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.

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.

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.

ACR Appropriateness Criteria® Plexopathy: 2021 Update.

Plexopathy may be caused by diverse pathologies, including trauma, nerve entrapment, neoplasm, inflammation, infection, autoimmune disease, hereditary disease, and idiopathic etiologies. For patients presenting with brachial or lumbosacral plexopathy, dedicated plexus MRI is the most appropriate initial imaging modality for all clinical scenarios and can identify processes both intrinsic and extrinsic to the nerves. Other imaging tests may be appropriate for initial imaging depending on the clinical scenario. This document addresses initial imaging strategies for brachial and lumbosacral plexopathy in the following clinical situations: nontraumatic plexopathy with no known malignancy, traumatic plexopathy (not perinatal), and plexopathy occurring in the context of a known malignancy or posttreatment syndrome. 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.

ACR Appropriateness Criteria® Suspected Spine Infection.

Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. 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.

ACR Appropriateness Criteria® Myelopathy: 2021 Update.

Myelopathy is a clinical diagnosis with localization of the neurological findings to the spinal cord, rather than the brain or the peripheral nervous system, and then to a particular segment of the spinal cord. Myelopathy can be the result of primary intrinsic disorders of the spinal cord or from secondary conditions, which result in extrinsic compression of the spinal cord. While the causes of myelopathy may be multiple, the acuity of presentation and symptom onset frame a practical approach to the differential diagnosis. Imaging plays a crucial role in the evaluation of myelopathy with MRI the preferred modality. 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.

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.

Acute traumatic intraosseous fluid sign predisposes to dynamic fracture mobility.

The intraosseous fluid sign (IFS) in chronic osteoporotic vertebral fractures is attributed to fluid accumulation within non-healing intervertebral clefts. IFS can also be seen in acute traumatic fractures, not previously described. We hypothesize a pathophysiological mechanism for the acute traumatic intraosseous fluid sign (ATIFS) and its predisposition to dynamic fracture mobility with axial loading on upright radiographs. Retrospective analysis was performed of 41 acute thoracic and lumbar compression or stable burst fractures with both supine CT and upright plain films completed within 1 week of each other. The presence of an intravertebral cleft with fluid attenuation and vertebral body height loss was assessed on CT scans. Changes in the fractured vertebral body height and angulation were measured on upright radiographs. The ATIFS was identified in 18 (44%) of the 41 acute fractures. Mean kyphotic angle increase was significantly greater (p = 0.000) for ATIFS fractures (8.2°, SD ±4.2) than fractures without ATIFS (1.6°, SD ±3.4). There was significantly greater mean anterior (p = 0.0009) and central (p = 0.026) height loss in ATIFS fractures (4.3 mm, SD ±3.76 and 1.89 mm, SD ±4.44, respectively) compared to fractures without ATIFS (0.59 mm, SD ±2.24 and -0.52 mm, SD ±2.01, respectively). The IFS can be seen in acute traumatic vertebral fractures and show dynamic mobility. These ATIFS fractures show statistically significant greater mean height loss ratio differences and have significantly greater changes in kyphotic angulation on upright imaging when compared to fractures without ATIFS.