Appropriateness Of CT Scanning In The Diagnosis Of Craniosynostosis
Ilana G. Margulies, MS1, Francis Graziano, MD1, Pedram Goel, BS2, Hope Xu, BA1, Anthony H. Bui, BS1, Stav Brown, BS3, Paymon Sanati-Mehrizy, MD1, Mark M. Urata, MD, DDS2, Peter J. Taub, MD, MS1.
1Icahn School of Medicine at Mount Sinai, New York, NY, USA, 2Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA, 3Sackler School of Medicine at Tel Aviv University, Tel Aviv, Israel.
Introduction: Craniosynostosis involves premature closure of cranial suture(s) that often requires operative intervention to correct the resultant deformity and address any increase in intracranial pressure. Although the diagnosis can be made on physical examination alone, CT imaging is often used for confirmation. While physicians from a variety of specialties including craniofacial surgeons, neurosurgeons, and pediatricians encounter infants with possible craniosynostosis, judicious use of CT imaging across specialties is important to avoid unnecessary radiation exposure and healthcare expense. The present study sought to determine whether differences in specialty of ordering physician impacted frequency of resulting diagnostic confirmations requiring operative intervention.
Methods: Radiology databases from two academic institutions were queried for CT reports or indications that included ‘craniosynostosis' or ‘plagiocephaly.' Patient demographics, specialty of ordering physician, confirmed diagnosis, and operative interventions were recorded. Statistical analysis was performed using Chi square test with Bonferroni correction (p<0.05). Logistic regression with interaction term between age and specialty was used to evaluate the impact of age at time of CT scan on likelihood of operative intervention by specialty type.
Results: 382 patients were included with 64.6% male patients and an average age of 8.67 (6.20) months at time of CT scan. 184 (48.17%) CT scans were ordered by craniofacial surgeons, 71 (18.59%) were ordered by neurosurgeons, and 127 (33.25%) were ordered by pediatricians. 104 (27.23%) patients ended up receiving a diagnosis of craniosynostosis requiring an operative intervention. Craniofacial surgeons and neurosurgeons were more likely than pediatricians to order CT scans that resulted in a diagnosis of craniosynostosis requiring operative intervention (p<0.001), with no difference between craniofacial surgeons and neurosurgeons in likelihood that ordered CT scans resulted in a diagnosis of craniosynostosis requiring operative intervention (p=1.0). Older patient age significantly decreased the odds of operative intervention after CT scan by 70.0% if ordered by a craniofacial surgeon (CI 0.157-0.575), while patient age did not significantly affect the likelihood of operative intervention after CT scan if ordered by a neurosurgeon (0.548, CI 0.201-1.495) or pediatrician (0.919, CI 0.220-3.849).
Conclusion: Surgeons who manage craniosynostosis as compared to pediatricians had a higher likelihood of ordering CT images that resulted in a diagnosis of craniosynostosis requiring operative intervention. The present study should prompt multi-disciplinary educational interventions aimed at improving evaluation of pretest probability prior to CT imaging to avoid unnecessary radiation exposure and healthcare expense.
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