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Erect Radiographs to Assess Clinical Instability in Patients with Blunt Cervical Spine Trauma
Simon Humphry, MRCS1; Andrew Clarke, FRCS (Orth)1; Michael Hutton, FRCS (Orth)1; Daniel Chan, FRCS (Orth)1
1 Peninsula Spine Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, United Kingdom. E-mail address for S. Humphry: simon.humphry@gmail.com
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Investigation performed at the Peninsula Spine Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, United Kingdom

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Dec 05;94(23):e174 1-4. doi: 10.2106/JBJS.K.01502
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Computed tomography (CT) and magnetic resonance imaging (MRI) are sensitive modalities for the assessment of the spine, but certain injuries remain poorly assessed with supine radiographs. We describe four cases in which cervical spine injuries were proven as unstable with erect radiographs after being previously evaluated with supine radiographs and CT scans.


A retrospective review of medical records and images was used to identify four patients who presented to a teaching hospital from April to December 2010 with unstable cervical spine injuries that were only demonstrated on erect radiographs.


All four patients sustained either C4-C5 or C5-C6 injuries. Prior to diagnosis, each had been evaluated with supine radiographs that did not demonstrate instability. Computed tomography identified the osseous injuries that were present but did not provide suitable assessment of stability. Three patients successfully underwent anterior cervical discectomy and fusion. The fourth was managed with a Halo jacket because of major comorbidities.


Despite major advances in imaging, these cases highlight the importance of physiological loading and radiographs. The controlled use of erect radiographs to test for clinical instability in patients with cervical spine injuries should be considered except in cases in which instability is already evident on other imaging modalities and/or surgical treatment is already indicated.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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