Bedside fluoroscopic flexion and extension cervical spine radiographs for clearance of the cervical spine in comatose trauma patients.

Abstract

Bedside flexion and extension fluoroscopic examinations have been proposed as an option for clearance of the cervical spine in comatose brain-injured patients. We hypothesized that these studies, when performed after normal static imaging of the cervical spine, would have an extremely low likelihood of identifying occult ligamentous instability and would not be adequate for visualizing the lower cervical spine. Radiographic images obtained from 56 consecutive comatose head-injured patients were reviewed. All patients had normal anteroposterior, lateral, and open mouth odontoid cervical spine radiographs and normal thin-cut axial computed tomographic images from the occiput to C2 and through the lower cervical spine if suspicious areas were identified on plain cervical spine radiographs. After these static images were determined to be normal by both the attending neurosurgeon and the attending radiologist, all 56 patients had bedside fluoroscopic flexion and extension studies performed by the neurosurgery resident, with the patients' arms being pulled down to their sides by the primary care nurse. The bedside fluoroscopic flexion and extension studies were considered to be adequate (visualization to the C7-T1 motion segment) in only 4% of the patients. Occult instability was identified in one patient (type II odontoid fracture) and significant instability was missed in one patient with C6 to C7 dislocation in whom flexion and extension radiographs failed to visualize the C6 to C7 motion segment. Bedside flexion and extension fluoroscopy was almost always inadequate for visualizing the lower cervical spine in comatose head-injured patients. Because of the extremely low likelihood of visualizing the entire cervical spine with this technique, we recommend that it no longer be considered an option in trauma center protocols for clearance of the cervical spine in comatose brain-injured patients.