Don't request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
Cervical spine imaging of every trauma patient is costly and results in significant radiation exposure to a large number of patients, very few of whom will have a spinal column injury. Clinical decision rules have been developed that identify patients who can safely be managed without imaging. These rules include the Canadian C-Spine rule or Nexus Low Risk Criteria. The Canadian C-Spine Rule provides higher specificity and lower imaging requirements, and should be used if possible.
This is a joint recommendation with Australasian College for Emergency Medicine (ACEM).
Recommendation released April 2015
- Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA. 2001; 286(15): 1841-8.
- Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998; 32(4): 461-9.
- Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003; 349(26): 2510-8.
- Miller P, Coffey F, Reid A-M, Stevenson K. Can emergency nurses use the Canadian cervical spine rule to reduce unnecessary patient immobilisation? Accid Emerg Nurs. 2006; 14(3): 133-40.
- Vaillancourt C, Stiell IG, Beaudoin T, Maloney J, Anton AR, Bradford P, et al. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med. 2009; 54(5): 663-71 e1.
- Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000; 343(2): 94-9.
- Mahler S, Pattani S, Caldito G. Use of a clinical sobriety assessment tool with the NEXUS low-risk cervical spine criteria to reduce cervical spine imaging in blunt trauma patients with acute alcohol or drug use: A pilot study. Ann Emerg Med. 2009; 54: S26-7.
- Griffith B, Bolton C, Goyal N, Brown ML, Jain R. Screening cervical spine CT in a level I trauma center: Overutilization? AJR Am J Roentgenol. 2011; 197(2): 463-7.
- Migliore S, Strelkauskas A, Matteucci M. The NEXUS criteria: Inter-rater reliability between residents versus attending physicians in the emergency department. Acad Emerg Med. 2011; 18: S139-40.
- Rethnam U, Yesupalan R, Gandham G. Does applying the Canadian Cervical Spine rule reduce cervical spine radiography rates in alert patients with blunt trauma to the neck? A retrospective analysis. BMC Med Imaging. 2008; 8: 12.
- Coffey F, Hewitt S, Stiell I, Howarth N, Miller P, Clement C, et al. Validation of the Canadian C-spine rule in the UK emergency department setting. Emerg Med J. 2011; 28(10): 873-6.
- Duane TM, Wilson SP, Mayglothling J, Wolfe LG, Aboutanos MB, Whelan JF, et al. Canadian Cervical Spine rule compared with computed tomography: A prospective analysis. J Trauma. 2011; 71(2): 352-7.
Paediatric Specific References
- Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001; 108(2): E20.
Clinical radiology recommendations 1-6 (April 2015)
A team of five Lead Radiologists were nominated to guide RANZCR's Choosing Wisely contribution. These Lead Radiologists analysed previous work completed by RANZCR, in particular a series of Education Modules for Appropriate Imaging Referrals.
These modules had been developed from an extensive evidence base and with multiple stakeholder input. Using the evidence from the Education Modules, the Lead Radiologists developed a draft recommendations list, which was then further developed and endorsed by RANZCR's Quality and Safety Committee, before being circulated to the RANZCR membership for consultation with a request for alternative recommendations. Member feedback was reviewed by the Lead Radiologists prior to ratification of the final recommendations by the Faculty of Clinical Radiology Council. The final six items selected were those that were felt to meet the goals of Choosing Wisely, i.e. those which are frequently requested or which might expose patients to unnecessary radiation.
Due to the fundamental role of diagnostic imaging in supporting diagnosis across the healthcare system, RANZCR worked closely with other Colleges throughout the project via the Advisory Panel. Following identification of two common recommendations with the Australasian College for Emergency Medicine, it was agreed by both Colleges to present these items jointly.
Radiation oncology recommendations 7-12 (October 2016)
Recommendations relating to radiation oncology from the Choosing Wisely and Choosing Wisely Canada were circulated around the Faculty of Radiation Oncology Council to determine which recommendations were applicable to the Australian and New Zealand context. The selected recommendations were then put to the Quality Improvement Committee and the Economics and Workforce Committee, with each being asked to rank the recommendations.
The five highest ranked recommendations were then put to the radiation oncology membership for consultation prior to being formally approved by the Faculty of Radiation Oncology Council.
Recommendations 7-10 are adapted from the American Society for Radiation Oncology (ASTRO) 2013 and 2014 lists. Recommendation 11 is adapted from Choosing Wisely Canada’s Oncology list. Each organisation was approached for—and subsequently granted—approval to adapt these recommendations as part of the Choosing Wisely Australia campaign.
- 1 Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
- 2 Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D dimer assay is positive.
Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
- 4 Don't perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
- 5 Don't request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.
- 7 Don’t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ≥50y with early-stage invasive breast cancer without considering shorter treatment schedules.
- 8 Don’t initiate management of low risk prostate cancer without discussing active surveillance.
- 9 Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases.
- 10 Don't routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
- 11 Don’t routinely use extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumour.