Cervical spine assessment in the unconscious trauma patient: a major trauma service's experience with passive flexion-extension radiography.

Background: There is no consensus on the most appropriate method of cervical spine assessment in unconscious trauma patients. Passive flexion-extension imaging is one option for further investigating unconscious patients whose plain cervical radiographs yield normal findings. This study examines the usefulness of this passive imaging in investigating for occult cervical injury. Methods: All unconscious patients admitted to The Alfred Trauma Intensive Care Unit over 1 year (January 1–December 31, 1998) who could not be clinically assessed within 48 hours in regard to the cervical spine were identified. Results of passive flexion-extension radiography were compared with final injury status and clinical outcome, as determined by retrospective review of the imaging reports, radiographic films, and case notes. Results: One hundred twenty-three patients whose three-view plain radiographs showed no abnormalities proceeded to passive functional investigation. These were false-negative for four of the seven patients with cervical spine injuries at presentation. No patients suffered any adverse neurologic events from delayed diagnosis or from the flexion-extension procedure. Conclusion: Passive flexion-extension imaging has inadequate sensitivity for detecting occult cervical spine injuries. Although no patients suffered adverse neurologic complications, the potential for devastating consequences from missed cervical injury has resulted in the removal of passive flexion-extension imaging from the screening protocol.