radiographs contributes no significant additional information in evaluating for cervical spine ligamentous injury after initial negative CT C-spine imaging. In addition, despite limited flexion/extension radiographs in 56% of examinations, additional imaging was rarely ordered or performed. Multi-detector row CT, if negative in the setting of blunt trauma, could obviate the use of additional radiographic imaging to exclude ligamentous cervical spine injury.

References

Padayachee L, Cooper DJ, Irons S, Ackland HM, et al. Cervical spine clearance in unconscious traumatic brain injury patients: dynamic flexion-extension fluoroscopy versus computed tomography with three-dimensional reconstruction. J Trauma 2006;60:341-5.

Freedman I, van Gelderen D, Cooper DJ et al. Cervical spine assessment in the unconscious trauma patient: a major trauma service's experience with passive flexion-extension radiography. J Trauma 2005;58:1183-8

Berlin L. CT Versus Radiography for Initial Evaluation of Cervical Spine Trauma: What Is the Standard of Care? Am. J. Roentgenol 2003;180: 911-915.

Griffen, MM, Frykberg EF, Kerwin AJ, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma 2003;55:222-6; discussion 226-7

Daffner RH. Cervical helical CT for trauma patients: a time analysis. AJR 2001; 177(3):677-679

Diaz JJ, Aulino JM, Collier B, et al. The early work-up for isolated ligamentous injury of the cervical spine: does computed tomography scan have a role?
J Trauma 2005;59:897-903; discussion 903-4.

Ferard JH, Suart EM, Kathirkamanathan, S, Thomas MS. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: Is MR imaging needed when multi-detector row CT findings are normal? Radiology 2005;237:106-113

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