If you haven’t been paying attention to the literature, then you’re practicing completely unawares of an epidemic of missed spinal cord injuries. From the literature that suggests CT isn’t adequately sensitive and the final common pathway for c-spine clearance should be MRI, to this new article that says all of those studies in summary aren’t enough – and patients might also need “erect cervical spine radiographs”.
This is a case series – the authors bill it as a retrospective review, but the methods are laughably absent, at best – of four patients the authors identified as having cervical spine instability missed through traditional diagnostic methods. These patients, aged 61 through 87, received Emergency Department evaluation for cervical spine injury, were treated conservatively initially, and eventually needed operative intervention. The ED work-up of these patients can probably best be described as “interesting” – e.g., a 61 year-old female thrown from horse whose initial work-up involved only three-view radiographs of the cervical spine. Or, a seventy-five year old man with a cervical fracture on CT who was managed initially in a semi-rigid collar without other assessment for ligamentous injury.
Regardless, each of these patients had some combination of eventual CT or MRI that failed to adequately describe the extent of cervical spine instability, but a simple erect radiograph demonstrated subluxation. Interestingly, this is a little bit of full circle back to the days of flexion/extension films. While other studies have demonstrated MRI picks up signal abnormalities not detected on CT imaging, the clinical significance of this is debatable. Conversely, these dynamic/load-bearing plain radiographs offer a true functional test without precisely describing the injury – akin to the difference between cardiac stress testing and coronary angiograms.
These injuries are quite rare, and not every patient needs an MRI or dynamic testing for cervical stability. However, in the end, these tests have a role and should be utilized as necessary in the appropriate clinical situation.
“Erect Radiographs to Assess Clinical Instability in Patients with Blunt Cervical Spine Trauma”
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