OBJECTIVE: This report reviews the case of a missed cervical spine fracture in a patient presenting for chiropractic manipulative therapy. A review of the literature suggests that radiographic examinations performed in emergency care settings following cervical spine trauma are often incomplete for the purposes of screening for contraindications to manipulative therapy. Sensitivity of the standard radiographic cervical spine series for detecting fracture suggest an unacceptable high level of false negatives and chiropractors are cautioned to requisition and review all X-rays and ensure a complete radiographic series before initiating treatment.

CLINICAL FEATURES: A 65-yr-old woman presented to a chiropractic office for examination and treatment of cervical spine injuries suffered in a deceleration type motor vehicle accident. Hospital X-rays were reported normal for fracture. Subsequent radiographs of the cervical spine demonstrated the presence of a posterior arch fracture of C2.

INTERVENTION AND OUTCOME: The patient was referred for further imaging and was treated conservatively with bracing of the cervical spine. Follow-up 5 months later demonstrated substantial recovery with some residual stiffness and headache.

CONCLUSION: Radiographs taken at emergency care settings are often incomplete for the purposes of screening for contraindications to manipulation. This case demonstrates that chiropractors should be extremely cautious in initiating manipulative therapy in those patients having sustained previous cervical spine trauma and who have had prior X-rays that have been reported normal.

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