From the Guidelines
For cervical X-rays after a horse fall, a minimum of three views is recommended: anteroposterior (AP), lateral, and open-mouth odontoid views. These three views are essential to adequately evaluate the cervical spine for potential fractures, dislocations, or alignment issues that may occur during high-energy trauma like a fall from a horse. The most recent and highest quality study, 1, supports this recommendation, emphasizing that radiographs of the cervical spine should consist of, at minimum, three views: anteroposterior, lateral, and open-mouth odontoid views.
Key Points to Consider
- The AP view shows the alignment of vertebral bodies and spinous processes.
- The lateral view demonstrates the overall alignment and potential compression fractures.
- The open-mouth odontoid view specifically evaluates the C1-C2 articulation, which is particularly vulnerable in falls.
- These multiple projections are necessary because a single view may miss significant injuries, as some fractures are only visible from certain angles.
- If there is continued clinical suspicion despite negative X-rays, advanced imaging such as CT or MRI may be warranted, as X-rays have limitations in detecting ligamentous injuries and subtle fractures, as noted in 1.
Limitations and Additional Considerations
- While CT is significantly more sensitive than radiographs for identifying cervical spine fractures, as mentioned in 1, the initial assessment with X-rays is still valuable for immediate evaluation and decision-making.
- The addition of flexion-extension views has not been shown to be of clinical usefulness, according to 1.
- MRI is the most sensitive modality for demonstrating isolated ligamentous injury but is not typically used as a screening modality due to its high false positive rate, as discussed in 1.
From the Research
Cervical X-rays after a Horse Fall
- The number of views recommended for cervical X-rays after a horse fall is not explicitly stated in the provided studies.
- However, study 2 mentions that all patients underwent dynamic upright C-spine X-rays, which suggests that at least two views (flexion and extension) are recommended.
- Study 3 discusses the use of flexion/extension radiography in trauma patients, but does not provide a specific recommendation for the number of views.
- Study 4 describes the use of radiographic examination to diagnose cervical fractures in horses, but does not provide information on the number of views recommended for human patients.
Imaging Techniques
- Study 5 discusses the use of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of cervical spine trauma, but does not provide information on the number of views recommended for X-rays.
- Study 6 compares the use of CT and MRI in obtunded patients without high impact trauma, but does not provide information on the number of views recommended for X-rays.
Clinical Relevance
- Study 2 suggests that bony alignment and dynamic upright X-rays remain the gold standard for evaluating ligamentous integrity of the C-spine.
- Study 3 concludes that flexion/extension radiography adds little diagnostic value to the evaluation of blunt trauma patients compared to CT and MRI.
- Study 6 suggests that CT is highly sensitive in detecting unstable injuries in obtunded patients without high impact trauma.