Introduction: The use of advanced radiology in the U.S. emergency setting has increased over the years causing dramatic increases in healthcare costs and overall emergency department length of stay without associated equal increases in patient outcomes. The purpose of emergent imaging is to identify patients requiring urgent intervention. As back and neck pain are frequent causes of emergency room visits commonly prompting radiographic evaluation, presentations requiring urgent neurosurgical intervention can be correlated to determine a protocol for obtaining spinal MRIs in the emergency setting.
Methods: A retrospective chart review was performed of all patients undergoing spinal MRIs ordered by emergency room physicians during a three month period at University Hospital-New Orleans, a Level 1 Trauma Center. The characteristics of the patient population were then analyzed by presenting symptoms (axial/radicular pain, weakness, sensory deficits, bowel or bladder incontinence/ retention), duration of symptoms (chronic, acute, subacute, traumatic, post-operative), physical exam (weakness, rectal tone, post-void residuals), and disposition (emergent/urgent/outpatient surgery vs. no neurosurgical intervention).
Results: 35 patients underwent a total of 45 emergent MRIs in our population of study. 3/35 patients were admitted and received surgery (1 emergently- epidural abscess; 2 urgently- post-operative recurrent lumbar disc and metastatic disease with compression). 5/35 patients were referred for outpatient surgery, 4 of which had chronic cervical myelopathy.10/35 patients had documented weakness on exam, and 6 of these were in the intervention groups outlined above. 29/35 patients presented with axial neck or back pain.
Conclusions: The results of this study demonstrate that urgent neurosurgical intervention is indicated in situations of acute processes causing spinal cord or nerve root compression. Chronic measurable deficits and pathologies can usually be evaluated with outpatient imaging. Furthermore, this study supports that axial neck and back pain alone are not reliable indicators for urgent interventions. Further evaluation of data is necessary to distinguish what characteristics have the highest predictive value in urgent neurosurgical intervention to determine a reliable protocol for emergency department spinal MRI.
Patient Care: There is much focus in today's society regarding rising healthcare costs, which in part is due to the abundance of unnecessary imaging studies. Also, imaging studies often significantly increase length of stay for emergency department visits and require a large amount of patient cooperation to complete. This described increase in emergency advanced imaging is not associated with an equal increase in improved patient outcomes.
Learning Objectives: To determine the percentage of MRI scans ordered at our institution lead to urgent neurosurgical intervention; To use that information to develop a protocol for physicians to determine which patients require emergent advanced radiologic evaluation.
References: 1. Korley F, Pham J, Kirsch T. Use of Advanced Radiology During Visits to US Emergency Departments for Injury-Related Conditions, 1998-2007. JAMA. 2010;304(13):1465-1471. doi:10.1001/jama.2010.1408
2. Friedman, B.W., et al., Diagnostic Testing and Treatment of Low Back Pain in United States Emergency Departments: A National Perspective. Spine (Phila Pa 1976), 2010. 35 (24): p. E1406- 11.