Variation in pediatric cervical spine imaging across trauma centers - A cause for concern?

BACKGROUND: Traumatic pediatric cervical spine injury can be challenging to diagnose, and the clinical algorithms meant to aid physicians differ from adult trauma protocols. Despite the existence of standardized guidelines, imaging decisions may vary according to physician education, subjective assessment, and experience with pediatric trauma patients. Our study investigates the rates of pediatric post-traumatic cervical spine imaging across trauma centers, hypothesizing that more specialized centers will have lower rates of advanced cervical spine imaging.

METHODS: The 2015-16 Trauma Quality Improvement Program database was reviewed for patients <18-years-old to assess rates of cervical spine imaging on presentation across different trauma centers. Propensity stratification logistic regression was performed controlling for patient and center-specific variables. P-values<0.05 were considered significant.

RESULTS: Of 110,769 pediatric trauma patients, 35.2% were female and the average age was 9.6 years. Overall, 3.6% had cervical spine CT and < 1% had cervical spine MRI or X-ray. Compared to all others, Level I trauma centers were significantly less likely to use cervical spine CT for the initial evaluation of younger (≤14 years) but not older trauma patients (AOR's 0.89,95%CI:0.80-0.99; 0.97,95%CI:0.87-1.09); Level I centers had higher odds of cervical spine MRI use, but only for patients ≤14 years (1.63,95%CI:1.09-2.44). Pediatric-designated trauma centers had significantly lower odds of cervical spine CT (≤14:0.70,95%CI:0.63-0.78; >14:0.67,95%CI:0.67-0.75) and higher odds of cervical spine X-ray (≤14:4.75,95%CI:3.55-6.36; >14:4.50,95%CI:2.72-7.45) for all ages, but higher odds of cervical spine MRI for younger patients only (≤14:2.10,95%CI:1.38-3.21).

CONCLUSIONS: Level I and Pediatric designations were associated with lower rates of cervical spine CT. Pediatric centers were also more likely to utilize cervical spine X-ray. This variability of imaging use further supports the need to disseminate and educate providers on pediatric-specific cervical spine evaluation guidelines.

LEVEL OF EVIDENCE: III, Prognostic and Epidemiological.