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Three Part Question

In a [trauma patient in whom standard lateral views of the cervical spine are inadequate] is a [swimmer's view better than supine oblique views] at [visualising the C7/T1 junction]?

Clinical Scenario

A 36 year old man is brought to the emergency department after a road traffic accident. He complains of neck pain. A 'pulled' lateral is taken, but fails to show the C7/T1 junction. You wonder whether a pair of supine oblique views or a swimmers view would be best to visualise this region.

Search Strategy

Medline 1966-07/02 using the OVID interface.
[supine oblique.mp OR trauma oblique.mp OR swimmers view.mp OR twining.mp] AND [exp x-rays OR x-ray$.mp or radiograph.mp OR exp radiography OR radiography.mp] AND [exp cervical vertebrae OR cervical spine.mp OR exp neck injuries OR neck injur$.mp OR cervicothoracic junction.mp] LIMIT to human AND English

Search Outcome

11 papers were found of which only one was relevant to the original question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ireland AJ et al, 1998, UK	427 consecutive patients who attended with acute trauma requiring cervical spine radiographs. 60 patients required additional swimmers view. 62 required additional paired supine oblique views.	Two phase prospective study	Able to visualise the vertebral bodies and posterior elements of the cervicothoracic junction	37% of the swimmers group and 38% of the supine oblique group were judged satisfactory. When vertebral bodies not shown adequately, 70% of supine obliques and 37% swimmers showed posterior elements adequately.	9 patients from supine oblique group lost, therefore not included in calculations.

Comment(s)

While there are numerous articles expressing personal views, there is only this one paper which attempts to answer the question. This paper showed no difference in visualising the vertebral bodies of C7/T1 junction between swimmers or supine obliques, but supine obliques did visualise the posterior elements better. But 9/62 of supine oblique data lost which could have swayed the results either way. Therefore more research is needed in this area.

Clinical Bottom Line

Local advice should be followed.

References

1. Ireland AJ, Britton I, Forrester AW. Do supine oblique views provide better imaging of the cervicothoracic junction than swimmer's views? J Accid Emerge Med 1998;15(3):151-4.