The (f)utility of flexion-extension C-spine films in the setting of trauma

Am J Surg. 2013 Dec;206(6):929-33; discussion 933-4. doi: 10.1016/j.amjsurg.2013.09.001. Epub 2013 Oct 1.


Background: Flexion-extension radiographs are often used to assess for removal of the cervical collar in the setting of trauma. The objective of this study was to evaluate their adequacy. We hypothesized that a significant proportion is inadequate.

Methods: This was a retrospective review of C-spine clearance at a level 1 trauma center. A trauma-trained radiologist interpreted all flexion-extension radiographs for adequacy. Studies performed within 7 days of injury were considered acute.

Results: Three hundred fifty-five flexion-extension radiographs were examined. Ninety-five percent% of these studies were inadequate (51% because of the inability to visualize the top of T1, whereas 44% had less than 30° of angulation from neutral). Two hundred ten studies were performed acutely; of these, 97% were inadequate. When performed 7 days or longer from injury, 91% were inadequate.

Conclusions: Injury to the C-spine may harbor significant consequences; therefore, its proper evaluation is critical. The majority of flexion-extension films are inadequate. As such, they should not be included in the algorithm for removal of the cervical collar. If used, adequacy must be verified and supplemental radiographic studies obtained as indicated.

Keywords: Adequacy; Cervical spine injury; Flexion/extension radiography; Trauma.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Algorithms*
  • Cervical Vertebrae / diagnostic imaging
  • Cervical Vertebrae / injuries*
  • Female
  • Humans
  • Male
  • Retrospective Studies
  • Spinal Injuries / diagnostic imaging*
  • Tomography, X-Ray Computed / methods*
  • X-Ray Film / statistics & numerical data*