Are too many neonatal lumbar spine ultrasounds being requested to interrogate ‘Sacral dimple’?

This audit assesses and reviews the number and quality of lumbar spine ultrasound scans (USS) performed in a department, specifically to investigate pathology associated with a sacral dimple (or other associated cutaneous stigmata) in the neonate.

Referrals for lumbar spine ultrasound to assess for possible spinal dysraphism are relatively common. They should be appropriate to ensure that examinations can be performed in a timely manner, avoiding inefficiency in the number of hours spent scanning and unnecessary financial expenditure by a department, as well as the parental anxiety caused by unnecessary investigations.

Background points to consider when designing this audit:

•    A lumbar spine USS performed > 4 months is unlikely to be useful due to ossification (age at time of scan)

•    Are the USS scans performed to departmental deadlines? Are delays due to there being too many unnecessary scans?

•    Is there a relevant clinical history provided to justify the scan? Does any particular referrer provide too little or too much information in the clinical history?

•    How would recommendations be delivered to professionals/ requestors of this service?

•    Does the clinical information provided correlate with USS findings?

The standard: 

All the following standards should be co-reviewed with local paediatric colleagues.

All USS lumbar spine/spine requests should be performed within an appropriate time frame and upper age limit - both agreed between the local radiology and paediatric departments.

All patients with “atypical dimples”, specifically: those that are large (>5mm), or high on the back (>2.5cm from the anus), or those with a base not visualised, or not in the midline, or appear with a combination of other lesions for example cutaneous markers, should be offered an USS lumbar spine/ spine as the initial investigation – (iRefer standard P8/P19)^1,2.

All patients with typical or atypical dimples, and with abnormal neurology should be offered an USS lumbar spine as the initial investigation (an MRI study would most likely follow) – (iRefer standard P8/P19)^1,2.

All patients with “stigmata of spinal dysraphism or associated congenital abnormalities such as infantile haemangiomas of the lumbosacral region”, should also be offered an USS lumbar spine/ spine as the initial investigation – (iRefer standard P8/P19)^1,2.

All patients with "typical dimples", specifically: those that are <5mm, and where the base of the dimple is visualised, and is situated </= 2.5cm from the anus, and is in the midline, and have normal neurology, would not require an USS lumbar sacral spine.

Target: 

100% of US lumbar spine/ spine requests should be justified AND accepted, declined or further discussed (with the referrer/requestor) against Royal College of Radiology guidance described above ^1,2 (see section “the standard”).

Indicators: 

• Compare the age at time of request to the age at time of examination – is there an established waiting time interval between requesting and performing the examination?

•   Clinical history provided  -  Does any particular referrer/requestor provide too little or too much information in the clinical history? Is the referral in accordance with the RCR iRefer standards P8/P19^1,2? 

•   USS findings - Does this correlate with the clinical information provided?

Data items to be collected: 

For each USS request collect the following data: Age of referral, Age at scan, Referral to scan times , Who referred the patient and/or who requested the scan?  Full clinical information provided by clinician? Outcome of scan

Suggested number: 

50-100 patients - dependant on departmental workload. Analyse data to work out number of scans in a particular time period, for example number of scans performed per week or month. 

Recommend following suggestions:

• Create a local guideline integrating RCR guidance^1,2,3 (see an example file under Resource used by the authors trust)

• Involve paediatric team input to review where service can be improved.

• Consider integrating/inserting iREFER standards into questions within the RIS requesting software, or limit the requesting of USS lumbar spine/spine for sacral dimples to certain members in the paediatric team.

• Inform relevant referrers/requesters (for e.g. junior doctors) by way of organised teaching and advertising posters/guidelines in department/ ward/ handover/ induction material.

• In the community, attend and teach at relevant meetings (for e.g. GP practice teaching seminars).

• Relay information to referrers in writing with copy of local guideline (see example in resource files) if US not justified.

Local PACS/RIS system to collect data or similar system enabling extraction of relevant patient data.

1. (Source iRefer) P08: Congenital disorders of the spine in children

   https://www.irefer.org.uk/guideline/congenital-disorders-spine-children

2. (Source iRefer) P19: Sacral dimple/pit or other cutaneous stigmata in children (e.g., hairy patch)

   https://www.irefer.org.uk/guideline/sacral-dimplepit-or-other-cutaneous-stigmata-children-eg-hairy-patch

3. The Staffordshire, Shropshire and Black Country Neonatal Operational Delivery Network Neonatal Guidelines. Link provided below.

   Guideline reference: Page number 297 version 2 (03.18): Click: “Neonatal Guidelines 2017 – 2019” for updated guideline. 

   https://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country-newborn/neonatal-guidelines

Dr Zubair Sarang

Co-authors

Dr Claire Keaney