Bolinger Bryan, Shartz Michael, Marion Donald
Department of Neurological Surgery, Prebyterian University Hospital, Pittsburgh, PA 15213, USA.
J Trauma. 2004 Jan;56(1):132-6. doi: 10.1097/01.TA.0000044629.69247.0A.
Bedside flexion and extension fluoroscopic examinations have been proposed as an option for clearance of the cervical spine in comatose brain-injured patients. We hypothesized that these studies, when performed after normal static imaging of the cervical spine, would have an extremely low likelihood of identifying occult ligamentous instability and would not be adequate for visualizing the lower cervical spine.
Radiographic images obtained from 56 consecutive comatose head-injured patients were reviewed. All patients had normal anteroposterior, lateral, and open mouth odontoid cervical spine radiographs and normal thin-cut axial computed tomographic images from the occiput to C2 and through the lower cervical spine if suspicious areas were identified on plain cervical spine radiographs. After these static images were determined to be normal by both the attending neurosurgeon and the attending radiologist, all 56 patients had bedside fluoroscopic flexion and extension studies performed by the neurosurgery resident, with the patients' arms being pulled down to their sides by the primary care nurse.
The bedside fluoroscopic flexion and extension studies were considered to be adequate (visualization to the C7-T1 motion segment) in only 4% of the patients. Occult instability was identified in one patient (type II odontoid fracture) and significant instability was missed in one patient with C6 to C7 dislocation in whom flexion and extension radiographs failed to visualize the C6 to C7 motion segment.
Bedside flexion and extension fluoroscopy was almost always inadequate for visualizing the lower cervical spine in comatose head-injured patients. Because of the extremely low likelihood of visualizing the entire cervical spine with this technique, we recommend that it no longer be considered an option in trauma center protocols for clearance of the cervical spine in comatose brain-injured patients.
床边颈椎屈伸透视检查已被提议作为昏迷脑损伤患者颈椎评估的一种选择。我们推测，在颈椎常规静态成像之后进行这些检查，识别隐匿性韧带不稳定的可能性极低，并且不足以观察下颈椎。
回顾了56例连续性昏迷颅脑损伤患者的影像学资料。所有患者前后位、侧位及张口位颈椎X线片均正常，若颈椎平片发现可疑区域，则自枕骨至C2以及下颈椎行薄层轴向计算机断层扫描图像均正常。在经主治神经外科医生和主治放射科医生确认这些静态图像正常后，56例患者均由神经外科住院医师进行床边透视下颈椎屈伸检查，患者的手臂由初级护理护士下拉至身体两侧。
仅4%的患者床边透视下颈椎屈伸检查被认为是充分的（可观察到C7 - T1活动节段）。1例患者发现隐匿性不稳定（II型齿突骨折），1例C6至C7脱位患者屈伸位X线片未能观察到C6至C7活动节段，从而漏诊了明显的不稳定。
床边颈椎屈伸透视检查几乎总是不足以观察昏迷颅脑损伤患者的下颈椎。由于用该技术观察整个颈椎的可能性极低，我们建议在创伤中心昏迷脑损伤患者颈椎评估方案中不再将其作为一种选择。
