Disparities in Provider Ordering Practices of Image-Guided Interventions and Surgery for Patients With Low Back Pain: A Cohort Study.

OBJECTIVE: To assess individual- and neighborhood-level sociodemographic factors associating with providers' ordering of nonpharmacologic treatments for patients with low back pain (LBP), specifically physical therapy, image-guided interventions, and lumbar surgery. METHODS: Our cohort included all patients diagnosed with LBP from 2000 to 2017 in a statewide database of all hospitals and ambulatory surgical facilities within Utah. We compared sociodemographic and clinical characteristics of (1) patients with LBP who received any treatment with those who received none and (2) patients with LBP who received invasive LBP treatments with those who only received noninvasive LBP treatments using the Student's t test, Wilcoxon's rank-sum tests, and Pearson's χ2 tests, as applicable, and two separate multivariate logistic regression models: (1) to determine whether sociodemographic characteristics were risk factors for receiving any LBP treatments and (2) risk factors for receiving invasive LBP treatments. RESULTS: Individuals in the most disadvantaged neighborhoods were less likely to receive any nonpharmacologic treatment orders (odds ratio [OR] 0.74 for most disadvantaged, P < .001) and received fewer invasive therapies (0.92, P = .018). Individual-level characteristics correlating with lower rates of treatment orders were female sex, Native Hawaiian or other Pacific Islander race (OR 0.50, P < .001), Hispanic ethnicity (OR 0.77, P < .001), single or unmarried status (OR 0.69, P < .001), and no insurance or self-pay (OR 0.07, P < .001). CONCLUSION: Neighborhood and individual sociodemographic variables associated with treatment orders for LBP with Area Deprivation Index, sex, race or ethnicity, insurance, and marital status associating with receipt of any treatment, as well as more invasive image-guided interventions and surgery.

A pioneer of neuroradiology: The life and career of Dr. Anne G. Osborn.

Dr. Anne G. Osborn is renowned for her pioneering contributions to neuroradiology and is internationally recognized in shaping the field and is widely acknowledged as a trailblazer and educator. This review encompasses her career trajectory, from her initial exposure to radiology in medical school and her seminal contributions. The following account explores her life, challenges, achievements, and enduring impact on neuroradiology.

Time for change? Radiologists highly concordant assessing change in stenoses on follow-up cervical spine MRI.

OBJECTIVE: There is considerable variability among radiologists when grading spinal canal and foraminal stenosis on MRI. However, to date, studies have not evaluated radiologists' agreement when assessing interval change in cervical spine stenoses. The purpose of this study was to evaluate radiologists' concordance for change in cervical spine stenoses on follow-up MRIs, a major indication for these exams. METHODS: Initial and follow-up cervical MRIs were retrospectively reviewed by three blinded radiologists. Spinal canal and foramina from C1 through T1 were rated for interval change and concordance between the blinded raters was calculated. The original MRI reports were also reviewed for specific language assessing interval change on the follow-up exams. RESULTS: 40 cervical MRI exams and 40 corresponding MRI follow-ups were assessed. Agreement for interval change in spinal canal and foraminal stenosis was near perfect amongst all readers (kappa values of 0.78-0.94). 97% of the original MRI reports used the standard severity scale. 68% of follow-up MRI reports specifically assessed for change. DISCUSSION: Blinded radiologists had high agreement when assessing for change in spinal canal and foraminal stenosis on follow-up cervical spine MRIs. Because of inter-rater variability in stenosis grading, reports that do not emphasize change assessment, may imply change that is not truly present. For clarity and consistency in reporting of cervical spine stenoses, change assessment should be emphasized and added to structured reporting templates.

Image-Guided Spine Interventions for Pain: Ongoing Controversies.

An expanding array of image-guided spine interventions have the potential to provide immediate and effective pain relief. Innovations in spine intervention have proceeded rapidly, with clinical adoption of new techniques at times occurring before the development of bodies of evidence to establish efficacy. Although new spine interventions have been evaluated by clinical trials, acceptance of results has been hindered by controversies regarding trial methodology. This article explores controversial aspects of four categories of image-guided interventions for painful conditions: spine interventions for postdural puncture headache resulting from prior lumbar procedures, epidural steroid injections for cervical and lumbar radiculopathy, interventions for facet and sacroiliac joint pain, and vertebral augmentations for compression fractures. For each intervention, we summarize the available literature, with an emphasis on persistent controversies, and discuss how current areas of disagreement and challenge may shape future research and innovation. Despite the ongoing areas of debate regarding various aspects of these procedures, effective treatments continue to emerge and show promise for aiding relief of a range of debilitating conditions.

Extrarenal malignant rhabdoid tumor infiltrating the brachial plexus and spinal canal.

Extrarenal malignant rhabdoid tumors are rare, aggressive lesions that primarily affect infants and children with characteristic SMARCB1/INI1 mutations. While rhabdoid tumors are most commonly found in the kidneys and central nervous system, they have been reported in virtually every soft tissue in the body. A 20-year-old previously healthy male presented with a 4-month history of left upper extremity weakness and pain and a 1-week history of lower extremity weakness. MRI showed a combined intradural and extradural mass arising from the C8 root and involving the lower trunk of the brachial plexus. CT guided biopsy followed with onsite cytologic analysis initially concerning for plasma cell etiology. Full body PET/CT showed no evidence of metastases. The tumor was surgically resected and debulked. Extensive immunohistochemical testing on the resected specimen revealed a diagnosis of extrarenal malignant rhabdoid tumor. Recurrence invading paraspinous muscles, left lateral paravertebral space, left apical lung, and brachial plexus was noted within 2 months. Radiation and chemotherapy were initiated. Here we present imaging findings, image-guided biopsy, surgical management, and pathologic diagnosis of a rare case of extrarenal, extracranial malignant rhabdoid tumor of the brachial plexus and surrounding paraspinous muscles in a young adult male.

Delineating the Subarachnoid Space in the Adult Lumbosacral Spine Using Computed Tomographic Myelography: An Aid for Clinical Target Volume Delineation in Craniospinal Irradiation.

Purpose: Our aim was to characterize the patterns of cerebrospinal fluid (CSF) extension in the lumbosacral spine using computed tomography (CT) myelograms to provide an evidence base for clinical target volume (CTV) definition in adults receiving craniospinal irradiation. Methods and Materials: This was a retrospective analysis of diagnostic CT lumbar myelograms performed in 30 patients between the ages of 22 and 50. Lateral extension of CSF beyond the thecal sac was measured along each lumbar and sacral nerve root to the nearest millimeter, as was the distance of inferior extension of CSF beyond the caudal end of the thecal sac. Each patient's lateral and inferior CSF extensions were mapped onto a standardized CT data set to create a model target volume in the lumbosacral spine that would contain the aggregate observed CSF distributions from the analyzed CT myelograms. The median extension distances, interquartile ranges, and 90th percentile for distance at each level were calculated. Results: The median lateral extension of CSF along nerve roots beyond the thecal sac-as measured perpendicular to the longitudinal axis-increased from 0 mm (interquartile range [IQR], 0-4 mm) at L1 to 8 mm (IQR, 6-12 mm) at S1 and 0 mm (IQR, 0-0 mm) at S4. The 90th percentile ranged from 5 to 14 mm laterally, with a pattern partially extending into the S1 and S2 sacral foramen. Median CSF extension inferior to the caudal sac was 5 mm (IQR, 2-8 mm), with 90% of patients within 12 mm. An atlas was generated to guide CTV delineation for highly conformal radiation techniques. Conclusion: These results provide information on patterns of CSF extension in the lumbosacral spine of adults and can serve as a model for CTV guidelines that balance comprehensive coverage of the CSF compartment while minimizing the dose to nontarget tissues.

ACR Appropriateness Criteria® Low Back Pain: 2021 Update.

In the United States, acute low back pain, with or without radiculopathy, is the leading cause of years lived with disability and the third ranking cause of disability-adjusted life-years. Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags, raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, fracture, or infection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Shifting Spine Interventional Pain Injections From the Hospital to a Clinic Setting: Increased Efficiency and Decreased Health System Costs.

OBJECTIVE: Spine interventional pain injections have dramatically increased in volume in the past three decades. High referral volumes at our institution necessitated using both a hospital-based interventional suite and a clinic-based suite scheduled on a first-come, first-served basis. We sought to determine whether the clinic-based suite provided benefits in efficiency and health system cost in comparison with the hospital suite without compromising quality of care. METHODS: To investigate differences between outpatient procedures performed in hospital-based procedure rooms (HBPRs) and clinic-based procedure rooms (CBPRs), we reviewed all consecutive outpatient spine interventional pain procedures performed by the interventional neuroradiology service over a 12-month period. We analyzed procedure complexity, fluoroscopic times, procedural times, patient wait times, and health system costs for each case, as well as any complications. RESULTS: Our analysis demonstrated similar procedural complexity between sites with decreased average fluoroscopic time (112 seconds versus 163 seconds, P = .002), procedural time (17 min versus 28 min, P < .001), and wait time (20 min versus 38 min, P < .001) in the CBPR versus the HBPR. In cases without trainee involvement, procedural and wait times were decreased (P < .001, P = .008) with no difference in fluoroscopy time (P = .18). There were no complications at either site. The analysis of cost to the health system demonstrated that procedures in the HBPR cost >14 times the amount to perform than in the CBPR. DISCUSSION: Performing spine interventional pain procedures in a CBPR adds value by decreasing procedural, fluoroscopic, wait times, and health system cost compared with an HBPR without compromising safety.

Defining Disc Biopsy Timing in Relation to Blood Culture Results for Inpatients with Suspected Discitis-Osteomyelitis.

PURPOSE: To determine optimal timing of biopsy for suspected discitis-osteomyelitis (DOM) with respect to preliminary blood culture results and the effect of biopsy timing on hospital length of stay (LOS). MATERIALS AND METHODS: This retrospective study reviewed disc/vertebral biopsies for suspected DOM performed between 2010 and 2018. A total of 107 disc/vertebral biopsies were performed on 96 inpatients (mean ± SD age 57.9 ± 14.5 years, 68 men/28 women) for suspected DOM, and 100 cases of DOM were clinically confirmed and treated. Descriptive and regression statistics were performed with LOS as the primary outcome. RESULTS: Of disc biopsies in clinically confirmed cases, 68% were positive; 20% of all biopsies had preliminary positive blood cultures after 2 hospital days. There was no difference in LOS between cases with biopsy performed ≤ 2 days after blood culture and cases with biopsy performed > 2 days after blood culture (P = .40). Regression analysis showed no association between positive biopsy results and sepsis, white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP). Biopsy yield was not significantly decreased in patients previously taking antibiotics (P = .09). CONCLUSIONS: Waiting 2 days for preliminary blood culture results could avoid disc/vertebral biopsy in 20% of patients and does not significantly impact hospital LOS. Additionally, clinical factors (sepsis, WBC count, CRP, and ESR) do not have predictive value for positive disc biopsy results.

Imaging Appropriateness for Neck Pain.

Imaging of neck pain contributes to a significant proportion of health care costs and is expected to increase with current practices that heavily use radiologic studies as a diagnostic tool. Though consensus guidelines are available to assist physicians in selection of appropriate imaging examinations for neck pain, it is unclear if current ordering practices reflect their use and understanding. To investigate this, we analyzed the number and types of imaging examinations performed for neck pain at a university medical center over the past year. Current trends at our institution suggest that clinicians use consensus imaging guidelines, but there is still controversy in the cervical spine for when not to image. To promote appropriate imaging utilization, we developed an algorithm to guide imaging of neck pain, based upon clinical presentation, referral patterns for neck pain, and a review of the literature.

Conventional Image-Guided Procedures for Painful Spine.

This article reviews image-guided approaches for the treatment of common spine pain generators. The following treatment targets are discussed: epidural space (interlaminar and transforaminal approaches), facet joint, sacroiliac joint, and synovial cysts.

Imaging of Vascular Disorders of the Spine.

Vascular disorders of the spine are more rare than cerebral vascular entities but can result in significant morbidity. These lesions frequently demonstrate distinguishing characteristics by imaging that are imperative for the radiologist to recognize to properly guide diagnosis and treatment. We review distinguishing imaging characteristics for spinal vascular malformations, spinal emergencies, and spinal vascular masses.

Gliosarcoma: Neuroimaging and Immunohistochemical Findings.

BACKGROUND AND PURPOSE: Gliosarcoma (GSC) is an intra-axial lesion which often abuts a dural margin and is composed of glial and mesenchymal elements. This lesion is considered a variant of isocitrate dehydrogenase (IDH)-wild type glioblastoma (GBM). The purpose of this study is to evaluate the imaging and molecular features of GSC in a large patient cohort. METHODS: Pathology-proved GSC cases were collected from our quaternary care center spanning the last 16 years and IDH status was documented. Older GSC cases without prior immunohistochemical testing underwent tissue block staining to obtain IDH status. When available, p53, phosphate and tensin (PTEN), MIB-1, EGFR amplification, and MGMT methylation were recorded and imaging findings tabulated. Logistic regression analyses were performed to determine correlation of molecular markers and imaging characteristics. RESULTS: A total of 25 cases were identified (21 de novo, 4 post-treatment). All lesions contacted a dural, pial, or ependymal surface and were negative for an IDH R132H mutation, including postradiation GSC. In total, 16 of 16 cases showed nonamplification of EGFR/CEP7, 2 of 16 demonstrated MGMT methylation, and multiple lesions demonstrated p53 and PTEN mutations. Imaging features included areas of nodular thickening in necrotic lesions which appeared to abut the site of dural contact. There was no significant correlation of molecular markers with imaging characteristics. CONCLUSION: GSC was IDH(-) in all cases, supporting the current understanding of this lesion being a wild-type GBM variant. Additional molecular markers demonstrated no significant correlation with imaging findings in this cohort.

Effects of implementing evidence-based appropriateness guidelines for epidural steroid injection in chronic low back pain: the EAGER (Esi Appropriateness GuidElines pRotocol) study.

Objective: Chronic low back pain is very common and often treated with epidural steroid injections (ESIs). As ESI referrals had been rapidly increasing at our Veterans' Administration hospital, we were concerned that they were supplanting more comprehensive care. The objective was to determine how referral patterns and multidisciplinary care might change with the implementation of evidence-based guidelines. Methods: In this retrospective observational study, multidisciplinary evidence-based guidelines were implemented in 2014 (EAGER: Esi Appropriateness GuidElines pRotocol) as part of the ordering process for an ESI. Time series analysis was performed to assess the primary outcome of subspecialty referral pattern, that is, the number of patients receiving referrals to ancillary services which might serve to provide a more comprehensive approach to their back pain. Secondary outcomes included patient-level changes (ie, body mass index, number of injections, opioid use), which were compared before and after protocol implementation. Results: Comparing preimplementation and postimplementation protocol periods, referrals to physical medicine/rehabilitation increased 11.7% (p=0.003) per year and integrative health increased 2.1% (p<0.001) per year among the 2294 individual patients who received ESI through the neurointerventional radiology service. Of 100 randomly selected patients for patient-level analysis, the median body mass index decreased from 31.57 to 30.22 (p=<0.001) and the mean number of injections decreased from 1.76 to 0.73 (p<0.001). The percentage of patients using oral opioid analgesics decreased from 72% to 49% (p=<0.001). Conclusion: Implementation of evidence-based guidelines for ESI referral helps guide patients into a more comprehensive care pathway for chronic low back pain and is correlated with patient-level changes such as decreased body mass index and decreased opioid usage.

Low b-value diffusion weighted imaging is promising in the diagnosis of brain death and hypoxic-ischemic injury secondary to cardiopulmonary arrest.

BACKGROUND: Cardiorespiratory arrest can result in a spectrum of hypoxic ischemic brain injury leading to global hypoperfusion and brain death (BD). Because up to 40% of patients with BD are viable organ donors, avoiding delayed diagnosis of this condition is critical. High b-value diffusion weighted imaging (DWI) measures primarily molecular self-diffusion; however, low b-values are sensitive to perfusion. We investigated the feasibility of low b-value DWI in discriminating the global hypoperfusion of BD and hypoxic ischemic encephalopathy (HIE). METHODS: We retrospectively reviewed cardiorespiratory arrest subjects with a diagnosis of HIE or BD. Inclusion criteria included brain DWI acquired at both low (50 s/mm2) and high (1000-2000 s/mm2) b-values. Automated segmentation was used to determine mean b50 apparent diffusion coefficient (ADC) values in gray and white matter regions. Normal subjects with DWI at both values were used as age- and sex-matched controls. RESULTS: We evaluated 64 patients (45 with cardiorespiratory arrest and 19 normal). Cardiorespiratory arrest patients with BD had markedly lower mean b50 ADC in gray matter regions compared with HIE (0.70 ± 0.18 vs. 1.95 ± 0.25 × 10-3 mm2/s, p < 0.001) and normal subjects (vs. 1.79 ± 0.12 × 10-3 mm2/s, p < 0.001). HIE had higher mean b50 ADC compared with normal (1.95 ± 0.25 vs. 1.79 ± 0.12 × 10-3 mm2/s, p = 0.016). There was wide separation of gray matter ADC values in BD subjects compared with age matched normal and HIE subjects. White matter values were also markedly decreased in the BD population, although they were less predictive than gray matter. CONCLUSION: Low b-value DWI is promising for the discrimination of HIE with maintained perfusion and brain death in cardiorespiratory arrest.

Novel Pattern of Iron Deposition in the Fascicula Nigrale in Patients with Parkinson's Disease: A Pilot Study.

Background and Purpose. To determine whether the pattern of iron deposition in the fascicula nigrale in patients with Parkinson's disease would be different from age-matched controls by utilizing quantitative susceptibility mapping to measure susceptibility change. Methods. MRIs of the brain were obtained from 34 subjects, 18 with Parkinson's disease and 16 age- and gender-matched controls. Regions of interest were drawn around the fascicula nigrale and substantia nigra using SWI mapping software by blinded investigators. Statistical analyses were performed to determine susceptibility patterns of both of these regions. Results. Measurements showed significantly increased susceptibility in the substantia nigra in Parkinson's patients and an increased rostral-caudal deposition of iron in the fascicula nigrale in all subjects. This trend was exaggerated with significant correlation noted with increasing age in the Parkinson group. Conclusion. The pattern of an exaggerated iron deposition gradient of the fascicula nigrale in the Parkinson group could represent underlying tract dysfunction. Significant correlation of increasing iron deposition with increasing age may be a cumulative effect, possibly related to disease duration.