Use of flexion-extension radiographs of the cervical spine in blunt trauma

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.

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.

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.

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.