Erect radiographs reveal missed cervical spine instability

Erect radiographs are necessary to rule out unstable cervical spine injuries, UK researchers report.

Writing in the US edition of the Journal of Bone and Joint Surgery, the team describes four patients whose unstable C4-C5 or C5-C6 injuries were missed by both supine radiographs and supine computed tomography (CT) and/or magnetic resonance imaging (MRI).

"We believe that erect radiographs of the cervical spine following blunt trauma are an important adjunct in avoiding the potentially catastrophic consequences of a missed unstable cervical spine injury," say Simon Humphry and colleagues, at the Royal Devon and Exeter Hospital.

"The controlled use of erect radiographs to test for clinical instability in cervical spine injuries should be considered except in cases in which instability is already evident on other imaging modalities and/or surgical treatment is already indicated," they emphasize.

The three women and one man, aged between 61 and 87 years, were admitted to the hospital between April and December 2010.

The first patient showed a clavicular fracture on supine radiographs but no cervical fracture after a riding accident. Three days later, the patient complained of neck pain and right-sided dysesthesia in the C5 area, and was diagnosed with unilateral C4-C5 fracture without subluxation using CT and MRI, and given a semi-rigid collar.

However, the patient returned to hospital 12 days later following elbow flexion weakness. Erect radiograph revealed subluxation that required anterior cervical discectomy and fusion.

The second patient reported midline cervical spine tenderness after a 2 m-high fall. Despite clean supine radiographs, CT scans revealed widespread degenerative changes and a possible left C5 inferior articular process, which was treated with a semi-rigid collar. Ten days after injury, however, the patient had meylopathy and erect radiographs demonstrated C5-C6 subluxation, confirmed on MRI. The patient was treated with anterior cervical discectomy.

C4-C5 subluxation and bilateral C5-C6 facet joint dislocation requiring surgery were also missed on initial supine radiographs and CT imaging for two further patients who experienced a fall and a road traffic accident, respectively, the researchers report. Both injuries were detected using erect radiographs.

All patients were neurologically intact at their last follow up.

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