Clinical instability, as described by Panjabi and White, is the “loss of the ability of the spine under physiologic loads to maintain its pattern of displacement so that there is no initial or additional neurological deficit, no other major deformity, and no incapacitating pain.” Cervical spine ‘hypermobility’ is increased segmental motion ostensibly due to a sprain of the cervical ligaments, where the injury does not cause clinical instability but may cause persistent symptoms of neck pain and cervicogenic headache. It is important to note the important distinction between the findings of CCJ ‘clinical instability’ versus ‘hypermobility’, which arguably represent different stages along a stability continuum. Given that injury to the cranio-cervical junction (CCJ) may lead to chronic symptoms following trauma, the role of CCJ injury is gaining greater recognition in non-responders to initial management of common injuries such as concussion and whiplash. There are concerns however, surrounding technical considerations and the reliability of these tools. CT or magnetic resonance imaging (MRI) may demonstrate articular subluxation or directly visualize ligamentous injury. CT used routinely in trauma patients has improved recognition of cervical fractures but ligamentous injuries can still be missed, as they cannot be easily visualized on CT. Given the limited utility of standard radiographs, more extensive radiographic studies are often performed including supine oblique views, flexion-extension radiographs, and computed tomography (CT). Early diagnosis of these injuries is imperative as delayed or missed diagnoses result in increased morbidity and mortality. Correlation with clinical findings is necessary to establish the utility of these measurements in clinical practice.Ĭervical spine injury complicates the care of approximately 4% of patients admitted to trauma centers across the United States. The qualitative and quantitative measurements used in this study demonstrated good to excellent inter-examiner reliability. ICC values for the quantitative measurements of dens-lateral mass spacing and “step off” between the lateral borders of the C2 articular pillars and C1 lateral mass were moderate to excellent (ICC range = .56–.97). Reliability (κ) for qualitative assessments were moderate to substantial for asymmetry of neutral C2 spinous position, dens-lateral mass spacing, and “step off” between the lateral borders of the articular pillars of C2 and C1 lateral mass (κ range = .47–.78). Reliability statistics were calculated for levels of agreement using kappa coefficients (κ) and Intraclass Correlation Coefficients (ICC) for dichotomous and continuous variables, respectively. Measurements included qualitative and quantitative assessments of the amount of asymmetry noted between various osseous landmarks. These images were interpreted by two musculoskeletal radiologists and two clinicians (physiatrist and chiropractor), using a standard set of measurements. MethodsĬervical open-mouth lateral-bending X-ray images were collected from 56 different patients between 18 and 60 years of age patients following cervical spine injury. This study explores the reliability of radiographic measurements of lateral-bending open-mouth cervical radiographs.

Unfortunately there is no established reliability surrounding the use of these measures. Frontal plane hypermobility is typically assessed using lateral bending and open mouth cervical radiographs. Sagittal plane hypermobility of the CCJ is evaluated using saggital view, flexion-extension cervical radiographs. The detection of hypermobility in this region is dependent on clinical examination and static imaging modalities such as x-ray, CT and MRI. Following head and neck trauma, the involvement of the cranio-cervical junction (CCJ) and its contribution to a patients transition to chronic pain, is poorly understood.

Normal lateral cervical spine x ray