Eur J Trauma Emerg Surg
DOI 10.1007/s00068-013-0302-6
ORIGINAL ARTICLE
Are soft tissue measurements on lateral cervical spine X-rays
reliable in the assessment of traumatic injuries?
M. S. Patel • S. Grannum • A. Tariq •
A. Qureshi • A. Watts • O. Gabbar
Received: 30 December 2012 / Accepted: 19 May 2013
Ó Springer-Verlag Berlin Heidelberg 2013
Abstract
Introduction Traumatic neck pain is a common presen-
tation to the emergency department. Lateral plain radio-
graphs remain the primary investigation in the assessment
of these injuries. Soft tissue assessment forms an integral
component of these radiographs. They can provide infor-
mation on subtle injuries that may not be obvious. Many
methods are used to assess the prevertebral soft tissue
shadows. The two more commonly used techniques include
the ‘seven at two and two at seven’ rule (method 1) and the
ratio of the soft tissues with respect to the vertebral width
(method 2).
Aim To assess which of the above two methods in
assessing cervical spine soft tissue shadows on lateral
radiographs is more sensitive in the presence of cervical
spine injuries.
Methods A retrospective analysis of consecutive trau-
matic cervical spine films performed within a busy trauma
tertiary centre over a period of 7 months. Patients were
divided into two groups: group 1—fractures; group 2—no
fractures. The prevertebral soft tissue shadows were mea-
sured at referenced points on the lateral cervical spine films
with respect to the above two methods and comparisons
between the groups were made.
Results Thirty-nine patients in group 1 were compared to
a control group of 60 patients in group 2. Both methods
failed to identify any significant differences between the
two groups. The sensitivity and specificity for method 1
M. S. Patel (&)
S. Grannum
A. Tariq
A. Qureshi

A. Watts
O. Gabbar
Trauma and Orthopaedic Department, Leicester General
Hospital, University Hospitals of Leicester NHS Trust,
Gwendolen Road, Leicester LE5 4PW, UK
e-mail: Shaqs@doctors.org.uk
was 7.6 and 93 %, and for method 2, they were 7.6 and
98 %, respectively.
Conclusion There is no significant difference between the
soft tissue shadows when comparing patients with and
without cervical spine fractures on lateral radiographs.
Both commonly used measures of soft tissue shadows in
clinical practice are insensitive in identifying patients with
significant osseous injuries. They, therefore, do not offer
any further value in interpreting traumatic cervical spine
radiographs. The management of patients with cervical
spine trauma in the absence of obvious osseous injury on
standard radiographs should warrant a computed tomog-
raphy (CT) scan if clinically indicated.
Keywords Cervical spine injuries
Cervical spine
fractures
Soft tissue measurements
Lateral cervical spine
radiographs
Introduction
Traumatic neck pain is a common presentation to the
emergency department, and one in which failure to ade-
quately diagnose holds significant implications, both with
regards to patient well being as well as professional
embarrassment and litigation. Due to the unforgiving nat-
ure of serious cervical spine injuries, many doctors find
interpreting these films occasionally difficult and often
request further expert opinions or more detailed imaging.
With the increasing availability of computed tomography
(CT) imaging, many such injuries are explored further,
resulting in fewer missed cervical spine injuries. Some
experts suggest there to be no room for simple cervical
spine radiographs and be replaced with CT as the first-line
investigation in assessing patients with blunt cervical spine
123

trauma [1]. However, simple radiographs of the cervical
spine remain the primary investigation and provide detailed
information, if interpreted correctly.
Cervical spine radiographs involve a lateral, anteropos-
terior (AP) and open-mouth odontoid peg views. The lat-
eral films demonstrate the prevertebral soft tissue shadows.
These are separated into the retropharyngeal shadow
proximal to the level of C5 and the retrotracheal shadow
distal to this level. The interpretation of this soft tissue
shadow is important in interpreting lateral cervical spine
radiographs, particularly in the absence of any obvious
bony injury. An increase of this shadow implies the pres-
ence of oedema or haematoma secondary to cervical spine
injury, either bony or soft tissue which may need to be
assessed further.
Variation in the size of the soft tissue shadows has been
demonstrated in previous studies highlighting the normal
ranges [2–4]. However, this complex analysis remains
academic. For the junior emergency doctor faced with a
daunting cervical spine X-ray in a busy department, two
simple methods exist when interpreting the prevertebral
soft tissue shadow, particularly in the absence of any
obvious bony injury. The first being the ‘seven at two and
two at seven’ rule [5] and the second being the ratio of the
soft tissue size to the vertebral width: one third of the size
of the vertebrae above C4 and the full size of a vertebra
below this level [2, 6–8].
Although many published works exist on the size of the
prevertebral shadow, to date, there have not been any pub-
lications comparing the efficacy of the above two methods
with respect to detecting enlargement of the prevertebral soft
tissue shadow in the presence of an osseous spinal injury.
With the advent of computerised radiograph archive sys-
tems, such measurements can be readily made using the in-
built software, with the accepted limitation that magnifica-
tion may differ between any two films. The ‘seven at two and
two at seven’ rule was originally put forward by the authors
as encompassing any negligible differences which may arise
from subtle alterations in magnification that may arise
between radiographs. The method assessing the ratio of soft
tissue shadows to vertebral width eliminates variation due to
magnification artefacts which may be present.
The purpose of this study was to assess whether the use
of soft tissue shadows on lateral cervical spine plain films
are reliable in identifying patients with cervical spine
injuries using the two methods discussed and, if so, which
is the more sensitive.
Methodology
A retrospective radiological analysis of consecutive cervical
spine films was performed within a busy trauma tertiary
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M. S. Patel et al.
Fig. 1 Method of measurement
as described by Penning [4].
Measurements are made along
the lines perpendicular to the air
shadow of the pharynx and
trachea
centre between February and August 2009. Data relating to
patient details for cervical spine X-rays were obtained
through the radiology information technology department.
Two groups of cervical spine radiographs were identified;
group 1 consisting of patients with cervical spine fractures
and group 2 consisting of patients without any radiological
evidence of injury. Both groups of patients presented fol-
lowing acute blunt traumatic injuries, with patients in group
2 being cleared by senior clinicians experienced in the
identification and management of cervical spine trauma.
This involved the use of the Canadian C-spine rule in addi-
tion to lateral cervical spine radiographs performed as part of
the Advanced Trauma Life Support (ATLS) protocol. This
group was, therefore, used as a standard for comparison.
Both groups had imaging as a result of suspected blunt
traumatic injury. All X-rays were performed as per the
ATLS protocol for suspected cervical spine trauma with
triple immobilisation, thereby, minimising any positional
effects on the prevertebral soft tissue shadows.
All patients were X-rayed in the radiology department
using the digital GE Healthcare Definium 8000 equipment
with AP and lateral cervical spine films using a standard
protocol, with a distance of 180 cm between the tube and
detector, with patients supine and placed midway.
These images were reviewed by two independent
orthopaedic trainees. The prevertebral soft tissue shadows
were then measured using established methods described
below. The ‘seven at two and two at seven’ rule was uti-
lised with the technique as described by Penning [4]
(Fig. 1). This involved a measurement from the anterior–
inferior aspect of the body of the second and seventh cer-
vical vertebrae to the posterior aspect of the air shadow of
the pharynx and trachea, respectively. In the presence of
bony spurs, measurements were made from the anterior
aspect of the vertebral body just superior to this and
recorded.
Are soft tissue measurements on lateral cervical spine X-rays reliable?

The second rule was also similarly assessed. Firstly, the

vertebral width of C3 and C6 at the inferior margin was
measured. Secondly, the distance from the anterior–inferior
margin of these vertebrae to the posterior aspect of the
pharyngeal or tracheal air shadow was again measured. The
soft tissue shadow at C3 was referenced to a third of the C3
vertebral width and that of C6 to the size of the full ver-
tebral width.
The measurements for ten patients were repeated by
both investigators to calculate the inter- and intra-observer
reliability.
All patients who had traumatic cervical spine radio-
graphs were included. Exclusion criteria involved: poor Fig. 2 Mechanism of injuries of patients in groups 1 and 2
quality lateral radiographs; missing medical notes; age
\16 years; patients who were intubated or had a naso-
gastric tube in place; patients in whom X-rays were per-
formed 24 h after injury; and patients who had penetrating
trauma or attempted hanging. Case notes were reviewed to
ensure that all patients were eligible to participate and that
patients without any evidence of injury were adequately
cleared.
Statistical analysis was performed using SPSS version
16. The Mann–Whitney U- and Fisher’s exact t-tests were
used to compare the prevertebral soft tissue width between
the groups. The sensitivities and specificities were calcu-
lated. The interclass correlation coefficient value was cal- Fig. 3 Frequency of vertebral fractures in group 1
culated with the ten repeat measurements to assess the
inter- and intra-observer reliability of measurements.
5.6–26.7) in group 2 (P = 0.7). Patients with cervical spine
fractures did not have any significant differences in the
Results prevertebral soft tissue shadows when compared to patients
without any fractures (Fig. 4).
Thirty-nine patients with cervical spine fractures (group 1), Eight of the 39 patients (20.5 %) in group 1 and 17 of
consisting of 21 males and 18 females with an average age the 60 patients (28 %) in group 2 had prevertebral soft
of 61 years, were compared to a separate control group of tissue shadows greater than 7 mm at the C2 vertebra
60 patients (35 males and 25 females) without any evi- (P = 0.480, Fisher’s exact test). Ten patients in group 1
dence of cervical spine injuries (group 2) of average age (25.6 %) had a prevertebral soft tissue size greater than
44 years. 2 cm at C7, with ten patients in group 2 (16.7 %) having
The majority of the injuries of patients in group 1 were similar sizes (P = 0.313, Fisher’s exact test). Only three
as a result of falls, with road traffic accidents being patients in group 1 and four patients in group 2 satisfied the
responsible for the majority of patients in group 2 (Fig. 2). ‘seven at two and two at seven’ rule. The sensitivity and
The frequency of fractures at the different cervical levels is specificity of this rule is 7.6 and 93 %, respectively
shown in Fig. 2. Thirteen patients had fractures at multiple (Table 1).
levels, with the most frequent fractured cervical vertebra
level being C6 (Fig. 3). Vertebral width

‘Seven at two and two at seven’ rule
The average soft tissue shadow at the level of the C2
vertebra was 5.8 mm (range 2.3–14.3) in group 1 and
6.5 mm (range 2.5–19.4) in group 2 (P = 0.095). At the
level of C7, the mean size of the soft tissue shadow was
16.4 mm (range 5.8–25) in group 1 and 14.9 mm (range
The second rule to be studied was the ratio of the prever-
tebral soft tissue to the vertebral width. C3 and C6 verte-
brae were used for this analysis. The mean width of the C3
vertebra was 19.9 mm (range 15.9–23.9) and 19.6 mm
(range 12.9–27.2) in groups 1 and 2, respectively
(P [ 0.05). The mean width of the C6 vertebra was 21.9
mm in both groups 1 (range 10.8–28.7) and 2 (range

123

Fig. 4 Difference between groups in the prevertebral soft tissue
measurements at C2 and C7
15–32.8) (P [ 0.05). There was, therefore, no significant
difference between the standards of measurements.
The average size of the soft tissue in group 1 was
6.7 mm (range 1.9–18.3) and 16.1 mm (range 6.3–24.6) at
the levels of C3 and C6, respectively (Fig. 5). Of the
patients in group 2, these measurements were 7.8 mm
(range 3.2–14.7) (P \ 0.05) and 15.1 mm (range 7–22.6)
(P [ 0.05), respectively (Table 2). The soft tissue width in
patients without a fracture was significantly greater than in
those patients with a fracture at the C3 vertebral level.
Patients in group 2 without any clinical or radiological
evidence of cervical spine fractures had significantly
greater prevertebral soft tissue shadows at the level of the
C3 vertebra in relation to a third of the vertebral width
when compared to patients with fractures (72 vs. 41 %,
respectively, P = 0.003). There was no significant differ-
ence at the C6 vertebral level when assessing the size of the
soft tissue shadow in relation to the full vertebral width
(13 vs. 3 % for groups 1 and 2, respectively; P = 0.109).
In total, only three patients (7.7 %) in group 1 had soft
tissue shadows of greater than a third of the C3 vertebral
width and full length of the C6 vertebral width as compared
to 1 (1.7 %) patient in group 2 (P = 0.297). The sensitivity
and specificity of this method were 7.6 and 98 %,
respectively.
Inter- and intra-observer reliability
Ten patients were selected and the measurements repeated.
The continuous measurements were then subjected to
Table 1 Differences in soft tissue shadows between groups 1 and 2
using the ‘seven at two and two at seven’ rule
Vertebral level Group 1 Group 2 P-value
C2 (mm) 5.8 6.5 0.095
C7 (mm) 16.4 14.9 0.7
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M. S. Patel et al.
interclass correlation coefficients to calculate the inter- and
intra-observer reliability.
The inter-observer interclass correlation was 0.973, with
the intra-observer interclass correlation being 0.993. Both
of these results, therefore, demonstrate excellent repro-
ducibility of measurement when repeated and when com-
pared between the two investigators.
Discussion
Injury to the cervical spine is often associated with a
pre- or paravertebral soft tissue swelling, which can be
demonstrated and assessed radiographically. Widening of
the prevertebral soft tissue space is, therefore, described
as one of the diagnostic signs of cervical spine injury
[9].
The first publication on the use of prevertebral soft tis-
sue measurements as a marker of cervical spine pathology
dates back to 1939 [10]. Since then, there have been var-
ious authors who have commented on the validity of such
measurements. Some conclude these measurements to be
effective in identifying cervical spine pathology [11],
whilst others conclude the opposite [12]. The majority of
these publications assess soft tissue measurements at spe-
cific levels [13–17], with only one assessing measurements
at every level [4]. Despite this, routine measurements of the
prevertebral soft tissue are used as a simple method that
may provide an important clue to subtle cervical spine
injury [18].
The methods commonly used are (1) the ‘seven at two
and two at seven’ rule [5] and (2) the ratio of the soft
tissues to the vertebral width [2, 6–8]. Although many
other measurement techniques exist, these two simple
methods can be used by junior doctors, who may find
interpreting these films challenging. Values greater than the
reference ranges in the absence of obvious bony injury
should typically warrant expert opinions, with more
detailed imaging techniques.
The results from this study suggest that prevertebral soft
tissue measurements using the common methods of
assessment to be a very poor indicator in patients with an
osseous cervical spine injury. They show very poor sensi-
tivity, although they exhibit high specificity. Despite hav-
ing fractures, very few patients exceeded prevertebral soft
tissue thresholds. Patients with subtle cervical spine inju-
ries would, therefore, be at risk if soft tissue measurements
are to be used as an indicator of such pathology. These
findings have been echoed by other authors [12], who have
also shown poor sensitivity with relatively good specificity.
Dai [11] however, in his review of 107 patients, concluded
that the diagnostic value of prevertebral soft tissue swelling
is significant.
Are soft tissue measurements on lateral cervical spine X-rays reliable?
Fig. 5 Mean vertebral and
prevertebral widths at C3 and
C6 (C3 = a third of the
vertebral width)
Table 2 Prevertebral width as a ratio of C3 and C6 vertebra
Vertebral level Group 1 Group 2 P-value
C3 (mm) 6.7 7.8 \0.05
C6 (mm) 16.1 15.1 [0.05
One of the aims of this project was to identify which
method of assessment of the prevertebral soft tissues was
superior and more sensitive. We conclude that both
methods of measurement have very low sensitivity and are
unreliable. With rapid access to more detailed imaging
modalities, any clinical suspicion of a cervical spine injury
in the absence of X-ray findings should prompt early CT
imaging.
Limitations of this study include, firstly, the small
number of patients within the fracture group, with the
larger number of patients in group 2. This may result in a
type 1 error and underestimate the sensitivity whilst over-
estimating the specificity within this sample. Secondly, the
relatively small number of patients did not allow for a
correlation analysis of the level of vertebral injury and the
prevertebral soft tissue measurements. However, Dai [11],
in his study, identified there to be no correlation between
soft tissue swelling and the level of cervical spine injury.
Thirdly, all patients presented following blunt trauma with
cervical spine immobilisation as per ATLS guidelines.
Cervical spine injury in patients in group 2 were excluded
through clinical assessment as per the Canadian C-spine
rule and further augmented with cervical spine X-rays as
per ATLS guidelines. All patients in this group were alert
and stable. The Canadian C-spine rule has a sensitivity of
92 % and a specificity of 54 % [19]. Although there may
be a chance that some patients with clinically significant
injuries could have been missed, we feel that the addition
of X-ray imaging would further reduce such an incidence.
Fourthly, patients in group 1 had an average age of 61
years compared to group 2, where the average age was 44
years. Due to the increased prevalence of spondylotic
changes in the ageing spine, the measurements may have
been hindered by the presence of osteophytes and the loss
of the cervical lordosis. However, with the presence of
osteophytes, the measurements were made from the ante-
rior aspect of the vertebral body just superior to these.
Conclusion
Soft tissue measurements of the cervical spine have very
poor sensitivity and high specificity. They should not be
used as an aid for the exclusion of subtle osseous cervical
spine injuries. Further imaging should be obtained in cases
where cervical spine injury is suspected, irrespective of the
prevertebral soft tissue size on lateral radiographs.
Conflict of interest There is no conflict of interest for this paper.
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