A Standardized Protocol for Cervical Spine Evaluation in Children Reduces Imaging Utilization: A Pilot Study of the Pediatric Cervical Spine Clearance Working Group Protocol

Abstract

Background: Cervical spine injuries (CSI) have the potential to cause severe morbidity in children. Multiple imaging studies are used during evaluation of CSIs but come at a cost, both financially and in radiation exposure. To reduce resource utilization and radiation exposure, we implemented the Pediatric Cervical Spine Clearance Working Group (PCSCWG) standardized protocol (SP) for evaluating CSIs in children. Methods: Children below 18 years old presenting with concern for CSI at a level 1 pediatric trauma center were reviewed before (July 2015 to May 2016) and after (November 2017 to June 2018) protocol implementation. Demographics, injuries, and imaging utilization were extracted. The primary outcomes were the proportion of patients cleared with clinical exam, and the proportion undergoing x-ray, computed tomography, or magnetic resonance image. The secondary outcome was the estimated difference in imaging charges based on the annual reduction in radiographic studies. Results: During the study 359 children were evaluated for CSIs (248 pre-SP, 111 post-SP). Patients were similar with respect to age, injury severity score, and mechanism of injury. Protocol adherence was 87.4%. The prevalence of CSI was similar in the preprotocol and postprotocol cohorts (2.8% vs. 1.8%, P=0.567). Children treated after protocol implementation were significantly more likely to be cleared by clinical exam (15.3% vs. 43.2%, P<0.001). Significantly fewer children had x-rays (70.2% vs. 55.0%, P=0.005) and computed tomography scans (14.5% vs. 5.4%, P=0.013) in the postprotocol period. There was no difference in the utilization of magnetic resonance image (6.9% vs. 7.2%, P=0.904) or the proportion of children discharged with a cervical collar (10.1% vs. 12.6%, P=0.476). No patients in either group were found to have a previously undiagnosed injury at follow-up. The reduction in radiographic studies translates to an estimated annual reduction in imaging charges of $396,476. Conclusions: The PCSCWG protocol for evaluating CSIs reduced the number of radiographic studies performed and estimated imaging charges while reliably identifying CSIs.

An audit of computed tomography request practices for suspected cervical spine injury post‐guideline change in a tertiary referral paediatric hospital

“…Our hospital Clinical Procedure has similarities to a subsequently published Paediatric Cervical Spine Clearance Working Group guideline that recommends CT scan in patients with a GCS ≤8 and reasonable suspicion for CSI, or at the request of a consultant spinal surgeon. 11 Pennell et al found guideline modification was associated with a decrease in CT scan use from 14.5% to 5.4%, compared with our study, which decreased from 8.8% to 7.3%. Furthermore, Luehmann et al 12 found CT scans reduced from 28% to 23% of children after updated guidelines were introduced.…”

“…This was an audit of the influence of guideline modification on medical imaging in cases of suspected paediatric CSI. Our hospital Clinical Procedure has similarities to a subsequently published Paediatric Cervical Spine Clearance Working Group guideline that recommends CT scan in patients with a GCS ≤8 and reasonable suspicion for CSI, or at the request of a consultant spinal surgeon 11 . Pennell et al found guideline modification was associated with a decrease in CT scan use from 14.5% to 5.4%, compared with our study, which decreased from 8.8% to 7.3%.…”

“…However, given the increase in digital imaging, smaller centres may benefit from seeking advice from an off‐site spinal surgeon. Our Clinical Procedure has many similarities with the recently published Paediatric Cervical Spine Clearance Working Group guideline 11 and, rather than develop guidelines for individual institutions, there are advantages in adopting an internationally published guideline, particularly with respect to consistency and evidence‐base. However, it is important to consider the effect of adopting guidelines within a local context.…”

Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre

“…A CT scan of the C-spine is only indicated in those patients for whom a fracture is seen on plain radiography or for whom there is clinical suspicion of CSI despite a negative result with plain radiography [20][21][22]. A CT scan of the C-spine is the primary imaging modality exclusively in patients who are haemodynamically unstable or who have a reduced level of consciousness [23,24]. The main reason for this is the increased risk of thyroid cancer: the relative risk from a CT scan is thought to be 13-25% higher than the risk from a plain radiograph [21,25,26], except for low dose CT.…”

A Retrospective Look at a Cervical Spine Clearance Protocol in Pediatric Trauma Patients at a Level-1 Trauma Center

“…Pennell and colleagues examined resource utilization and radiation exposure in pediatric patients over 2 time periods before and after implementation of a clearance protocol at a single level-1 trauma center. They demonstrated an estimated annual reduction in imaging charges of nearly $400k 11. In addition, Frank et al9 showed decreased length of ICU stay, in aggregate representing an estimated average cost savings of over $7.7k per patient.…”