Variation in the use of MRI for cervical spine clearance: an opportunity to simultaneously improve clinical care and decrease cost

The Effect of the Eastern Association for the Surgery of Trauma Guideline on Spinal Magnetic Resonance Imaging Use in Obtunded Adult Blunt Trauma Patients Over Time

BACKGROUND

Evidence-based guidelines suggest computed tomography without magnetic resonance imaging (MRI) is sufficient to rule out clinically significant cervical spine injury in obtunded adult blunt trauma patients. This study evaluated MRI utilization over time to investigate the impact of the 2015 Eastern Association for the Surgery of Trauma guidelines suggesting cervical collar clearance with computed tomography alone in this population. We hypothesized that MRI utilization would decrease following the guidelines.

MATERIALS AND METHODS

We performed a retrospective cross-sectional study of the National Trauma Data Bank from 2007 to 2018 using multivariable logistic regression of the likelihood of spinal MRI utilization. Blunt trauma patients 18 y and older with a Glasgow Coma Scale (GCS) of 8 or less, Abbreviated Injury Score head of 4 or greater, intubated for at least 72 h were included.

RESULTS

The sample consisted of 76,450 patients from 567 trauma centers. Controlling for age, gender, race/ethnicity, insurance status, injury mechanism, Injury Severity Score, GCS, GCS motor, hospital teaching status and trauma center level, patients seen after 2015 had a higher odds ratio (OR) of undergoing spinal MRI relative to those seen before 2015 (OR 1.77, 95% CI 1.49-2.09; P < 0.001). Each year was associated with a significantly increased OR of undergoing spinal MRI compared to the year prior (OR 1.10, 95% CI 1.05-1.15; P < 0.001).

CONCLUSIONS

Spinal MRI use has been increasing in obtunded adult blunt trauma patients including after the release of the Eastern Association for the Surgery of Trauma guidelines in 2015. Future work should identify whether this is driven by improper MRI utilization and, if so, strategies to promote guideline adherence.

Utilization of computerized tomography and magnetic resonance imaging for diagnosis of traumatic C-Spine injuries at a level 1 trauma center: A retrospective Cohort analysis

Background

Computerized tomography (CT) is a common imaging modality for trauma patients, but there is debate regarding the role of magnetic resonance imaging (MRI) in cervical (C)-spine clearance. We aim to investigate the utilization of CT and MRI imaging in traumatic C-spine clearance and associated outcomes on patients who undergo both imaging modalities.

Methods

A 4-year retrospective review was performed to evaluate the trauma patient imaging algorithm at our institution. The algorithm required CT as a screening examination for traumatic injury patients who are unexaminable because of distracting injury, altered mental status, an abnormal neurological examination, and/or central neck pain. MRI was performed after CT in patients with C-spine injuries identified on CT, those who remained unexaminable, had an abnormal neurological examination, or experienced persistent central neck tenderness. Univariate analyses and adjusted multivariate logistic regression were performed with significance defined as p < 0.05.

Results

805 patients were analyzed. Compared to MRI, CT had a sensitivity of 50.2%, specificity of 76.6%, positive predictive value of 69.7%, and negative predictive value of 59.0% in detecting C-spine injuries. CT and MRI differed significantly in their ability to detect C-spine soft tissue injuries and C1 vertebral fractures (p < 0.05).

Conclusions

MRI is more capable of detecting soft tissue injuries whereas CT is superior in detecting vertebral fractures. Our findings support the need to utilize CT and MRI in conjunction to detect both bony and soft tissue C-spine injuries in traumatically injured patients, who are either unexaminable, have an abnormal neurologic examination, or ongoing central neck tenderness.

Does preoperative magnetic resonance imaging alter the surgical plan in patients with acute traumatic cervical spinal cord injury?

BACKGROUND

Whether magnetic resonance imaging (MRI) adds value to surgical planning for patients with acute traumatic cervical spinal cord injury (ATCSCI) remains controversial. In this study, we compared surgeons' operative planning decisions with and without preoperative MRI. We had two hypotheses: (1) the surgical plan for ATCSCI would not change substantially after the MRI and (2) intersurgeon agreement on the surgical plan would also not change substantially after the MRI.

METHODS

We performed a vignette-based survey study that included a retrospective review of all adult trauma patients who presented to our American College of Surgeons-verified level 1 trauma center from 2010 to 2019 with signs of acute quadriplegia and underwent computed tomography (CT), MRI, and subsequent cervical spine surgery within 48 hours of admission. We abstracted patient demographics, admission physiology, and injury details. Patient clinical scenarios were presented to three spine surgeons, first with only the CT and then, a minimum of 2 weeks later, with both the CT and MRI. At each presentation, the surgeons identified their surgical plan, which included timing (none, <8, <24, >24 hours), approach (anterior, posterior, circumferential), and targeted vertebral levels. The outcomes were change in surgical plan and intersurgeon agreement. We used Fleiss' kappa (κ) to measure intersurgeon agreement.

RESULTS

Twenty-nine patients met the criteria and were included. Ninety-three percent of the surgical plans were changed after the MRI. Intersurgeon agreement was "slight" to "fair" both before the MRI (timing, κ = 0.22; approach, κ = 0.35; levels, κ = 0.13) and after the MRI (timing, κ = 0.06; approach, κ = 0.27; levels, κ = 0.10).

CONCLUSION

Surgical plans for ATCSCI changed substantially when the MRI was presented in addition to the CT; however, intersurgeon agreement regarding the surgical plan was low and not improved by the addition of the MRI.

LEVEL OF EVIDENCE

Diagnostic, level II.