Cervical spine clearance in unconscious traumatic brain injury patients: dynamic flexion-extension fluoroscopy versus computed tomography with three-dimensional reconstruction.
BACKGROUND
An optimal protocol for clearing the cervical spine in unconscious patients with traumatic brain injury remains controversial. Protocols include plain radiographs and computed tomography (CT), and ligamentous injury may be identified with flexion-extension radiographs. We questioned whether cervical CT with three-dimensional (3D) reconstructions may obviate the need for flexion-extension radiology in the detection of occult ligamentous injury.


METHODS
Between July 1999 and November 2001, 276 unconscious traumatic brain injured patients admitted to The Alfred Hospital received cervical spine plain radiographs, CT with 3D reconstructions, and dynamic flexion-extension X-ray studies with fluoroscopy as part of a routine protocol. These patients were identified from a prospective intensive care unit database and all radiology reports were reviewed.


RESULTS
Dynamic flexion-extension X-ray studies with fluoroscopy identified no new fractures or instability; there were no instances of true-positive results. Dynamic flexion-extension was true-negative in 260 of 276 (94%) patients, falsely positive in six patients (2.2%) and falsely negative in one (0.4%) patient. In nine patients, dynamic flexion-extension was inadequate.


CONCLUSIONS
Dynamic flexion-extension X-ray studies with fluoroscopy delayed cervical spine clearance and were almost always reported as normal. In a cervical spine clearance protocol for unconscious traumatic brain injury patients, dynamic flexion-extension X-ray studies with fluoroscopy did not identify any patients with cervical fracture or instability not already identified by plain radiographs and fine-cut CT (C0 to T2) with 3D reconstructions.
Padayachee
Laven
L
Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
Cooper
D James
DJ
Irons
Steven
S
Ackland
Helen M
HM
Thomson
Ken
K
Rosenfeld
Jeffrey
J
Kossmann
Thomas
T
D000465:Algorithms; D001930:Brain Injuries / Q000150:complications*; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries / Q000503:physiopathology; D002985:Clinical Protocols / Q000592:standards; D003663:Decision Trees; D005188:False Negative Reactions; D005189:False Positive Reactions; D005471:Fluoroscopy / Q000379:methods* / Q000592:standards; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods* / Q000592:standards; D008023:Ligaments, Articular / Q000293:injuries; D008279:Magnetic Resonance Imaging / Q000379:methods / Q000592:standards; D018579:Patient Selection; D011446:Prospective Studies; D016059:Range of Motion, Articular; D015203:Reproducibility of Results; D012307:Risk Factors; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000379:methods* / Q000592:standards; D014193:Trauma Centers; D014474:Unconsciousness / Q000150:complications*; D014739:Victoria