Flexion-Extension Cervical Spine Plain Films Compared with MRI in the Diagnosis of Ligamentous Injury

Abstract

The purpose of this study was to compare flexion-extension (FE) plain films with MRI as the gold standard in the diagnosis of ligamentous injury (LI) of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma from January 2000 to December 2008 (n = 22929) who had both FE and MRI of the cervical spine was performed. Two hundred seventy-one patients had 303 FE films. Forty-nine also had MRI. The average Injury Severity Score was 15.6 ± 10.2, Glasgow Coma Scale was 13.8 ± 3.5, lactate 2.2 ± 1.7 mmol/L, and hospital stay of 8 ± 11.2 days. FE failed to identify all eight LIs seen on MRI. FE film sensitivity was 0 per cent (zero of eight), specificity 98 per cent (40 of 41), positive predictive value 0 per cent (zero of one), and negative predictive value 83 per cent (40 of 48). Although classified as negative for purposes of analysis, FE was incomplete 20.5 per cent (62 of 303) and ambiguous 9.2 per cent (28 of 303) of the time. The charge of FE is $535 so $48150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. FE should no longer be used to diagnose LI. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury.

Get full access to this article

View all access options for this article.

References

American College of Surgeons. Advanced Trauma Life Support Program for Doctors. Chicago, IL: American College of Surgeons; 1997.

Hoffman

J.R.

, Mower

W.R.

, Wolfson

A.B.

Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.

N Engl J Med 2000; 343: 94–9.

Como

J.J.

, Diaz

J.J.

, Dunham

C.M.

Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee.

J Trauma 2009; 67: 651–9.

Barba

C.A.

, Taggert

, Morgan

A.S.

A new cervical spine clearance protocol using computed tomography.

J Trauma 2001; 51: 652–6.

Berne

J.D.

, Velmahos

G.C.

, El-Tawil

Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study.

J Trauma 1999; 47: 896–902.

Diaz

J.J.

Jr. , Gillman

, Morris

J.A.

Jr. . Are five-view plain films of the cervical spine unreliable? A prospective evaluation in blunt trauma patients with altered mental status. J Trauma 2003; 55: 658–63.

Griffen

M.M.

, Frykberg

E.R.

, Kerwin

A.J.

Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan?

J Trauma 2003; 55: 222–6.

Anglen

, Metzler

, Bunn

, Griffiths

Flexion and extension views are not cost-effective in a cervical spine clearance protocol for obtunded trauma patients.

J Trauma 2002; 52: 54–9.

Duane

T.M.

, Dechert

, Wolfe

L.G.

Clinical examination and its reliability in identifying cervical spine fractures.

J Trauma 2007; 62: 1405–8.

10.

Holmes

J.F.

, Akkinepalli

Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis.

J Trauma 2005; 58: 902–5.

11.

Mathen

, Inaba

, Munera

Prospective evaluation of multislice computed tomography versus plain radio-graphic cervical spine clearance in trauma patients.

J Trauma 2007; 62: 1427–31.

12.

Brown

C.V.

, Antevil

J.L.

, Sise

M.J.

, Sack

D.I.

Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come.

J Trauma 2005; 58: 890–5.

13.

Adams

J.M.

, Cockburn

M.I.

, Difazio

L.T.

Spinal clearance in the difficult trauma patient: a role for screening MRI of the spine.

Am Surg 2006; 72: 101–5.

14.

Como

J.J.

, Thompson

M.A.

, Anderson

J.S.

Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma?

J Trauma 2007; 63: 544–9.

15.

Hogan

G.J.

, Mirvis

S.E.

, Shanmuganathan

, Scalea

T.M.

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: 106–13.

16.

Duane

T.M.

, Scarcella

, Cross

Do flexion extension plain films facilitate treatment after trauma?

Am Surg. In press.

17.

Menaker

, Philp

, Boswell

, Scalea

T.M.

Computed tomography alone for cervical spine clearance in the unreliable patient—are we there yet?

J Trauma 2008; 64: 898–903.

18.

Sarani

, Waring

, Sonnad

, Schwab

C.W.

Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients.

J Trauma 2007; 63: 637–40.

19.

Diaz

J.J.

Jr. , Aulino

J.M.

, Collier

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.

20.

Insko

E.K.

, Gracias

V.H.

, Gupta

Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma.

J Trauma 2002; 53: 426–9.

21.

Griffiths

H.J.

, Wagner

, Anglen

The use of forced flexion/extension views in the obtunded trauma patient.

Skeletal Radiol 2002; 31: 587–91.

22.

Freedman

, van Gelderen

, Cooper

D.J.

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.

23.

Goodnight

T.J.

, Helmer

S.D.

, Dort

J.M.

A comparison of flexion and extension radiographs with computed tomography of the cervical spine in blunt trauma.

Am Surg 2008; 74: 855–7.

24.

Duane

T.M.

, Dechert

, Brown

Is the lateral cervical spine plain film obsolete?

J Surg Res 2008; 147: 267–9.