The Use of Flexion and Extension MR in the Evaluation
of Cervical Spine Trauma: Initial Experience in 100
Trauma Patients Compared with 100 Normal Subjects

This section is compiled by Frank M. Painter, D.C.
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FROM:   Emerg Radiol 2002 (Nov); 9 (5): 249—253

Giuliano V, Giuliano C, Pinto F, Scaglione M

Vincon MRI Center,
5732 Canton Cove,
Winter Springs, FL 32708, USA.

The purpose of this study was to determine the value of flexion and extension MR in traumatized cervical spines following rear low-impact acceleration-deceleration injury. The cervical spines of 100 consecutive uninjured normal asymptomatic adults and 100 adult accident victims following rear low-impact motor vehicle accidents were evaluated using rapid T2-weighted MRI. Subjects were matched for age but not gender. The age range was 18 to 53 years, with a mean of 35 years. Injured subjects were evaluated during the subacute period, at 12 to 14 weeks after injury, following clinically resolved muscle spasm. Imaging findings were compared between normal and injured subjects. The normal subjects showed a stepwise segmental motion pattern that started at C1-C2 and transmitted to the lower cervical segments. Loss of normal cervical lordosis (hypolordosis) was observed in 4% (4 of 100) patients. Normal range of motion (rounded to the nearest 5 masculine ) was quantified as 50 masculine flexion (range, 45-65 masculine; standard deviation, 6.5 masculine ) and 60 masculine extension (range, 50-70 masculine; standard deviation, 6.5 masculine ). Asymptomatic disk herniations were observed in 2% (2 of 100) patients. In the subacute post-traumatic subjects, there was a loss of the normal segmental motion pattern, with hypolordosis in 98% (98 of 100) patients. Range of motion (rounded to the nearest 5 masculine ) was restricted, quantified as 25 masculine flexion (range, 5-40 masculine; standard deviation, 15 masculine ) and 35 masculine extension (range, 20-50 masculine; standard deviation, 10 masculine ). Disk herniations were observed in 28% (28 of 100) patients. Biomechanical changes in the herniated disk were noted, with mildly increased spinal stenosis following flexion. The authors conclude that flexion and extension MR can be a valuable adjunct examination in the evaluation of patients in the clinical setting of subacute cervical spine trauma.

Key Points about this article from Dan Murphy, D.C.

Thanks to the American Chiropractor for permission to reproduce this information!

1. Subacute whiplash patients have about half the range of motion when compared to normal control subjects.

2. In this study, the normal control subjects showed that 4 percent had hypolordosis and 2 percent had disk herniations.

3. In this study, the whiplash injured patients showed that 98 percent had hypolordosis and 28 percent had disk herniations.

4. These authors note that plain film lateral flexion and extension views to evaluate soft tissue and diskoli-gamentous injuries are poor, that videofluoroscopy is better, and that flexion and extension magnetic resonance imaging (MRI) is best. In this study, the flexion/extension MRI’s showed much pathology that was not seen with plain radiographs.

5. Flexion/extension MRI shows the "pattern of segmental motion."

6. The "pattern of segmental motion" is normal in non-traumatic hypolordosis and non-traumatic disk herniation, but abnormal in post-traumatic hypo-lordosis.

7. In this study, 12–14 weeks after injury, the whiplash patients complained of neck pain, headache, arm pain and arm numbness. This is more evidence that not all patients recover in a period of 6-8 weeks.

8. Flexion and extension MRI optimizes the functional significance of disk herniations in symptomatic patients, offering a distinct advantage to conventional MRI examinations performed in the neutral position.

9. These authors recommend flexion and extension MRI’s in the clinical setting of subacute cervical spine trauma (more than 12 weeks following injury). The clinical indication includes persistent neurologic deficit and clinical evidence of instability despite normal radiographs.

10.[Recent studies are showing that weight-bearing flexion/extension MRI’s show more soft tissue pathology. Life Chiropractic College West now has an upright weight-bearing MRI unit: (510) 780-4500.]

A 1978 graduate of Western States Chiropractic College, Dr. Dan Murphy is on the faculty of Life Chiropractic College West, and is the Vice President of the International Chiropractic Association. For more information, visit

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