Cervical Spine Injuries in Older Patients with Falls Found on Magnetic Resonance Imaging After Computed Tomography

Introduction: In this study we aimed to determine the rate of traumatic abnormalities on cervical spine magnetic resonance imaging (MRI) after a normal cervical spine computed tomography (CT) in older patients with ground-level falls. We hypothesized that MRI is low yield following a normal physical examination and normal CT after a ground-level fall. Methods: This was a retrospective cohort study of patients 65 years and older evaluated with a cervical spine MRI following a ground-level fall. Inclusion criteria included age 65 years and older, ground-level fall, normal cervical spine CT followed by a cervical spine MRI. We abstracted data following accepted methodologic guidelines. Patients with any focal neurological finding were considered to have an abnormal neurological examination. Imaging studies were considered to be abnormal if there was a report of an acute traumatic injury. The primary outcome was a traumatic abnormality identified on MRI. We described data with simple descriptive statistics. Results: Eighty-seven patients with a median age of 74 (interquartile range [IQR] 69, 83]) years had an MRI following a normal cervical spine CT. Median emergency department length of stay was 8.2 hours (IQR 5.3, 13.5). Sixty-four (73.6%) patients had a normal neurological examination on arrival; eight of these patients (12.5% (95% confidence interval [CI], 5.6-23.2%) had an abnormal cervical spine MRI. Twenty-three patients (26.4%) had an abnormal neurological examination on arrival; two of these patients (8.7%, 95% CI, 1.1-28%) had an abnormal cervical spine MRI. Overall, 10 patients (11.5%) had an abnormal cervical spine MRI. One patient underwent operative intervention due to an unstable injury. Of the remaining nine patients with acute findings on cervical spine MRI, there were no other unstable injuries; two patients were managed with cervical orthosis, and seven patients had no additional management. Conclusion: In this study of older patients with ground-level falls and normal, atraumatic, cervical spine CT, a small portion had traumatic abnormalities on MRI, with few requiring further intervention. Further study is required to identify criteria to determine when MRI should be performed in older patients after a ground-level fall.

Combined Lumbar Spine MRI and CT Appropriateness Checklist: A Quality Improvement Project in Saskatchewan, Canada

Background As rates of advanced imaging for lower back pain continue to increase, there is a need to ensure appropriateness of imaging. The goal of this project was to reduce the number of inappropriate MRI and CT requests for lower back pain patients and facilitate appropriate imaging by developing a combined imaging appropriateness checklist for lumbar spine MRI and CT. Methods In prior work, we developed and adopted individual evidence-based lumbar spine MRI and CT checklists into the radiology requisition process. In the current project, a combined checklist was developed and trialed in one of the former Saskatchewan health regions (Five Hills) beginning in May 2018. Using statistical process control (SPC), control charts compared monthly number of imaging requests pre- and post-checklist implementation from May 2017 to February 2020. Monthly number of lumbar spine MRI and CT requisitions in the nearby former Saskatchewan Regina Qu’Appelle Health Region, in which the combined checklist was not trialed, were also plotted and compared as a balancing measure. Results In Five Hills, a shift (decrease) was observed in the monthly number of lumbar spine MRI requisitions seven months following the implementation of the combined checklist. However, the monthly number of lumbar spine CT requisitions did not change significantly. In the Regina Qu’Appelle Health Region, there was a shift (increase) in the monthly number of lumbar spine MRI requisitions, while the monthly number of lumbar spine CT requests decreased after the implementation of the combined checklist. Conclusions The combined checklist with evidence-based indications for lumbar spine MRI and CT imaging in lower back pain patients appeared to reduce the complexity associated with two previous individual checklists and facilitate imaging appropriateness. Accountable benefits may include the reduction of radiation exposure as a result of unnecessary and repeated imaging and reduction in wait times for CT and/or MRI.