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Three Part Question

In [a neurologically intact child with neck pain following trauma but normal plain xrays] do [flexion/extension xrays] aid [diagnosis of ligamentous or soft tissue injury with instability]?

Clinical Scenario

A child attends the emergency department, he has been involved in a high speed RTA, complains of neck pain and midline neck spinal tenderness but has no neurological signs/symptoms. Static cervical spine radiology (lateral, AP & odontoid views) reveal no abnormality. You wonder if flexion/extension xrays would show any significant injury/instability.

Search Strategy

Medline 1966-11/04 and Embase 1988 11/04 using the Ovid interface.
Medline: [exp neck injuries OR neck trauma.mp OR cervical spine trauma.mp OR exp spinal injuries OR exp spinal cord injuries OR exp spinal fractures OR exp fractures OR cervical spine injuries.mp OR exp dislocations OR exp cervical vertebrae OR cervical spinal cord trauma.mp OR exp spinal cord compression] AND [flexion-extension.ti OR dynamic cervical spine radiography.mp OR flexion-extension radiography.mp OR flexion-extension cervical spine radiography.mp OR flexion-extension radiographs.mp] AND [exp joint instability OR ligamentous injury.mp OR ligament injury.mp OR cervical vertebrae OR exp fractures OR ligamentous instability.mp OR exp soft tissue injuries OR soft tissue injury.mp] AND [BestBETs paediatric filter] LIMIT to human AND English language.
Embase: [exp neck injuries OR neck trauma.mp OR cervical spine trauma.mp OR exp spinal injuries OR exp spinal cord injuries OR exp spinal fractures OR exp fractures OR cervical spine injuries.mp OR exp dislocations OR exp cervical vertebrae OR cervical spinal cord trauma.mp OR exp spinal cord compression] AND [flexion-extension.ti OR dynamic cervical spine radiography.mp OR flexion-extension radiography.mp OR flexion-extension cervical spine radiography.mp OR flexion-extension radiographs.mp] AND [exp joint instability OR ligamentous injury.mp OR ligament injury.mp OR cervical vertebrae OR exp fractures OR ligamentous instability.mp OR exp soft tissue injuries OR soft tissue injury.mp] AND [exp child OR child$.mp OR exp infant OR exp pediatrics OR pediatric$.mp OR paediatric$.mp] LIMIT to human AND English language.

Search Outcome

Altogether 32 papers were found from Medline and 19 from Embase, of which 3 were relevant and are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Dwek JR & Chung CB, 2000, USA	247 1.6-18 year olds with history of trauma who had SCSR followed by FECSR done at the time the GCS permitted (could be delayed days)	Retrospective observational study	Radiological abnormality on SCSR & FECSR	All with normal SCSR - had normal FECSR	Retrospective Abnormality on FECSR assessed qualitatively by radiologists 8% of FECSR inadequate – not further commented on other than no late instability in those attending at 2/52
Woods WA et al, 1998, USA	137 alert 0-18 year olds following blunt trauma who underwent Static Cervical Spine Radiography (SCSR) and Flexion Extension Cervical Spine Radiography (FECSR)	Retrospective descriptive study	Radiological instability on FECSR	93 (70%) normal static CSR - all had normal FECSR 30% (40) abnormal SCSR of whom 7 (5%) had abnormal FECSR but none required invasive spinal surgery & all had satisfactory neurological outcome	Retrospective
			Complications of FECSR	No complications of FECSR
Ralston ME et al, 2001, USA	129 patients under age 17 with blunt trauma who had SCSR & FECSR within 7 days of injury	Retrospective review	Radiographic assessment of abnormality on SCSR & FECSR	83 suspicious SCSR led to 75 normal and 8 abnormal FECSR Normal SCSR unlikely to have an abnormal FECSR Out of 46 Out of 46 normal SCSR one had an abnormal FECSR (abnormal subluxation) but was given a clinical diagnosis of physiological subluxation based on clinical course	Retrospective Don't correlate radiographic review with clinical findings Only 1 radiographic reviewer looked at all films
			Complications from FECSR	Abnormal SCSR – FECSR limited use in confirming injury but useful to rule out injury No permanent complications

Comment(s)

All studies are retrospective so the evidence base is limited. FECSR appears to have resulted in no permanent complications in these studies. However, the utility of FECSR in patients with normal SCSR is low. In the current era of ther imaging modalities such as CT and MRI the need for FECSR may decline

Clinical Bottom Line

If SCSR is normal FECSR is unlikely to be abnormal. If SCSR is equivocal/abnormal FECSR is still unlikely to be abnormal but may help may help to rule out injury in an alert child with no neurological signs complaining of pain & neck tenderness.

References

1. Dwek JR, Chung CB. Radiography of cervical spine injury in children: are flexion-extension radiographs useful for acute trauma? Am J Roentgenol 2000;174(6):1617-9.
2. Woods WA, Brady WJ, PollockG, et al. Flexion-extension cervical spine radiography in pediatric blunt trauma. Emerg Radiol 1998;5:381-384.
3. Ralston ME, Chung K, Barnes PD, et al. Role of flexion-extension radiographs in blunt pediatric cervical spine injury. Acad Emerg Med 2001;8(3):237-45.