to the editor: The assessment of spinal injuries requires a methodical and rapid, focused assessment with special attention to the trauma care protocols as outlined in the article, “Cervical Spine Radiographs in the Trauma Patient.”¹ Cervical spine and spinal cord trauma have the potential as the most devastating injuries and, unfortunately, patients in their early 20s comprise the majority of these victims. Motor vehicle and motorcycle collisions serve as the most common mechanism of injury, followed by falls, firearms and sporting activities.^2,3

Fundamental radiographic studies in patients with spinal injuries include a minimum of three views: the lateral view, the anteroposterior view and the open-mouth odontoid view. Oblique cervical films should be ordered as clinically appropriate. Flexion-extension views should not be a part of the cervical spine evaluation in trauma patients. If a question or discrepancy is identified on the initial films, a computed tomographic (CT) scan should be the next study ordered. Any questions in terms of the bony alignment, cartilage-space placement or soft tissue measurements should be pursued through CT scanning. Of note, the routine cervical spine films may be inadequate in patients with blunt trauma, with upwards of 25 percent of lateral views being inadequate for visualization at the C7-T1 level.⁴

To determine what approach the residency-trained, board-certified, emergency medicine colleagues at my institution routinely order for spinal trauma patients, the questions that accompanied the cervical spine article¹ were distributed for completion and comments. All 20 of the emergency medicine physicians surveyed concurred that flexion-extension views should not be considered routine and are rarely, if ever, indicated in the emergency assessment of cervical injury patients.

Although standard emergency medicine textbooks will refer to the use of these films if the lesion is considered stable, in the real world of practice, emergency medicine physicians prefer to maintain spinal immobilization in patients with spinal trauma and immediately order a CT scan. In some cases, a neurosurgical consultation will be obtained and flexion-extension manipulation testing will be performed by the subspecialist. It is important to keep in mind that patients may present with an apparent acutely stable cervical spine because of significant spasm, but may over time (even up to several weeks) develop a subacute instability of the cervical spine.^5,6 This phenomenon is related to the significant muscle tension that prevents subluxation initially, but produces instability with gradual relaxation.

editor's note: This letter was sent to the authors of “Cervical Spine Radiographs in the Trauma Patient,” who did not reply.