La Radiologia medica
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Missing cervical spine fractures during the initial plain film study may lead to severe neurological complications for patients and to medicolegal responsibilities for the physician. The upper cervical spine tract (C1-C2) is considered to be at high risk for misdiagnoses. We decided to investigate the possible causes of mistake in the cases of missed fractures on the initial plain film, performed in the emergency room. ⋯ Among the causes of false-negative interpretation, osteoporosis, suboptimal film quality due to associated fractures and overlapping bone structures must be considered unavoidable. On the other hand these possibilities should be indicated on the X-ray report because, if painful symptoms persist, a CT exam is strongly advised. Subtle alterations like dens tilting, double cortex sign, lateral subluxation of C1 and prevertebral soft tissue swelling should be regarded as highly suspicious for fracture. Missing these lesions might be considered a true diagnostic mistake with possible legal consequences, which may also expose the patient to the risk of neurological complications. The satisfaction of search phenomenon can be avoided only by trying to use a search pattern for every film, which includes checking all the visible anatomical structures even in the presence of a particularly evident lesion. In all questionable cases or high-risk fracture patients, even with an apparently negative plain film, it is advisable to perform CT instead of additional plain films. Finally, in all the patients treated in the intensive care unit for head trauma, an upper cervical CT scan should be routinely carried out at the same time as the brain scan.