Unnecessary Examinations

Skull Series

Except for a depressed skull fracture or the presence of intracranial metallic fragments, there is no reason to order a skull series for trauma. This was once one of the most abused examinations in radiology, costing millions of dollars per year unnecessarily. Although the number of unnecessary skull films has decreased, they remain a costly burden in many emergency departments. There is virtually no finding on a skull series that will alter the next step in the patient’s workup. Presence or absence of a fracture should not influence whether or not the patient receives a computed tomography (CT) scan or a magnetic resonance imaging (MRI) exam. A CT scan or an MRI exam are obtained for other reasons: continued unconsciousness or focal neurologic signs. The plain films only delay the eventual diagnosis, and in a patient with a subdural or an epidural hematoma, that delay could be fatal. The mortality from intracranial bleeds is significantly increased as the time to surgical decompression is increased; therefore any delay caused by obtaining unnecessary examinations (skull films) is potentially harmful. There are no findings on a plain skull series to indicate (or not indicate) subdural or epidural hematoma ( Fig. 1.1 ). Fewer than 10% of patients with fractures have subdural or epidural hematomas, and up to 60% of patients with subdural or epidural bleeds have no fractures. Therefore why order the examinations? Medicolegal reasons? On the contrary! It is well documented that delays in diagnosis in this setting can be fatal, so ordering unnecessary examinations might in fact be asking for a lawsuit! The American College of Radiology has published appropriateness criteria for when to order particular exams, and has endorsed head CT as the initial study of choice in trauma.

In spite of much documentation in the radiology and emergency room literature showing the lack of utility of skull films in trauma, they still are frequently routinely ordered in many emergency rooms throughout North America. A survey performed in 1991 by Hackney and published in Radiology showed that over 50% of the hospitals in the study “often or always” obtained skull films for trauma. Every hospital had CT available. What were they thinking? Obviously they are not thinking about what a skull film will show them that might affect their treatment, because it won’t change a thing, whether it’s positive or negative.

Sinus Series

It is true that an opaque sinus and/or an air–fluid level can be seen with sinusitis. But often the patient with these findings is asymptomatic, and just as often in another patient, the sinus series can be normal when the patient has typical clinical findings of sinusitis. Both of these patients are treated based on their clinical, not radiographic, presentation, which is appropriate. Therefore the information from the sinus series is ignored. If that is the way you practice—and many recommend that as being proper—don’t order the sinus series; treat the patient. Reserve the sinus series for the patient who doesn’t respond to treatment or has an unusual presentation. Also, if it is only sinusitis you are concerned with, most times, a simple upright Waters’ view ( Fig. 1.2 ) to examine the maxillary and frontal sinuses, rather than a full sinus series, will suffice, saving money and decreasing patient exposure.

Nasal Bone

A nasal series is often requested to see if a patient has suffered a broken nose after trauma to the face. So what if the nasal bone is fractured? It won’t be casted. It won’t be reduced. In other words, no treatment will be given regardless of what the x-ray shows. Therefore don’t order the films in the first place. Occasionally a nasal bone is badly enough displaced to warrant intervention, but even then an acute, posttraumatic x-ray adds nothing for the patient except expense and radiation exposure. A facial series or a CT to search for additional fractures might be in order, but not a nasal series.