Diagnosis of cervical spine injury in motor vehicle crash victims: how many X-rays are enough?

As delay in diagnosing unstable cervical spine injuries unnecessarily exposes patients to risk of neurologic injury, it is often recommended that complex radiologic investigations be performed on alert patients with neck pain, tenderness, or neurologic deficit despite normal plain radiographs. The optimal investigation of patients unable to reliably provide such information is less clear. How many X-rays are enough to clear the cervical spine? In order to answer this question, a retrospective review of 775 motor vehicle crash (MVC) victims was conducted. Ninety-two (12%) sustained cervical spine injury. Sixteen of these injuries were missed initially and, in a further 18 cases, the lateral cervical spine X-ray was wrongly interpreted as positive. Fifty-five per cent of patients with cervical injury had a Glasgow Coma Score (GCS) of less than 15 on admission. Lateral radiographic visualization of the complete cervical spine (including a swimmer's view as required) had a sensitivity of 83% and a specificity of 97%. The addition of open mouth (OM) and anteroposterior (AP) views detected all patients with unstable fractures except one man with a head injury who was unable to provide clinical clues to the diagnosis, but who suffered no additional harm as a result. A single lateral X-ray of the cervical spine is inadequate to exclude cervical spine injury in severely traumatized patients and the addition of OM and AP views still failed to identify unstable fractures in one of 385 patients in this series of MVC victims with GCS less than 15.(ABSTRACT TRUNCATED AT 250 WORDS)