pISSN 1738-2262/eISSN 2093-6729

CASE REPORT http://dx.doi.org/10.14245/kjs.2015.12.3.146

Korean J Spine 12(3):146-149, 2015 www.e-kjs.org

Delayed or Missed Diagnosis of Cervical Instability after Traumatic Injury :

Usefulness of Dynamic Flexion and Extension Radiographs

Chang Gi Yeo, Ikchan Jeon, Sang Woo Kim

Department of Neurosurgery, Yeungnam University College of Medicine, Daegu, Korea

Prompt and accurate diagnosis of cervical spine injury is important to prevent the catastrophic results that can be caused
by undetected lesions. Delayed or missed diagnosis of cervical spine injury occurs with an incidence of 5 to 20% according
to previous studies. In this study, we report four cases of cervical instability without initial radiologic evidence. These cases
demonstrate that dynamic flexion and extension radiographies can be a proper choice of modality to diagnose and exclude
the possibility of cervical instability in a patient with a suspicious ligament injury on the static radiographies following acute
cervical trauma.

Key Words: Cervical vertebraeㆍDislocationㆍRadiography

days to weeks following traffic accidents. All patients presen-

INTRODUCTION ted persistent neck pain without neurological deterioration
or radiological abnormalities on static radiographies, with the
Prompt and accurate detection of traumatic cervical spine exception of one case of spinous process fracture that did not
lesion is important, because delayed or missed diagnosis might involve lamina in the initial work-up. The clinical features of
lead to catastrophic consequences for patients, ranging from the enrolled patients are summarized in Table 1.
minor neurological deficits to complete tetraplegia1,5). The inci- The first case was a 57-year-old woman presenting with mul-
dence of delayed or missed diagnosis of cervical spine injury tiple trauma caused by a rollover motor vehicle accident. She
is between 4.9 to 20%3,6,8). There has been a reduction in the complained of left shoulder and neck pain, and was diagnosed
incidence of delayed or missed diagnosis in recent years with with multiple fractures in the upper and lower extremities.
developments in radiological diagnostic examination tools inclu- A spinous process fracture was identified on C5 without invol-
ding computed tomography (CT) scan and magnetic resonance ving lamina under routine X-ray (Fig. 1C and D, including
(MR) imaging. Nevertheless, incomplete radiological studies antero-posterior, lateral, and open mouth views) and CT scan
and misinterpretation are still common causes of delayed or mi- (Fig. 1A). The patient was found to have suspicious posterior
ssed diagnosis6). In addition, suspicion of an injury of the pos- ligament complex injuries including inter- and supra-spinous
terior cervical ligament complex using only static radiogra- ligaments and ligamentum flavum on T2 fat suppression sagi-
phies, including MR imaging, may be insufficient to permit an ttal MR imaging (Fig. 1B). We decided to prescribe for the patient
exact diagnosis and determine proper management. a conservative treatment, because of a low possibility of insta-
bility with the above radiological examination under the Sub-
axial Cervical Injury Classification (SLIC)11). She complained
CASE REPORT of intermittent neck pain and discomfort during follow-up
periods at the outpatient department. Subluxation of the facet
Four patients were diagnosed with cervical instability several joint on C5-6 was identified by dynamic flexion and extension
radiographies after 9 weeks. The anterior longitudinal liga-
● Received: April 21, 2015 ● Revised: August 11, 2015
ment (ALL) and intervertebral disc presented intact, and only
● Accepted: August 13, 2015
Corresponding Author: Sang Woo Kim, MD, PhD a posterior column injury was observed. She underwent poste-
Department of Neurosurgery, Yeungnam University College of Medicine, rior fusion on C5-6 with a lateral mass screw system and inter-
170, Hyeonchung-ro, Nam-gu, Daegu 42415, Korea
spinous wiring (Fig. 1E and F).
Tel: +82-53-620-3790, Fax: +82-53-620-3770
E-mail: [email protected] The second case was a 46-year-old man who was transferred
∝This is an Open Access article distributed under the terms of the Creative
◯ to our outpatient department under the impression of sublu-
Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution,
xation of the facet joint on C5-6 after a motor vehicle acci-
and reproduction in any medium, provided the original work is properly cited. dent. He had been admitted 7 weeks previously to another

146 Copyright © 2015 The Korean Spinal Neurosurgery Society

 Delayed or Missed Traumatic Cervical Instability

Table 1. Clinical features of all patients

Patients Level of The interval between Initial Initial Frankel’s grade Neck motion range Other bony abnormality
* Operation
(Age/Sex) subluxation diagnosis and initial injury SLIC Score (postop.) on dynamic views on static view
1 (57/F) C5-6 9 weeks 1 E (E) 45.4 C5 Spinous process Posterior
(Intermediate fracture
DLC† injury)
2 (46/M) C5-6 7 weeks 1 E (E) 12.6 Non Anterior
(Intermediate
DLC injury)
3 (61/M) C4-5 3 days 2 E (E) 15.6 Kyphosis /widening of Posterior
(disrupted interspinous space on
DLC injury) C4-5
4 (56/F) C4-5 3 days 1 E (E) 10.4 Straightening Posterior
(Intermediate
DLC injury)
*
SLIC: Subaxial cervical injury classification system, †DLC: Disco-ligamentous complex

Fig. 1. One of our patients (1st) showing cervical instability. CT th

Fig. 2. The other patient (4 ) showing cervical instability. CT scan
scan (A) and T2 fat suppression sagittal MR image (B) at the time (A) at the time of initial injury present suspicious mild kyphosis
of initial injury present a C5 spinous process fracture and high on C4-5. Dynamic flexion and extension views (B, C) on 3 days
signal intensity around fracture site which suggest suspicious pos- later following the injury show subluxation on C4-5. Although
terior ligament complex injury. Dynamic flexion and extension views an inadequate dynamic study with decreased amount of motion
(C, D) on 9 weeks later following the injury show subluxation on range (10.4 degree) caused by neck pain and muscle spasm, cer-
C5-6. The patient was underwent posterior fusion on C5-6 with late- vical instability could be assessed. There was high signal intensity
ral mass screw system and inter-spinous wiring (E, F). at C4-5 posterior structure on T2 fat suppression sagittal MR
image (D), which suggests posterior ligament complex injury. The
patient was underwent posterior fusion on C4-5 with lateral mass
medical center with neck pain caused by the accident, and had
screw system and inter-spinous wiring (E, F).
been diagnosed with cervical sprain under CT scan, MR ima-
ging, and cervical X-ray including antero-posterior and lateral MRI. He initially underwent anterior cervical discectomy and
views. No definite acute fracture line or other deformity was fusion with plate on C5-6, and additional posterior fusion was
visible, but only subtle high signal intensity was present at the considered if sustained instability was observed during the
posterior ligament complex including inter- and supraspinous follow-up period. Fortunately, no further instability was pre-
ligaments on T2 fat suppression sagittal MR imaging. Howe- sent by the 26-month.
ver, his neck pain persisted, and follow-up CT scan and dyna- The third and fourth cases were a 61-year-old man and
mic flexion and extension radiographies presented a subluxa- his 56-year-old wife, who visited our emergency room with
tion on C5-6. The injury of ALL was also noted on follow-up mild neck pain. The couple experienced the same car accident,

Korean J Spine 12(3) September 2015 147

Yeo CG et al.

and they received the similar radiological findings of a mild tant reason for developing delayed or missed diagnosis of cer-
focal kyphosis on C4-5 and straightening of cervical spine vical instability was an incomplete set of radiographies, and
under routine X-ray and CT scan (Fig. 2A) without dynamic MR imaging did not act as a crucial diagnostic modality. The
flexion and extension radiographies. There were no acute frac- application of dynamic flexion and extension radiographies
ture lines related to the patients’ symptoms. They had under- can be a helpful diagnostic tool to rule out instability.
gone a conservative treatment with cervical collar and without Dynamic flexion and extension radiographies are often recom-
performing MR imaging. The patients complained of persistent mended for patients complaining of neck pain or tenderness
neck pain, and the symptom was exacerbated under the con- after an acceleration-deceleration mechanism injury, especially
dition of weight-bearing posture such as sitting or standing. for patients presenting persistent symptoms in the absence of
Dynamic flexion and extension radiographies (Fig. 2B and C) abnormal findings on standard 3-view radiographies including
were performed 3 days after the accident; they showed sub- antero-posterior, lateral, and open mouth views7). Previous
luxation of the facet joint on C4-5 on both patients. There report has shown three main reasons for delayed or missed
6)
were suspicious posterior ligament complex injuries including diagnosis of cervical spine injuries . Misinterpretation, inade-
inter- and supra-spinous ligaments and ligamentum flavum on quate radiological study with a limitation of neck motion, and
T2 fat suppression sagittal MR imaging (Fig. 2D). ALL and incomplete set of radiographies were indicated. Among these
intervertebral disc presented as intact in both patients, and reasons, incomplete set of radiographies was regarded as the
posterior column injury was regarded as the main lesion. Both main cause for the incorrect diagnosis of cervical instability like
patients underwent posterior fusion on C4-5 with a lateral our cases. The performance of dynamic flexion and extension
mass screw system and inter-spinous wiring (Fig. 2E and F). radiographies is recommended, in addition to standard 3-view
radiographies and CT scan in conscious patients after exclu-
ding unstable bony injuries. Several studies have also found
DISCUSSION those dynamic radiographies to be a safe and effective method
for detecting disco-ligamentous injuries under the condition
9,12)
of intact bony structures on previous static radiographies .
The patients with cervical spine injury presenting with neck
When there is a high level of uncertainty related to bony or
pain require radiological examination, even if the neurological
ligamentous injury in the static radiographies, dynamic flexion
examination shows normal condition2). In a disco-ligamentous
and extension radiographies should be avoided until the extent
injury, 30% of patients with ligamentous disruption displayed 6)
of the lesion is determined by CT scan or MR imaging .
a negative result on static radiographies and CT scan, and
When adequate flexion and extension motions are possible,
it was identified by subsequent MR imaging10). However, MR
dynamic flexion and extension radiographies for the evaluation
imaging as a screening tool has not been definitively shown
of cervical instability are associated with a very low false-nega-
to be cost-effective in initial evaluation, and the indications 2,4)
tive rate . Some authors have recommended the average
are also less clear for detecting instability10). The majority of range of motion in patients judged to have adequate motion
patients with posterior ligament complex injury that has been 12)
was 40.6 degrees (range, 23-58 degrees) . However, because
noted on MR imaging do not require surgical stabilization10). 30% of cervical trauma patients have a limitation to flex and
It is an important point that MR imaging findings cannot be extend due to acute neck pain following an accident, the inci-
an absolute factor to identify cervical instability. In addition, dence of positive results of dynamic flexion and extension
the healing of once-injured posterior ligament complex is usually radiographies in emergency rooms is very low (0.34%)
2,4,12)
.
less predictable in adult patients than that of bone healing, and These patients may have an increased risk of disco-ligamentous
progressive instability and deformity are possible11). Assessment 2,4)
injury, and further imaging tools might be suggested . Fortu-
of the integrity of the disco-ligament complex is a critical and nately, in our cases, cervical instability could be detected under
independent component of surgical decision- making. insufficient motion range (range, 10.4-45.4 degrees) and even
In this study, all patients presented a flexion-distraction in the early period following the accident. Nevertheless, the
injury with bilateral facet subluxation. There were varying deg- examination is preferred to be performed under surveillance
rees of disco-ligamentous complex injuries, ranging from only to avoid neurologic problems when the improvement of neck
posterior ligamentous structures to additional posterior annulus pain and sufficient neck motion are obtained.
of disc, which have a higher risk of instability leading to tran-
slation and dislocation and require surgical treatment. These
lesions could not be identified with static radiological studies CONCLUSION
until dynamic flexion and extension radiographies were app-
lied. From these cases, we can expect that the most impor- Dynamic flexion and extension radiographies are required

148 www.e-kjs.org
 Delayed or Missed Traumatic Cervical Instability

to exclude the possibility of cervical instability in the patient victims: how many X-rays are enough? J Trauma 30:392-397,
with cervical trauma in initial or follow-up studies. However, 1990
6. Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler
the examination should be performed carefully to avoid neuro-
C: Delayed or missed diagnosis of cervical spine injuries. J
logic deterioration. Trauma 61:150-155, 2006
7. Pollack CV Jr., Hendey GW, Martin DR, Hoffman JR, Mower
WR: Use of flexion-extension radiographs of the cervical spine
REFERENCES in blunt trauma. Ann Emerg Med 38:8-11, 2001
8. Reid DC, Henderson R, Saboe L, Miller JD: Etiology and clinical
1. Alker GJ, Oh YS, Leslie EV, Lehotay J, Panaro VA, Eschner course of missed spine fractures. J Trauma 27:980-986, 1987
EG: Postmortem radiology of head neck injuries in fatal traffic 9. Sees DW, Rodriguez Cruz LR, Flaherty SF, Ciceri DP: The use
accidents. Radiology 114:611-617, 1975 of bedside fluoroscopy to evaluate the cervical spine in obtunded
2. Gelalis ID, Christoforou G, Arnaoutoglou CM, Politis AN, trauma patients. J Trauma 45:768-771, 1998
Manoudis G, Xenakis TA: Misdiagnosed bilateral C5-C6 disloca- 10. Shah VM, Marco RA: Delayed presentation of cervical ligamen-
tion causing cervical spine instability: a case report. Cases J 2: tous instability without radiologic evidence. Spine (Phila Pa 1976)
6149, 2009 32:E168-174, 2007
3. Gerrelts BD, Petersen EU, Mabry J, Petersen SR: Delayed diag- 11. Vaccaro AR, Hulbert RJ, Patel AA, Fisher C, Dvorak M, Lehman
nosis of cervical spine injuries. J Trauma 31:1622-1626, 1991 RA Jr., et al: The subaxial cervical spine injury classification sys-
4. Insko EK, Gracias VH, Gupta R, Goettler CE, Gaieski DF, tem: a novel approach to recognize the importance of morpho-
Dalinka MK: Utility of flexion and extension radiographs of logy, neurology, and integrity of the disco-ligamentous com-
the cervical spine in the acute evaluation of blunt trauma. J plex. Spine (Phila Pa 1976) 32:2365-2374, 2007
Trauma 53:426-429, 2002 12. Wang JC, Hatch JD, Sandhu HS, Delamarter RB: Cervical fle-
5. MacDonald RL, Schwartz ML, Mirich D, Sharkey PW, Nelson xion and extension radiographs in acutely injured patients. Clin
WR: Diagnosis of cervical spine injury in motor vehicle crash Orthop Relat Res:111-116, 1999

Korean J Spine 12(3) September 2015 149