Association for Academic Surgery| Volume 184, ISSUE 1, P411-413, September 2013

Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan?



      There are variations in cervical spine (CS) clearance protocols in neurologically intact blunt trauma patients with negative radiological imaging but persistent neck pain. Current guidelines from the current Eastern Association for the Surgery of Trauma include options of maintaining the cervical collar or obtaining either magnetic resonance imaging (MRI) or flexion-extension films (FEF). We evaluated the utility of FEF in the current era of routine computerized tomography (CT) for imaging the CS in trauma.

      Materials and methods

      All neurologically intact, awake, nonintoxicated patients who underwent FEF for persistent neck pain after negative CT scan of the CS at our level I trauma center over a 13-mo period were identified. Their charts were reviewed and demographic data obtained.


      There were 354 patients (58.5% male) with negative cervical CS CT scans who had FEF for residual neck pain. Incidental degenerative changes were seen in 37%—which did not affect their acute management. FEF were positive for possible ligamentous injury in 5 patients (1.4%). Two of these patients had negative magnetic resonance images and the other three had collars removed within 3 wk as the findings were ultimately determined to be degenerative.


      In the current era, where cervical CT has universally supplanted initial plain films, FEF appear to be of little value in the evaluation of persistent neck pain. Their use should be excluded from cervical spine clearance protocols in neurologically intact, awake patients.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Surgical Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Stiell I.G.
        • Clement C.M.
        • McKnight R.D.
        • et al.
        The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.
        N Engl J Med. 2003; 349: 2510
        • Besman A.
        • Kaban J.
        • Jacobs L.
        False-negative plain cervical spine x-rays in blunt trauma.
        Am Surg. 2003; 69: 1010
        • Crim J.
        • Moore K.
        • Brodke D.
        Clearance of the cervical spine in multitrauma patients: the role of advance imaging.
        Semin Ultrasound CT MR. 2001; 22: 283
        • Woodring J.
        • Lee C.
        Limitations of cervical radiography in the evaluation of acute cervical trauma.
        J Trauma. 1993; 34: 32
        • Diaz J.
        • Gillman C.
        • Morris J.
        • et al.
        Are five-view plain films of the cervical spine unreliable? a prospective evaluation in blunt trauma patients with altered mental status.
        J Trauma. 2003; 55: 658
        • Duane T.M.
        • Dechert T.
        • Brown H.
        • et al.
        Is the lateral cervical spine plain film obsolete?.
        J Surg Res. 2008; 147: 267
        • Como J.J.
        • Diaz J.J.
        • Dunham C.M.
        • et al.
        Cervical spine injuries following trauma, identification of (2009 update).
        J Trauma. 2009; 67: 651
        • Menaker J.
        • Philp A.
        • Boswell S.
        • Scalea T.M.
        Computed tomography alone for cervical spine clearance in the unreliable patient–are we there yet?.
        J Trauma. 2008; 64: 898
        • Como J.J.
        • Thompson M.A.
        • Anderson J.S.
        • et al.
        Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma?.
        J Trauma. 2007; 63: 544
        • Sarani B.
        • Waring S.
        • Sonnad S.
        • Schwab C.W.
        Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients.
        J Trauma. 2007; 63: 637
        • Schuster R.
        • Waxman K.
        • Sanchez B.
        • et al.
        Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits.
        Arch Surg. 2005; 140: 762
        • Fazl M.
        • LaFebvre J.
        • Willinsky R.A.
        • Gertzbein S.
        Posttraumatic ligamentous disruption of the cervical spine, an easily overlooked diagnosis: presentation of three cases.
        Neurosurgery. 1990; 26: 674
        • Lewis L.M.
        • Docherty M.
        • Ruoff B.E.
        • Fortney J.P.
        • Keltner Jr., R.A.
        • Britton P.
        Flexion-extension views in the evaluation of cervical-spine injuries.
        Ann Emerg Med. 1991; 20: 117
        • Brady W.J.
        • Moghtader J.
        • Cutcher D.
        • Exline C.
        • Young J.
        ED use of flexion-extension cervical spine radiography in the evaluation of blunt trauma.
        Am J Emerg Med. 1999; 17: 504
        • Insko E.K.
        • Gracias V.H.
        • Gupta R.
        • Goettler C.E.
        • Gaieski D.F.
        • Dalinka M.K.
        Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma.
        J Trauma. 2002; 53: 426
        • Pollack Jr., C.V.
        • Hendey G.W.
        • Martin D.R.
        • Hoffman J.R.
        • Mower W.R.
        • NEXUS Group
        Use of flexion-extension radiographs of the cervical spine in blunt trauma.
        Ann Emerg Med. 2001; 38: 8
        • Sanchez B.
        • Waxman K.
        • Jones T.
        • et al.
        Cervical spine clearance in blunt trauma: evaluation of a CT-based protocol.
        J Trauma. 2005; 59: 179
        • Bolinger B.
        • Shartz M.
        • Marion D.
        Bedside fluoroscopic flexion and extension cervical spine radiographs for clearance of the cervical spine in comatose trauma patients.
        J Trauma. 2004; 56: 132
        • Padayachee L.
        • Cooper D.J.
        • Irons S.
        • et al.
        Cervical spine clearance in unconscious traumatic brain injury patients: dynamic flexion-extension fluoroscopy versus computed tomography with three-dimensional reconstruction.
        J Trauma. 2006; 60: 341
        • Spiteri V.
        • Kotnis R.
        • Singh P.
        • et al.
        Cervical dynamic screening in spinal clearance: now redundant.
        J Trauma. 2006; 61: 1171
        • Duane T.M.
        • Scarcella N.
        • Cross J.
        • et al.
        Do flexion extension plain films facilitate treatment after trauma?.
        Am Surg. 2010; 76: 1351
        • Khan S.N.
        • Erickson G.
        • Sena M.J.
        • Gupta M.C.
        Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans.
        J Orthop Trauma. 2011; 25: 51
        • Goodnight T.J.
        • Helmer S.D.
        • Dort J.M.
        • Nold R.J.
        • Smith R.S.
        A comparison of flexion and extension radiographs with computed tomography of the cervical spine in blunt trauma.
        Am Surg. 2008; 74: 855