Getting the Request Right: Ensuring Optimal Imaging Modality for Suspected Cervical Spine Fractures- A Quality Improvement Project

Introduction

It is estimated that the prevalence of cervical spine (c-spine) fractures following low impact falls in those over 65 is around 3.4%. These debilitating injuries carry a 12% 3-month mortality rate and a high morbidity rate. The gold standard investigation for suspected c-spine fractures is a c-spine computed tomography (CT). However, c-spine X-rays (XR) are often requested instead. As a department treating over 1000 falls a year, we suspected CT c-spines were being under-requested. Specifically, this QI project (QIP) aimed to ensure the cervical spine is being assessed with the correct imaging modality whenever clinically indicated. 

Method

In this closed loop QIP, initial retrospective analysis was performed by screening indications of all c-spine XRs and CTs performed by the Medicine of the Elderly Department, Western General Hospital between January and December 2023. Following this, a simplified local pathway was developed by a multidisciplinary consensus group involving colleagues from Emergency Medicine, Neurosurgery, Radiology and Nursing. This guideline was then expanded and introduced Trust wide. Use of c-spine XRs and CTs in the department were then re-evaluated from January to May 2024 in accordance with the new local guidelines. 

Results

For the initial study period (01/23-12/23, 12 months), only 1 CT and 2 XR c-spines were requested post-fall. Following intervention, further data collection for a shorter period (01/24-05/24, 5 months) showed 6 CT and 1 XR c-spines were performed in the re-evaluation period. 

Conclusion

The use of appropriate c-spine imaging studies following low impact trauma has significantly improved with awareness of the new pathway. However, given the established prevalence rate, our service would expect to see >30 c-spine fractures annually, with more studies requested than this. Consistent education is needed to continue improvement of awareness in both permanent and rotating cohorts of doctors in the department and solidify these gains.