| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
1
Children's Radiologic Institute, Children's Hospital of Columbus, 700
Children's Dr., Columbus, OH 43205.
2
Division of Osteoradiology, University of California at San Diego, 3350 La
Jolla Village Dr., La Jolla, CA 92161.
Received September 9, 1999;
accepted after revision November 19, 1999.
Address correspondence to J. R. Dwek.
Abstract
 Top Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
MATERIAL AND METHODS. We performed a retrospective review of all pediatric trauma patients who underwent static cervical spine radiography followed by flexion—extension radiography during a 22-month period. We reviewed the mechanism of injury, physical examination findings, and patient age, and tabulated the results of initial and follow-up imaging studies.
RESULTS. Two hundred forty seven children (age range, 1.6-18 years; mean age, 11.5 years) with a history of trauma underwent cervical spine radiography followed by flexion—extension radiography. Static cervical spine radiographs revealed normal findings in 224 patients (91%). Flexion—extension radiographs revealed normal findings for all patients with normal findings on cervical spine radiographs. Of 23 children (9%) with abnormal findings on static cervical spine radiographs, seven (30%) had congenital abnormalities visible on flexion—extension radiographs; 10 (43%) had traumatic injuries including fracture, subluxation, or soft-tissue swelling; two (9%) had instability; and six (26%) had questionable abnormalities that were noted on static cervical spine radiographs. In four patients (66%) with abnormal findings on static cervical spine radiographs, flexion—extension radiographs were helpful in ruling out abnormality.
CONCLUSION. In children with a history of trauma and normal findings on static cervical spine radiographs, additional flexion—extension radiographs are of questionable use.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Previous studies reported conflicting results regarding the use of flexion—extension radiographs when static cervical spine radiographs revealed normal findings [8, 9]. Our study considered the use of flexion—extension radiographs in children with a history of trauma and normal findings on static cervical spine radiography. Additionally, we evaluated the usefulness of flexion—extension radiography when cervical spine radiography reveals definite or questionable abnormalities. To search for study participants, we used our institution's trauma database. Our institution registers more than 63,000 annual pediatric emergency department visits and supports a level 1 pediatric trauma unit.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
All studies had been interpreted by board-certified radiologists who had certificates of added qualification in pediatric radiology.
The standard static cervical spine radiography at our institution follows American College of Radiology guidelines reference and consists of anteroposterior and lateral conventional radiographs. An odontoid view is added in children older than 4 years.
Our pediatric radiologists qualitatively assessed the flexion—extension radiographs without measurement of specific angles. The anterior atlanto-dental interval may not have exceeded 5 mm.
A review of admissions for the study period showed 22 patients with cervical spine injuries, consisting of either fracture or subluxation. Twelve of these patients did not undergo flexion—extension radiography at the pretreatment assessment because the patient had a neurologic deficit at presentation and the injury diagnosed on cervical spine radiographs was clearly unstable. These patients were not included in the study population. In the remaining 10 patients, the injury revealed on static cervical spine radiographs was not immediately suggestive of instability and flexion—extension radiography was performed.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
In all patients with minor trauma, dynamic radiography was performed on the same day as the initial static cervical spine radiography. The dynamic examination was delayed for several days in all patients with altered mental status.
The indication for flexion—extension radiography was most commonly pain or tenderness (169/247; 68%). In 55 patients (22%), routine flexion—extension radiographs were obtained because the patients had sustained major trauma and had unreliable physical examinations, resulting from altered mental status. Ten patients (4%) had dynamic radiography performed to evaluate instability when a fracture or subluxation was diagnosed on static cervical spine radiographs. In seven patients (3%), flexion—extension radiography was performed to evaluate congenital abnormalities noted on static cervical spine radiography. In six patients (2%), flexion—extension radiography was performed to evaluate questionable abnormalities that appeared on static cervical spine radiography.
Static cervical spine radiography revealed normal findings in 224 (91%) of 247 patients. Seventy-six percent (171/224) of these patients had normal Glasgow coma scores on arrival; 16% (35/224) had a significantly depressed mental status with Glasgow coma scores of 10 or less. All patients with normal findings on static cervical spine radiography also had normal findings on flexion—extension radiography. Static cervical spine radiography revealed abnormal findings in 23 (9%) of 247 patients.
In seven (30%) of 23 patients, cervical spine radiography revealed congenital abnormalities and dynamic radiography was performed to assess instability. None of the congenital abnormalities appeared unstable on flexion—extension radiographs.
In 16 (70%) of 23 patients, injury was either diagnosed or suspected on the basis of cervical spine radiography. In 10 (43%) of 23 patients, a fracture or subluxation was visible on static cervical spine radiography. Two of these patients had Glasgow coma scores less than or equal to 10. The same two patients had unstable injuries on flexion—extension radiographs and received surgical fusion.
In six patients (26%), injury was suspected because of findings of local kyphosis, soft-tissue swelling, or questionable abnormalities. In these patients, dynamic radiography was performed to evaluate instability and presumed abnormality using additional views. These radiographs were obtained on the same day or in one patient, 2 days later. In one of these six patients, the Glasgow coma score was 10 or less. In four patients (67%), flexion—extension radiographs revealed normal findings. The remaining two patients (33%) required CT or MR imaging for the evaluation of their injuries; CT and MR imaging findings were normal.
In 92% of examinations, flexion and extension was adequate. Eight percent of patients were unable to flex or extend because of pain and spasm. All patients were instructed to return in 2 weeks for neurosurgical clinic follow-up. No patients returned with delayed cervical spine instability.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
A study by Hubbard [9] reported that 42.8% of pediatric patients with unstable cervical spine injuries had spasm and only 3.5% of patients with stable injuries had instability. In this study, 8% of patients exhibited inadequate flexion caused by spasm. Although none of these patients had cervical spine injuries, limitations of flexion caused by spasm highlight a weakness of dynamic radiography, at least in the acute setting.
Two studies reported the scientific usefulness of flexion—extension radiographs [8, 10], and the results are conflicting. The first retrospective study [8] reported the findings in 141 adults for whom flexion—extension radiographs were obtained after trauma. The cervical spine radiography was unequivocally normal in 71 of 141 patients. Of these patients, four had abnormal findings on flexion—extension radiography and three required surgical intervention [8]. The static cervical spine radiographs were interpreted as equivocal in 56 patients, and 14 patients had fractures that were identified on static cervical spine radiography alone. However, these results were statistically insignificant. Interestingly, the flexion—extension radiographs revealed false-negative findings in one patient, possibly caused by spasm.
The second study, by Woods et al. [10], examined 137 patients, 18 years old or younger, selected from an academic emergency department averaging 60,000 visits per year, of which 20% were pediatric. The retrospective study was performed over a 4-year period. Ninety-three (68%) patients had normal findings on static cervical spine radiography. In this study, no patient had abnormal findings on flexion—extension radiographs when static cervical spine radiography revealed normal findings [10]. Despite these results, no definite conclusion was drawn by the authors.
In our study, no patients had abnormal findings on flexion—extension radiographs, if static cervical spine radiography revealed normal findings. Our study group of 224 patients with normal findings on static cervical spine radiography yields a 95% confidence interval of 1.3 patients per 100 patients who statistically could have abnormal findings on flexion—extension radiographs if the static cervical spine radiographs revealed normal findings. This finding implies that flexion—extension radiographs are of questionable value if static cervical spine radiographs reveal normal findings.
The results of studies performed in pediatric and adult populations are not completely interchangeable. The spine in patients younger than 11 years differs from the adult spine because there is more ligamentous laxity and more flexibility, as witnessed by the high incidence of spinal cord injury without radiographic abnormality. The adult spine may show significant degenerative abnormality that may worsen the effects of hyperflexion and hyperextension. The stability of the degenerative spine under traumatic circumstances may be compromised more easily. These differences may explain the discrepancy between adult and pediatric studies.
Dynamic radiography is helpful in evaluating questionable abnormalities. A finding of prevertebral soft-tissue swelling may be artifactually caused by the patient's swallowing at the time the radiograph is obtained. This problem is obviated during extension when swallowing is less likely and true soft-tissue swelling is more obvious. Patients with questionable or definite congenital abnormalities also benefit from flexion-extension radiography. Fusion in the posterior parts or the vertebral bodies become more obvious on flexion—extension radiography. Thus, flexion—extension radiographs are helpful when cervical spine radiographs reveal questionable findings.
In conclusion, in the setting of acute pediatric trauma, cervical spine flexion—extension radiographs are of questionable benefit if static cervical spine radiographs reveal normal findings.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  E. Pitt and S. Thakore Role of flexion/extension radiography in paediatric neck injuries Emerg. Med. J., March 1, 2005; 22(3): 192 - 193. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. S. Lustrin, S. P. Karakas, A. O. Ortiz, J. Cinnamon, M. Castillo, K. Vaheesan, J. H. Brown, A. S. Diamond, K. Black, and S. Singh Pediatric Cervical Spine: Normal Anatomy, Variants, and Trauma RadioGraphics, May 1, 2003; 23(3): 539 - 560. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
