Cervical Angiograms in Cervical Spine Trauma Patients 5 Years After The Data: Has Practice Changed?
Cervical Angiograms in Cervical Spine Trauma Patients 5 Years After The Data: Has Practice Changed?
Cervical Angiograms in Cervical Spine Trauma Patients 5 Years After The Data: Has Practice Changed?
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Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: All
authors; (IV) Collection and assembly of data: KA Rebehn; (V) Data analysis and interpretation: KA Rebehn; (VI) Manuscript writing: All authors; (VII)
Final approval of manuscript: All authors.
Correspondence to: Kelsey Rebehn, MD. Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Avenue, St.
Louis, MO 63110, USA. Email: rebehnk@slu.edu.
© Journal of Hospital Management and Health Policy. All rights reserved. J Hosp Manag Health Policy 2019;3:17 | http://dx.doi.org/10.21037/jhmhp.2019.06.04
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rates of VAI that are diagnosed in the trauma population are is recorded which includes all patients who arrive in the
approximately 0.1% (2). In populations where asymptomatic emergency department for evaluation of trauma related
trauma patients are also screened, rates of VAI among the complaints. The trauma registry from 2011 to 2016 was
trauma patient population approaches 1% (2-4). However, used to identify all patients from 18–89 with a diagnosis of
prior studies have shown that often the clinical significance cervical spine injury or pain, using both ICD 9 and 10 codes
of diagnosing VAI in poly-trauma patients is minimal, as to ensure all patients with relevant injuries were included.
many of the patient who are diagnosed with an injury are This time frame begins after the prior referenced study by
not candidates for treatment, and no changes are made to Dreger et al. was completed.
patient management after diagnosis (2,3). Previous studies These 1,201 eligible charts were reviewed for age, gender,
at the author’s institution discussed the limited indications mechanism of injury, cervical injury sustained and injury
for a CTA of the cervical spine, and recommended limiting location, cervical injury treatment, neurologic examination,
the use of this diagnostic test to symptomatic patients presence of head injury, and the use of further diagnostic
and those who can have a change in course of treatment testing to evaluate the cervical injury. All records were
if they are diagnosed with an injury (2). This initial study assessed for the completion of a CTA or magnetic resonance
was done over 5 years at a level 1 trauma center, and the imaging angiography (MRA), diagnosis of VAI, treatment
recommendations outlined in that paper were disseminated of any vascular injury, any complications from the CTA,
among the staff at the in trauma and orthopedic presence of a radiology report recommending CTA before
departments. CTA imaging performed, and any complications noted as
CT angiograms of the cervical spine provide an a result of the VAI. Inclusion criteria were ages 18–89, and
interesting lens into possible applications of a treatment imaging of the cervical spine performed. Exclusion criteria
algorithm designed to better guide a health care system were ballistic or penetrating trauma to the neck, death
focused on reducing excess. CT angiograms are not risk- on arrival to the emergency department without imaging
free; the test requires an additional contrast dye load, as performed, and imaging performed at outside institution
well as radiation dose to patients who already are subject only. Statistical analysis was performed using SPSS.
to significant physiologic stressors and a multitude of
imaging studies during a trauma evaluation (4-7). The
Results
purpose of this study will be to provide evaluation of a level
1 trauma system’s response to data demonstrating the range Review of the institutional trauma registry showed 1,201
of patients most appropriate for cervical CTA, and will patients who met initial inclusion criteria. From these,
allow for evaluation of any changes in practice made in the exclusions due to death in the trauma bay or on arrival and
trauma system in response to published evidence. It will penetrating/ballistic mechanisms resulted in 1,142 eligible
also evaluate for the possible role of a treatment algorithm patients for review. A total of 186 CTA/MRA studies were
in trauma patients to guide decisions for angiography in the done in this patient population. Six hundred forty patients
cervical spine trauma patient in a trauma facility. in this included population had a cervical spine fracture,
Previous studies have showed that cervical CTA is and of these patients 158 had a CTA/MRA. There has not
often performed in the evaluation of cervical spine trauma been a formal protocol for CTA study use implemented
patients, but a positive finding rarely results in either in our facility in the past 5 years, so clinical judgment
treatment or correlation with clinical symptoms (2,3). With of the ordering provider was the main ordering criteria.
the availability of data demonstrating the limited utility of Additionally, radiologist recommendations were also present
cervical spine CTA in all but a small subset of patients, our on initial CT cervical spine studies, which may also play a
study plans to examine results over a subsequent 5-year role in ordering provider decision making.
period to see if treatment patterns have changed in a level 1 Of the 158 CTA/MRA studies performed in patients with
academic trauma center. cervical spine fracture, a total of 24 studies were positive
for VAI injury, and ten showed pertinent findings in other
vessels. Of these patients, 12 were treated with either aspirin
Methods
(ASA), heparin drip, Coumadin, or therapeutic Lovenox
After IRB approval, a chart review was conducted at our for VAI. One patient treated with a heparin drip developed
level 1 trauma hospital. At our institution, a trauma registry increasing blood loss requiring cessation of the drip and
© Journal of Hospital Management and Health Policy. All rights reserved. J Hosp Manag Health Policy 2019;3:17 | http://dx.doi.org/10.21037/jhmhp.2019.06.04
Journal of Hospital Management and Health Policy, 2019 Page 3 of 4
© Journal of Hospital Management and Health Policy. All rights reserved. J Hosp Manag Health Policy 2019;3:17 | http://dx.doi.org/10.21037/jhmhp.2019.06.04
Page 4 of 4 Journal of Hospital Management and Health Policy, 2019
systems could be utilized to guide and target the appropriate of complete cervical helical computed tomographic
ordering of this study. As more hospital systems move scanning in identifying cervical spine injury in the
towards utilizing an electronic medical ordering and records unevaluable blunt trauma patient with multiple injuries:
system, this system should not be overlooked for its possible a prospective study. J Trauma 1999;47:896-902;
role in helping to aid clinicians improve their quality of discussion 902-3.
care and treatment choices. Consideration of systems based 2. Dreger T, Place H, Mattingly T, et al. Analysis of Cervical
changes to help provide a more targeted, high clinical yield Angiograms in Cervical Spine Trauma Patients, Does it
use of this test could help targeted the use of this imaging Make a Difference? Clin Spine Surg 2017;30:232-5.
study and reduce unnecessary testing. 3. Lockwood MM, Smith GA, Tanenbaum J, et al. Screening
via CT angiogram after traumatic cervical spine fractures:
narrowing imaging to improve cost effectiveness.
Conclusions
Experience of a Level I trauma center. J Neurosurg Spine
In the acute poly-trauma setting, cervical spine CTA is 2016;24:490-5.
a useful tool for at risk patients, but in daily practice it is 4. Berne JD, Norwood SH. Blunt vertebral artery injuries in
often utilized in a fashion that does not result in a change to the era of computed tomographic angiographic screening:
treatment. We propose that given the statistically significant incidence and outcomes from 8,292 patients. J Trauma
rise in tests ordered without an associated increase in 2009;67:1333-8.
positive test results or patients treated, an institutional 5. Biffl WL, Moore EE, Elliott JP, et al. The devastating
algorithm for test utilization may be considered to guide the potential of blunt vertebral arterial injuries. Ann Surg
use of this diagnostic tool. 2000;231:672-81.
6. Markus HS, Hayter E, Levi C, et al. Antiplatelet treatment
compared with anticoagulation treatment for cervical
Acknowledgments
artery dissection (CADISS): a randomised trial. Lancet
This study was funded by the St. Louis University Neurol 2015;14:361-7.
Department of Orthopedic Surgery. 7. Cohnen M, Wittsack HJ, Assadi S, et al. Radiation
exposure of patients in comprehensive computed
tomography of the head in acute stroke. AJNR Am J
Footnote
Neuroradiol 2006;27:1741-5.
Conflicts of Interest: The authors have no conflicts of interest 8. Kuperman GJ, Gibson RF. Computer physician order
to declare. entry: benefits, costs, and issues. Ann Intern Med
2003;139:31-9.
Ethical Statement: The study was approved by institutional 9. Charles K, Cannon M, Hall R, et al. Can utilizing a
ethics committee/ethics board of St. Louis University computerized provider order entry (CPOE) system
Hospital (No. 27424). The authors are accountable for prevent hospital medical errors and adverse drug events?
all aspects of the work in ensuring that questions related Perspect Health Inf Manag 2014;11:1b.
to the accuracy or integrity of any part of the work are 10. Ip IK, Schneider LI, Hanson R, et al. Adoption and
appropriately investigated and resolved. meaningful use of computerized physician order entry
with an integrated clinical decision support system for
radiology: ten-year analysis in an urban teaching hospital.
References
J Am Coll Radiol 2012;9:129-36.
1. Berne JD, Velmahos GC, El-Tawil Q, et al. Value
doi: 10.21037/jhmhp.2019.06.04
Cite this article as: Rebehn KA, Place HM. Cervical
angiograms in cervical spine trauma patients 5 years after
the data: has practice changed? J Hosp Manag Health Policy
2019;3:17.
© Journal of Hospital Management and Health Policy. All rights reserved. J Hosp Manag Health Policy 2019;3:17 | http://dx.doi.org/10.21037/jhmhp.2019.06.04