Spokane Journal of Business

Guidelines could reduce unnecessary CT scans

Some cervical spine injuries could have been ruled out without imaging, study says

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A study conducted at Detroit's Henry Ford Hospital has found that better use of commonly accepted diagnostic guidelines for detecting cervical spine injuries could reduce unnecessary computed tomography scans and spare patients from radiation exposure.

The study showed that a significant number of CT scans could have been avoided if physicians adhered to the National Emergency X-Radiology Study criteria, which aid emergency department physicians with determining whether C-spine injuries exist.

In the study's first phase, 24 percent of more than 1,500 CT scans were found to be potentially unnecessarily, and in the second phase, 16 percent of more than 500 scans were determined by researchers to have been possibly unneeded.

"While imaging testing is an important aspect of patient care, we have to make sure that these tests are ordered appropriately," says Dr. Brent Griffith, chief resident of radiology at Henry Ford and the study's lead author.

An estimated 1 million people are treated for a potential C-spine injury from blunt trauma in emergency departments every year, with falls and motor vehicle accidents being the most common causes. Because a delay or failure to diagnose C-spine injuries can lead to permanent paralysis, physicians often have a low threshold for ordering imaging tests.

In 2000, the NEXUS criteria established low-risk guidelines to identify patients with a low probability of cervical spine injury that didn't need an imaging test. To be cleared of a C-spine injury, a patient must have the following: no tenderness at the middle of the neckline, no evidence of intoxication, a normal level of alertness, no evidence of focal neurologic deficit (numbness or weakness), and no other painful distracting injury.

The NEXUS criteria, coupled with the Canadian C-Spine Rule, a highly sensitive clinical decision rule for detecting C-spine injury, comprise the American College of Radiology Appropriateness Criteria for imaging a suspected C-spine injury.

Despite these preliminary screening tools, prior research has shown that patients continue to receive imaging tests without meeting the criteria. Researchers sought to evaluate whether adherence to the NEXUS criteria could decrease the number of imaging tests ordered.

In the study's Phase 1, researchers evaluated 1,524 imaging tests that were negative for an acute c-spine injury. Of those tests, 24 percent showed no documentation of the NEXUS criteria being applied.

In the study's Phase 2, researchers enrolled patients who showed up at an emergency department between March and November 2011 and for whom a CT scan was ordered for detecting a C-spine injury. For each CT scan ordered, the requesting clinician was instructed to complete a survey about the type of injury, reason for ordering the scan, and clinical suspicion of injury. The CT scans were evaluated by a board-certified radiologist blinded to the survey data to determine the presence or absence ofC-spine injury.

Researchers theorize the heightened awareness of the survey was a factor in the reduction of CT scans in Phase 2.

For the study's Phase 3, researchers established an education program to instruct physicians about the NEXUS criteria for ordering imaging tests for C-spine injuries.

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