Cervical Spine Instability: Clearance Using Dynamic Fluoroscopy

Purpose Clearing the cervical spine in a multiply injured trauma patient is a dilemma because clinical examination for ligamentous instability cannot be performed, and the standard cervical spine series can miss isolated ligamentous injury. Static flexion/extension views are unsafe, as the obtunded patient has no protective reflexes and cannot complain of pain during the exam. This results in a need for prolonged spinal immobilization and its attendant complications. Dynamic fluoroscopy may be useful in the detection of otherwise occult injuries. Methods We performed a prospective study of a cervical spine clearance algorithm incorporating dynamic fluoroscopy with flexion/extension views. Inpatient records over a 3-year period were reviewed. Patient demographic data, results of cervical spine films and fluoroscopic exams, interventions based on positive results, and missed injuries were recorded. Results One hundred ten patients with normal spine plain films underwent dynamic fluoroscopy with flexion and extension views of the cervical spine. The average Glasgow Coma Score was 9.2 and the average revised Trauma Score was 9.5. Nine patients had evidence of cervical instability on exam. Six of these were deemed stable by the orthopedic or neurosurgical spine consultants, and these patients had their hard collars removed. One patient with positive findings had cervical immobilization with hard collar continued, a second had halo placement, and a third underwent spinal fusion for atlanto-occipital disassociation. No patients undergoing dynamic fluoroscopy were subsequently found to have missed cervical spine injury. Conclusions With our protocol, 3 patients had significant cervical instability that would have been missed without dynamic fluoroscopy. Given the significant medical and legal ramifications of missed cervical spine injury and the benefits of early removal of cervical collars, more widespread use of dynamic fluoroscopy of the cervical spine is warranted