Jw. Davis et al., Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: A reappraisal, J TRAUMA, 50(6), 2001, pp. 1044-1047
Background: The mechanism for clearing the cervical spine in patients with
altered mental status remains controversial, Recommendations have ranged fr
om removal of the cervical collar after 24 hours in patients with normal ra
diographs, to indefinite immobilization in a cervical collar, and recently
cervical flexion-extension examinations using dynamic fluoroscopy, The purp
ose of this study was to evaluate the efficacy and safety of dynamic fluoro
scopy flexion-extension examinations in identifying ligamentous cervical sp
ine,injury and clearing the cervical spine in patients with altered mental
status after trauma.
Methods: Patients with a Glasgow Coma Scale score < 13 for greater than 48
hours after admission and normal cervical spine radiographs were candidates
for fluoroscopic evaluation. The protocol required visualization of the en
tire cervical spine, through T1, through full extension and flexion under t
he direct supervision of a radiologist. Oblique fluoroscopic views were obt
ained, as necessary, to visualize the cervicothoracic junction. Demographic
data, fluoroscopy time, total time per study, true and false positives and
negatives. and complications were recorded.
Results: From July 1992 through December 1999, fluoroscopic examinations we
re performed on 301 patients. There were 297 true-negative examinations, 2
true-positive examinations (stable injuries), 1 false-negative examination,
and I false-positive examination, The incidence of ligamentous injury iden
tified by fluoroscopy in this study was 2 of 301 (0.7%). Unstable cervical
spine ligamentous injuries were identified in only 0.02% of all trauma pati
ents, One patient developed quadriplegia when fluoroscopic evaluation was p
erformed after two protocol violations,
Conclusion: Unstable cervical spine Ligamentous injury without fracture is
a rare occurrence. The cervical spine may be cleared after a normal cervica
l spine series (plain radiograph and computed tomographic scan) as recommen
ded in the 1998 Eastern Association for the Surgery of Trauma guidelines, I
f dynamic fluoroscopy is to be used, adherence to the protocol, including r
eview of the cervical spine radiographs before fluoroscopy and visualizatio
n of the entire cervical spine, C1-T1, is mandatory to ensure:patient safet
y.