Hospital Variation in Cervical Spine Imaging of Young Children With Traumatic Brain Injury

Abstract

Objectives Cervical imaging practices are poorly understood in young children with Traumatic Brain Injury (TBI). We therefore sought to: identify child-level and hospital-level factors associated with performance of cervical imaging of children with TBI from falls and abusive head trauma (AHT); and describe across-hospital variation in cervical imaging performance. We hypothesized that imaging decisions would be influenced by hospital volume of young injured children. Methods We performed a retrospective study of children younger than 2 years of age with TBI from 2009-2013 in the Premier Perspective Database. After adjustment for observed patient characteristics, we evaluated variation in advanced cervical imaging (computed tomography or magnetic resonance imaging) in children with AHT and TBI from falls. Results Of 2,347 children with TBI, 18.7% were from abuse, and 57.1% were from falls. Fifteen percent of children with TBI underwent advanced cervical imaging. Moderate or severe head injuries were associated with increased odds of cervical imaging in AHT (OR 7.10; 95% CI 2.75, 18.35) and falls (OR 2.25; 95% CI 1.19, 4.27). There was no association between annual hospital volume of injured children and cervical imaging performance. The adjusted probability of imaging across hospitals ranged from 4.3 to 84.3% in AHT and 3.1 to 39.0% in TBI from falls (P < 0.001). Conclusions These results highlight variation across hospitals in adjusted probability of cervical imaging in AHT (nearly twenty-fold) and TBI from falls (over ten-fold) not explained by observed patient characteristics. This variation suggests opportunities for further research to inform imaging practices.

Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts

“… 1 Based on the existing literature on pediatric cervical spine trauma, 25%-44% of injuries have been reported to involve ligamentous disruptions. 5 6 7 8 Henry et al . 8 reported 78% incidence of ligamentous injuries following inflicted trauma, as against 46% incidence in children with accidental trauma.…”

“… 5 6 7 8 Henry et al . 8 reported 78% incidence of ligamentous injuries following inflicted trauma, as against 46% incidence in children with accidental trauma. Majority of the pediatric cervical spine injuries (CSIs) occur between the skull and C4 vertebra; and around 10.8% to 38.7% of these injuries involve C1 and C2 vertebrae.…”

“… 37 Additional radiological evaluations are computerized tomography (CT) and magnetic resonance imaging (MRI), need for which includes abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft tissue status. 8 …”

Editorial. Screening for spine injury in abusive head trauma

“…4 The practice of cMRI screening in patients with AHT currently varies widely across institutions. 5 The American College of Radiology (ACR) has recommended cMRI when craniocervical junction or c-spine injury is suspected on the basis of the clinical examination or abnormal results on other imaging modalities. 13 The ACR guidelines also suggest considering cMRI if a brain MRI study is ordered, reflecting the hospital policy instituted by Dr. Oh and colleagues in 2012.…”

A Retrospective Study of Cervical Spine MRI Findings in Children with Abusive Head Trauma

“…Although current recommendations suggest performing cervical MRI as part of the evaluation of AHT [5] , Henry et al [6] describe a variation among hospitals in advanced cervical spine (c-spine) imaging as part of the evaluation of AHT.…”