Utility of CT angiography in cervical spine trauma: analysis of radiation and cost

Joseph Hidalgo,Arvind Arvind,Waqas Shuaib,Ajeet Mehta,Aizaaz Khan

doi:10.14319/ijcto.0204.3

Abstract

Purpose: Vertebral artery injuries (VAIs) can be seen in cervical injuries. This investigation was conducted to assess the impact of head and neck computed tomography (CT) angiography (CTA) on planning treatment of vertebral artery injuries, if these tests were ordered appropriately, and to estimate cost and associated exposure to radiation and contrast material. Methods : This retrospective review included all patients who underwent CT of the cervical spine and CTA of the head and neck from March 2011 to October 2012 at a single institution. Patients were divided into two groups, those with and those without cervical spine fracture appreciated on CT of the cervical spine. The frequency of vascular injury on CTA in those with a cervical fracture was assessed. The frequency of vascular injury treatment and modifications owed to a positive CTA of head and neck were also assessed. A study was considered appropriate if it was ordered in accordance with the modified Denver Screening criteria. Effective radiation dose (mSv) was calculated by multiplying dose length product (DLP) from the scanner with the standard conversion coefficient (k) (k = 0.0021 mSv/mGy x cm). Results: In the 387 CTAs of head and neck, a cervical injury was recorded in 128 patients. Twenty CTA scans were correctly ordered for non-spinal indications, and 19 were ordered off protocol. CTA was found positive in 1 patient for whom the imaging was off protocol and 1 for whom the clinical indication was non-cervical. There were 19 positive CTA cases of head and neck, none of which underwent surgical intervention. CTA was positive in 13 of 48 patients who had suffered a C2 fracture; this accounted for 13 of the 19 positive CTA studies (p < 0.01). Estimated fee for CTA was $3783, and radiation exposure was 4 mSv with a standard deviation (±1.3). Conclusion : CTA of head and neck ordered off an institutional imaging protocol has a low probability of being positive. Adherence to protocols for CTA of head and neck can reduce costs and decrease unnecessary exposure to radiation and contrast medium. --------------------------------------- Cite this article as: Shuaib W, Khan AA, Mehta AS, Vijayasarathi A, Hidalgo J. Utility of CT angiography in cervical spine trauma: analysis of radiation and cost. Int J Cancer Ther Oncol 2014; 2 (4):02043. DOI : 10.14319/ijcto.0204.3

Highlights

Vertebral artery injuries (VAI) have often gone undiagnosed until devastating consequences present.[1,2,3] An early diagnosis allows time to initiate early therapy, including antiplatelet therapy, anticoagulation, and/or surgery if needed.[4,5,6,7] While digital subtraction angiography (DSA) has been regarded as the gold standard in diagnosing vertebral artery injuries (VAI), its invasiveness makes it a less desirable imaging modality.[8]The advent of computed tomography angiography (CTA) has quickly gained momentum in patients who are recognized for screening of VAI.[9]
In 16% (21/128) of the patients VAI was appreciated on CTA
Irrespective of treatment, all patients with VAI were neurologically intact with no evidence of sequelae from the cerebrovascular injury at their last medical follow-up

Summary

Introduction

Vertebral artery injuries (VAI) have often gone undiagnosed until devastating consequences present.[1,2,3] An early diagnosis allows time to initiate early therapy, including antiplatelet therapy, anticoagulation, and/or surgery if needed.[4,5,6,7] While digital subtraction angiography (DSA) has been regarded as the gold standard in diagnosing VAI, its invasiveness makes it a less desirable imaging modality.[8]The advent of computed tomography angiography (CTA) has quickly gained momentum in patients who are recognized for screening of VAI.[9]. Vertebral artery injuries (VAI) have often gone undiagnosed until devastating consequences present.[1,2,3] An early diagnosis allows time to initiate early therapy, including antiplatelet therapy, anticoagulation, and/or surgery if needed.[4,5,6,7] While digital subtraction angiography (DSA) has been regarded as the gold standard in diagnosing VAI, its invasiveness makes it a less desirable imaging modality.[8]. The non-invasive nature, shorter turnaround time, and the lesser amount of contrast used in CTA add to the feasibility of CTA over DSA.[8] While many studies have credited CTA as an excellent non-invasive alternative to DSA in diagnosing VAI, reports on its appropriate utilization in accordance with the modified Denver Screening Criteria remains an area interest. We assess the application of CTA of head and neck and determine how often imaging protocol was followed, the outcome of those studies, the effect of CTA findings on treatment of cervical fractures, and the outcome of inappropriately ordered studies

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Discussion

Conclusion