Does Every Patient Require Imaging after Cervical Spine Trauma? A Knowledge Translation Project to Support Evidence-Informed Practice for Physiotherapists

Awareness and use of five imaging decision rules for musculoskeletal injuries: a systematic review

BACKGROUND

Several validated decision rules are available for clinicians to guide the appropriate use of imaging for patients with musculoskeletal injuries, including the Canadian CT Head Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study (NEXUS) guideline, Ottawa Ankle Rules and Ottawa Knee Rules. However, it is unclear to what extent clinicians are aware of the rules and are using these five rules in practice.

OBJECTIVE

To determine the proportion of clinicians that are aware of five imaging decision rules and the proportion that use them in practice.

DESIGN

Systematic review.

METHODS

This was a systematic review conducted in accordance with the 'Preferred reporting items for systematic reviews and meta-analyses' (PRISMA) statement. We performed searches in MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Scopus databases to identify observational and experimental studies with data on the following outcomes among clinicians related to five validated imaging decision rules: awareness, use, attitudes, knowledge, and barriers and facilitators to implementation. Where possible, we pooled data using medians to summarise these outcomes.

RESULTS

We included 39 studies. Studies were conducted in 15 countries (e.g. the USA, Canada, the UK, Australasia, New Zealand) and included various clinician types (e.g. emergency physicians, emergency nurses and nurse practitioners). Among the five decision rules, clinicians' awareness was highest for the Canadian C-Spine Rule (84%, n = 3 studies) and lowest for the Ottawa Knee Rules (18%, n = 2). Clinicians' use was highest for NEXUS (median percentage ranging from 7 to 77%, n = 4) followed by Canadian C-Spine Rule (56-71%, n = 7 studies) and lowest for the Ottawa Knee Rules which ranged from 18 to 58% (n = 4).

CONCLUSION

Our results suggest that awareness of the five imaging decision rules is low. Changing clinicians' attitudes and knowledge towards these decision rules and addressing barriers to their implementation could increase use.

Cervical Fracture With Posterior Ligamentous Injury While Skydiving

A 46-year-old male soldier reported to an emergency department with severe acute neck pain immediately following a hyperflexion injury during recreational skydiving. He was evaluated in the emergency department, including radiographs, and released with a diagnosis of "acute neck strain." After presenting with continued neck pain, he was sent for consultation with a physical therapist. The physical therapist ordered cervical spine radiographs, which revealed findings consistent with cervical fracture and ligamentous disruption. In addition, the radiologist recommended computed tomography and magnetic resonance imaging, which confirmed bilateral C6 lamina fractures and multiple ligamentous disruption at C5-6. J Orthop Sports Phys Ther 2019;49(2):113. doi:10.2519/jospt.2019.8360.