Neonatal spinal ultrasound for closed spinal dysraphism: an audit of the referral indications and results across three North London hospitals.
Jessica Carter, Ronica Pulikal , Jody Maclachlan, Maria Nordlander, Jeremy Berger
Royal Free Hospital NHS Foundation Trust, Whittington Hospital NHS Trust
BACKGROUND:
•Closed spinal dysraphism is a rare developmental abnormality that can cause spinal cord tethering and neurological injury.
•This is readily detectable in neonates with ultrasound (US) owing to the cartilaginous posterior elements of the neonatal spine (figure).
•US within 2 weeks is the first-line investigation in neonates with specific clinical findings on the newborn exam (below)1,2,3.
•US is limited in older children due to patient movement, and ossification of the posterior spinal elements.
STANDARD:
100% of sacral dimple ultrasound requests should meet at least one of the following criteria:
•Cutaneous stigmata
•Abnormal neurological examination
•Associated conditions such as VACTERL
•Sacral dimple assessment: >5mm diameter, OR > 2.5 cm from anus, OR unable to see base
The US should ideally be performed within 2 weeks of the referral.
AIMS/OBJECTIVES:
•Understand the patterns and pitfalls of US requests across 3 North London Hospitals
•Determine the proportion of requests that meet the standard
•Devise recommendations for referral practice
METHOD:
•Retrospective review of US scans performed for patients with suspected spinal dysraphism across Barnet, Whittington, and Royal Free Hospitals.
•Examination search terms on PACS were used to find ~80 spine scans/hospital.
•Scan requests were excluded if the patient did not attend the appointment, or if the clinical question did not relate to occult spinal dysraphism.
RESULTS:
•45% of all US requests met the standard, (112/248)
•65% of hospital requests met the standard, (114/175)
•30% of GP requests met the standard, (22/73)
•Most common incorrect referral was a ‘sacral dimple alone’.
•8% of patients, (20/248), were >6 months of age at examination.
•Average Interval between request and examination was 16-24 days with no concerning patterns of delay noted.
•5 ultrasounds were abnormal, 4 of these met guidelines and required MRI/neurosurgical review.
RECOMMENDATIONS:
Findings were presented and discussed locally in each hospital’s radiology department and disseminated to neonatal consultants. Recommendations include:
1.Improve Royal Free Trust guidance by adding images of normal/abnormal sacral dimples
2.Create Whittington Trust guidance (none currently)
3.Provide educational sessions for requesting practitioners in GP and hospital settings
References:
1.(iRefer) P08: Congenital disorders of the spine in children
2.(iRefer) P19: Sacral dimple/pit or other cutaneous stigmata in children (e.g., hairy patch)
3.(Intranet): Royal Free NHS Foundation Trust guidance “Sacrococcygeal Dimples” May 2023
