Chronic sacroiliac joint dysfunction and CT-guided percutaneous fixation: a 6-year experience.

PURPOSE: Reporting the clinical outcomes, patient satisfaction, and complications following an imaging-guided percutaneous screw fixation in the treatment of sacroiliac joint dysfunction and evaluating the safety and effectiveness of this method. METHODS: We performed a retrospective study on a prospectively gathered cohort of patients with physiotherapy-resistant pain due to sacroiliac joint incompetence that underwent percutaneous screw fixation, between 2016 and 2022 in our center. A minimum of two screws were used in all patients to obtain fixation of the sacroiliac joint, using percutaneous screw insertion under CT guidance, coupled with a C-arm fluoroscopy unit. RESULTS: The mean visual analog scale significantly improved at 6 months of follow-up (p < 0.05). One hundred percent of the patients reported significant improvement in pain scores at the final follow-up. None of our patients experienced intraoperative or postoperative complications. CONCLUSION: The use of percutaneous sacroiliac screws provides a safe and effective technique for the treatment of sacroiliac joint dysfunction in patients with chronic resistant pain.

Trends in opioid use following balloon kyphoplasty or vertebroplasty for the treatment of vertebral compression fractures.

This retrospective analysis of insurance claims evaluated real-world trends in prescription fills among patients treated with balloon kyphoplasty (N = 6,656) or vertebroplasty (N = 2,189) following diagnosis of vertebral compression fracture. Among those with evidence of opioid use, nearly half of patients discontinued or reduced prescription fills relative to pre-operative levels. INTRODUCTION: Vertebral compression fractures (VCF) are associated with debilitating pain, spinal misalignment, increased mortality, and increased healthcare-resource utilization in elderly patients. This study evaluated the effect of balloon kyphoplasty (BKP) or vertebroplasty (VP) on post-procedure opioid prescription fills and payer costs in patients with VCF. METHODS: This was a retrospective analysis of a large, nationally representative insurance-claims database. Clinical characteristics, opioid prescription patterns, and payer costs for subjects who underwent either BKP or VP to treat VCF were evaluated beginning 6 months prior to surgery through 7-month follow-up that included a 30-day, postoperative medication washout. Patient demographics, changes in opioid utilization, and payer costs were analyzed. RESULTS: A total of 8,845 patients met eligibility criteria (75.3% BKP and 24.7% VP) with a mean of age 77 and 74% female. Among the 75% of patients who used opioids, 48.7% of patients discontinued opioid medication and 8.4% reduced prescription fills versus preoperative baseline. Patients who reduced or discontinued prescriptions exhibited a decrease in all-cause payer costs relative to pre-intervention levels, which was a significantly greater change relative to patients with no change, increase, or new start of opioids. CONCLUSIONS: Interventional treatment for VCF was associated with decreased or discontinued opioid prescription fills and reduced payer costs in follow-up in a significant proportion of the study population. Reduction of opioid-based harms may represent a previously unrecognized benefit of vertebral augmentation for VCF, especially in this elderly and medically fragile population.

Correction to: Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty "sham" trials?

The article Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty "sham" trials?, written by K. L. Ong, D. P. Beall, M. Frohbergh, E. Lau, and J. A. Hirsch was originally published electronically on the publisher's internet portal.

Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty "sham" trials?

The 5-year period following 2009 saw a steep reduction in vertebral augmentation volume and was associated with elevated mortality risk in vertebral compression fracture (VCF) patients. The risk of mortality following a VCF diagnosis was 85.1% at 10 years and was found to be lower for balloon kyphoplasty (BKP) and vertebroplasty (VP) patients. INTRODUCTION: BKP and VP are associated with lower mortality risks than non-surgical management (NSM) of VCF. VP versus sham trials published in 2009 sparked controversy over its effectiveness, leading to diminished referral volumes. We hypothesized that lower BKP/VP utilization would lead to a greater mortality risk for VCF patients. METHODS: BKP/VP utilization was evaluated for VCF patients in the 100% US Medicare data set (2005-2014). Survival and morbidity were analyzed by the Kaplan-Meier method and compared between NSM, BKP, and VP using Cox regression with adjustment by propensity score and various factors. RESULTS: The cohort included 261,756 BKP (12.6%) and 117,232 VP (5.6%) patients, comprising 20% of the VCF patient population in 2005, peaking at 24% in 2007-2008, and declining to 14% in 2014. The propensity-adjusted mortality risk for VCF patients was 4% (95% CI, 3-4%; p < 0.001) greater in 2010-2014 versus 2005-2009. The 10-year risk of mortality for the overall cohort was 85.1%. BKP and VP cohorts had a 19% (95% CI, 19-19%; p < 0.001) and 7% (95% CI, 7-8%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the NSM cohort, respectively. The BKP cohort had a 13% (95% CI, 12-13%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the VP cohort. CONCLUSIONS: Changes in treatment patterns following the 2009 VP publications led to fewer augmentation procedures. In turn, the 5-year period following 2009 was associated with elevated mortality risk in VCF patients. This provides insight into the implications of treatment pattern changes and associated mortality risks.

The NAP motif of activity-dependent neuroprotective protein (ADNP) regulates dendritic spines through microtubule end binding proteins.

The NAP motif of activity-dependent neuroprotective protein (ADNP) enhanced memory scores in patients suffering from mild cognitive impairment and protected activities of daily living in schizophrenia patients, while fortifying microtubule (MT)-dependent axonal transport, in mice and flies. The question is how does NAP fortify MTs? Our sequence analysis identified the MT end-binding protein (EB1)-interacting motif SxIP (SIP, Ser-Ile-Pro) in ADNP/NAP and showed specific SxIP binding sites in all members of the EB protein family (EB1-3). Others found that EB1 enhancement of neurite outgrowth is attenuated by EB2, while EB3 interacts with postsynaptic density protein 95 (PSD-95) to modulate dendritic plasticity. Here, NAP increased PSD-95 expression in dendritic spines, which was inhibited by EB3 silencing. EB1 or EB3, but not EB2 silencing inhibited NAP-mediated cell protection, which reflected NAP binding specificity. NAPVSKIPQ (SxIP=SKIP), but not NAPVAAAAQ mimicked NAP activity. ADNP, essential for neuronal differentiation and brain formation in mouse, a member of the SWI/SNF chromatin remodeling complex and a major protein mutated in autism and deregulated in schizophrenia in men, showed similar EB interactions, which were enhanced by NAP treatment. The newly identified shared MT target of NAP/ADNP is directly implicated in synaptic plasticity, explaining the breadth and efficiency of neuroprotective/neurotrophic capacities.

Minimally Invasive Stent Screw-Assisted Internal Fixation Technique Corrects Kyphosis in Osteoporotic Vertebral Fractures with Severe Collapse: A Pilot "Vertebra Plana" Series.

BACKGROUND AND PURPOSE: Fractures with "vertebra plana" morphology are characterized by severe vertebral body collapse and segmental kyphosis; there is no established treatment standard for these fractures. Vertebroplasty and balloon kyphoplasty might represent an undertreatment, but surgical stabilization is challenging in an often elderly osteoporotic population. This study assessed the feasibility, clinical outcome, and radiologic outcome of the stent screw-assisted internal fixation technique using a percutaneous implant of vertebral body stents and cement-augmented pedicle screws in patients with non-neoplastic vertebra plana fractures. MATERIALS AND METHODS: Thirty-seven consecutive patients with vertebra plana fractures were treated with the stent screw-assisted internal fixation technique. Vertebral body height, local and vertebral kyphotic angles, outcome scales (numeric rating scale and the Patient's Global Impression of Change), and complications were assessed. Imaging and clinical follow-up were obtained at 1 and 6 months postprocedure. RESULTS: Median vertebral body height restoration was 7 mm (+74%), 9 mm (+150%), and 3 mm (+17%) at the anterior wall, middle body, and posterior wall, respectively. Median local and vertebral kyphotic angles correction was 8° and 10° and was maintained through the 6-month follow-up. The median numeric rating scale score improved from 8/10 preprocedure to 3/10 at 1 and 6 months (P < .001). No procedural complications occurred. CONCLUSIONS: The stent screw-assisted internal fixation technique was effective in obtaining height restoration, kyphosis correction, and pain relief in patients with severe vertebral collapse.

Correlation of Call Burden and Sleep Deprivation with Physician Burnout, Driving Crashes, and Medical Errors among US Neurointerventionalists.

BACKGROUND AND PURPOSE: High call frequency can lead to inadequate sleep, fatigue, and burnout, resulting in detrimental effects on physicians and patients. We aimed to assess the correlation between the frequency and burden of neurointerventional surgery calls and sleep deprivation with physician burnout, physical and driving safety, and fatigue-related medical errors. MATERIALS AND METHODS: We sent an online questionnaire to the members of the 2 neurointerventional surgery societies comprising 50 questions and spanning 3 main topics: 1) overnight/weekend call burden, 2) sleeping patterns, and 3) Copenhagen Burnout Inventory. RESULTS: One hundred sixty-four surveys were completed. Most (54%) neurointerventional surgeons reported burnout. Call burden of ≥1 every 3 days and being in practice >10 years were independent predictors of burnout. Thirty-nine percent reported falling asleep at the wheel, 23% reported a motor vehicle crash/near-crash, and 34% reported medical errors they considered related to call/work fatigue. On multivariate logistic regression, high call burden (called-in >3 times/week) was an independent predictor of sleeping at the wheel and motor vehicle crashes. Reporting <4 hours of uninterrupted sleep was an independent predictor of motor vehicle crashes and medical errors. Most neurointerventional surgeons recommended a maximum call frequency of once every 3 days. CONCLUSIONS: Call frequency and burden, number of years in practice, and sleep deprivation are associated with burnout of neurointerventional surgeons, sleeping at the wheel, motor vehicle crashes, and fatigue-related medical errors. These findings contribute to the increasing literature on physician burnout and may guide future societal recommendations related to call burden in neurointerventional surgery.

CTA Protocols in a Telestroke Network Improve Efficiency for Both Spoke and Hub Hospitals.

BACKGROUND AND PURPOSE: Telestroke networks support screening for patients with emergent large-vessel occlusions who are eligible for endovascular thrombectomy. Ideal triage processes within telestroke networks remain uncertain. We characterize the impact of implementing a routine spoke hospital CTA protocol in our integrated telestroke network on transfer and thrombectomy patterns. MATERIALS AND METHODS: A protocol-driven CTA process was introduced at 22 spoke hospitals in November 2017. We retrospectively identified prospectively collected patients who presented to a spoke hospital with National Institutes of Health Stroke Scale scores ≥6 between March 1, 2016 and March 1, 2017 (pre-CTA), and March 1, 2018 and March 1, 2019 (post-CTA). We describe the demographics, CTA utilization, spoke hospital retention rates, emergent large-vessel occlusion identification, and rates of endovascular thrombectomy. RESULTS: There were 167 patients pre-CTA and 207 post-CTA. The rate of CTA at spoke hospitals increased from 15% to 70% (P < .001). Despite increased endovascular thrombectomy screening in the extended window, the overall rates of transfer out of spoke hospitals remained similar (56% versus 54%; P = .83). There was a nonsignificant increase in transfers to our hub hospital for endovascular thrombectomy (26% versus 35%; P = .12), but patients transferred >4.5 hours from last known well increased nearly 5-fold (7% versus 34%; P < .001). The rate of endovascular thrombectomy performed on patients transferred for possible endovascular thrombectomy more than doubled (22% versus 47%; P = .011). CONCLUSIONS: Implementation of CTA at spoke hospitals in our telestroke network was feasible and improved the efficiency of stroke triage. Rates of patients retained at spoke hospitals remained stable despite higher numbers of patients screened. Emergent large-vessel occlusion confirmation at the spoke hospital lead to a more than 2-fold increase in thrombectomy rates among transferred patients at the hub.

Medicare for All: Considerations for Neuroradiologists.

The year 2019 featured extensive debates on transforming the United States multipayer health care system into a single-payer system. At a time when reimbursement structures are in flux and potential changes in government may affect health care, it is important for neuroradiologists to remain informed on how emerging policies may impact their practices. The purpose of this article is to examine potential ramifications for neuroradiologist reimbursement with the Medicare for All legislative proposals. An institution-specific analysis is presented to illustrate general Medicare for All principles in discussing issues applicable to practices nationwide.

Implications of the Revisions and Revaluation of Office/Outpatient Evaluation and Management Codes for Neuroradiology Reimbursement.

In the 2020 Final Rule, the Center for Medicare & Medicaid Services adopted a new coding structure and accepted the substantial increase in valuation for office/outpatient Evaluation and Management codes set to begin in 2021. Given budget neutrality requirements, the projected increase in reimbursement will require a reduction in the conversion factor to offset such increases. The aim is to inform neuroradiologists the impact of these proposed changes on reimbursement and the profession.

Preserving Access: A Review of Stroke Thrombectomy during the COVID-19 Pandemic.

Thrombectomy for large-vessel-occlusion stroke is a highly impactful treatment. The spread of coronavirus 19 (COVID-19) across the United States and the globe impacts access to this crucial intervention through widespread societal and institutional changes. In this document, we review the implications of COVID-19 on the emergency care of large-vessel occlusion stroke, reviewing specific infection-control recommendations, available literature, existing resources, and expert consensus. As a population, patients with large-vessel occlusion stroke face unique challenges during pandemics. These are broad in scope. Responses to these challenges through adaptation of stroke systems of care and with imaging, thrombectomy, and postprocedural care are detailed. Preservation of access to thrombectomy must be prioritized for its public health impact. While the extent of required changes will vary by region, tiered planning for both escalation and de-escalation of measures must be a part of each practice. In addition, preparations described serve as templates in the event of future pandemics.

Number Needed to Treat with Vertebral Augmentation to Save a Life.

BACKGROUND AND PURPOSE: Evidence from randomized controlled trials for the efficacy of vertebral augmentation in vertebral compression fractures has been mixed. However, claims-based analyses from national registries or insurance datasets have demonstrated a significant mortality benefit for patients with vertebral compression fractures who receive vertebral augmentation. The purpose of this study was to calculate the number needed to treat to save 1 life at 1 year and up to 5 years after vertebral augmentation. MATERIALS AND METHODS: A 10-year sample of the 100% US Medicare data base was used to identify patients with vertebral compression fractures treated with nonsurgical management, balloon kyphoplasty, and vertebroplasty. The number needed to treat was calculated between augmentation and nonsurgical management groups from years 1-5 following a vertebral compression fracture diagnosis, using survival probabilities for each management approach. RESULTS: The adjusted number needed to treat to save 1 life for nonsurgical management versus kyphoplasty ranged from 14.8 at year 1 to 11.9 at year 5. The adjusted number needed to treat for nonsurgical management versus vertebroplasty ranged from 22.8 at year 1 to 23.8 at year 5. CONCLUSIONS: Both augmentation modalities conferred a prominent mortality benefit over nonsurgical management in this analysis of the US Medicare registry, with a low number needed to treat. The calculations based on this data base resulted in a low number needed to treat to save 1 life at 1 year and at 5 years.

Board Certification Characteristics of Practicing Neuroradiologists.

BACKGROUND AND PURPOSE: Insight into the status of neuroradiology subspecialty certification across the United States could help to understand neuroradiologists' perceived value of subspecialty certification as well as guide efforts to optimize pathways for broader voluntary certification participation. Our aim was to assess board certification characteristics of practicing US neuroradiologists. MATERIALS AND METHODS: The American Board of Radiology public search engine was used to link Medicare-participating radiologists with American Board of Radiology diplomates. Among linked diplomates, 4670 neuroradiologists were identified on the basis of 3 criteria: current or prior neuroradiology subspecialty certification or currently >50% clinical work effort in neuroradiology based on work relative value unit-weighted national Medicare claims ("majority-practice neuroradiologists"). Subspecialty certification status was studied in each group, using Centers for Medicare & Medicaid Services data to identify additional physician characteristics. RESULTS: Of 3769 included radiologists ever subspecialty certified, 84.1% are currently subspecialty certified. Of 1777/3769 radiologists ever subspecialty-certified and with lifetime primary certificates (ie, nonmandated Maintenance of Certification), only 66.6% are currently subspecialty certified. Of 3341 included majority-practice neuroradiologists, 73.0% were ever subspecialty certified; of these, 89.1% are currently subspecialty certified. Of 3341 majority-practice neuroradiologists, the fraction currently subspecialty certified was higher for those in academic (81.3%) versus nonacademic (58.2%) practices, larger versus smaller practices (72.1% for those in ≥100 versus 36.1% for <10-member practices), US regions other than the West (64.1%-70.6% versus 56.5%), fewer years in practice (77.5% for 11-20 years versus 31.3% for >50 years), and time-limited (73.5%) versus lifetime (54.9%) primary certificates. CONCLUSIONS: More than one-quarter of majority-practice neuroradiologists never obtained neuroradiology subspecialty certification. Even when initially obtained, that certification is commonly not maintained, particularly by lifetime primary certificate diplomates and those in nonacademic and smaller practices. Further investigation is warranted to better understand neuroradiologists' decisions regarding attaining and maintaining subspecialty certification.

Armed Kyphoplasty: An Indirect Central Canal Decompression Technique in Burst Fractures.

BACKGROUND AND PURPOSE: Burst fractures are characterized by middle column disruption and may feature posterior wall retropulsion. Indications for treatment remain controversial. Recently introduced vertebral augmentation techniques using intravertebral distraction devices, such as vertebral body stents and SpineJack, could be effective in fracture reduction and fixation and might obtain central canal clearance through ligamentotaxis. This study assesses the results of armed kyphoplasty using vertebral body stents or SpineJack in traumatic, osteoporotic, and neoplastic burst fractures with respect to vertebral body height restoration and correction of posterior wall retropulsion. MATERIALS AND METHODS: This was a retrospective assessment of 53 burst fractures with posterior wall retropulsion and no neurologic deficit in 51 consecutive patients treated with armed kyphoplasty. Posterior wall retropulsion and vertebral body height were measured on pre- and postprocedural CT. Clinical and radiologic follow-up charts were reviewed. RESULTS: Armed kyphoplasty was performed as a stand-alone treatment in 43 patients, combined with posterior instrumentation in 8 and laminectomy in 4. Pre-armed kyphoplasty and post-armed kyphoplasty mean posterior wall retropulsion was 5.8 and 4.5 mm, respectively (P < .001), and mean vertebral body height was 10.8 and 16.7 mm, respectively (P < .001). No significant clinical complications occurred. Clinical and radiologic follow-up (1-36 months; mean, 8 months) was available in 39 patients. Three treated levels showed a new fracture during follow-up without neurologic deterioration, and no retreatment was deemed necessary. CONCLUSIONS: In the treatment of burst fractures with posterior wall retropulsion and no neurologic deficit, armed kyphoplasty yields fracture reduction, internal fixation, and indirect central canal decompression. In selected cases, it might represent a suitable minimally invasive treatment option, stand-alone or in combination with posterior stabilization.

Comparison of Advanced Imaging Resources, Radiology Workforce, and Payment Methodologies between the United States and Canada.

The purpose of this Practice Perspectives was to review the United States and Canadian approaches to health care access and payment for advanced imaging. The historical background, governmental role, workforce, coding, payment, radiologic challenges, cost, resource intensity, and overall outcomes in longevity are reviewed.

John Nash and the Organization of Stroke Care.

The concept of Nash equilibrium, developed by John Forbes Nash Jr, states that an equilibrium in noncooperative games is reached when each player takes the best action for himself or herself, taking into account the actions of the other players. We apply this concept to the provision of endovascular thrombectomy in the treatment of acute ischemic stroke and suggest that collaboration among hospitals in a health care jurisdiction could result in practices such as shared call pools for neurointervention teams, leading to better patient care through streamlined systems.