Now is a good time to double down on implementing clinical guidelines for ordering CT scans in patients who present with head and neck trauma, according to an article published January 6 in Radiology.
Specifically, the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-Spine Rule (CCR) can help identify patients who are either at high risk for traumatic injury and require imaging, or at low risk and likely do not need imaging, noted lead author Shadi Asadollahi, MD, of MetroHealth Medical Center in Cleveland, OH, and colleagues.
“With the increased availability of cervical spine CT, it is essential to improve imaging decisions with respect to patient impact and health care costs while minimizing radiation exposure,” the authors wrote.
The number of patients presenting to U.S. emergency departments for blunt trauma was estimated to be over 25 million in 2017, yet the incidence of positive CT imaging findings in these patients is relatively low, the authors explained. Retrospective studies indicate that only up to 4% of all cervical spine CT examinations show positive results, including just 0.3% in asymptomatic adult patients.
The NEXUS criteria and the CCR were each developed approximately 25 years ago, and in their review, Asadollahi and colleagues evaluated their implementation and effectiveness for triaging these cases.
Both the NEXUS criteria and CCR are intended for patients who are alert and hemodynamically stable following blunt trauma, the authors noted. The NEXUS criteria are five inclusive criteria to preclude imaging:
-
Absence of midline cervical tenderness
-
Absence of focal neurologic deficits
-
Normal alertness
-
No intoxication
-
No painful distracting injuries
The CCR includes three high-risk criteria that necessitate imaging:
-
Age 65 years or older
-
Dangerous mechanism of injury
-
Paresthesia in the extremities
Although radiologists may not be familiar with the specific criteria that anchor NEXUS criteria and the CCR, these protocols guide the practice of ordering CT examinations in patients with head and neck trauma in most emergency departments, the authors wrote. They also noted that the American College of Radiology (ACR) recommends CT as the initial imaging method for adults meeting NEXUS or CCR criteria.
In terms of reducing unnecessary imaging, the authors cited a systematic review published in 2018 that found the use of the NEXUS criteria, the CCR, or a combination of both for assessing cervical spine trauma was linked to a 26% reduction in cervical spine imaging. They also noted that prospective validation studies have shown that imaging rates could be reduced by an average of 44.1% with the use of the CCR and up to 33.4% with the use of the NEXUS criteria without missing clinically important injuries.
However, many emergency departments do not mandate the use of the NEXUS criteria or the CCR, and this has led to inconsistent implementation, according to the authors.
“If the radiology community wishes to address appropriate use criteria for cervical spine injuries, it must understand the current standard of care driving cervical spine CT implementation in the [emergency department],” the group suggested.
In an accompanying editorial, Masis Isikbay, MD, and Jason Talbott, MD, PhD, of the University of California, San Francisco, wrote that the workup and evaluation of traumatic injury to the cervical spine can be difficult for both ordering providers and radiologists alike.
“Screening for cervical spine trauma represents a critical shared responsibility between emergency physicians and radiologists, requiring close collaboration to prioritize patient safety,” they wrote.
Understanding how current criteria are used by ordering providers, outlined in the review by Asadollahi and colleagues, is essential in addressing the issue of increased study volumes, Isikbay and Talbott concluded.
The full article can be found here.