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.

Trigeminal amyloidoma: case report and review of the literature.

The authors present a case of amyloid infiltration involving the trigeminal nerve that mimicked a malignant cavernous sinus tumor with perineural tumor infiltration. A 64-year-old man presented with trigeminal nerve numbness. Imaging revealed a plaque-like enhancing lesion along the right lateral cavernous sinus extending anteriorly into Meckel's cave and involving the proximal V2 and V3 branches of the trigeminal nerve. The patient underwent an extradural frontotemporal craniotomy with middle fossa exposure of the cavernous sinus to diagnose and treat the presumed malignant cavernous sinus tumor. A reddish mass involving the lateral dural wall of the cavernous sinus was resected. The gasserian ganglion, V2, and V3, the latter of which was biopsied, were enlarged. Permanent histopathological studies showed microscopic eosinophilic, amorphous material, which stained positive for Congo red, and an absence of neoplastic cells. The final diagnosis was amyloidoma. Thus, amyloidomas can involve the trigeminal nerve or ganglia and should be considered in the differential diagnosis of a cavernous sinus lesion mimicking a tumor. Patients may have symptomatic improvement of trigeminal neuropathy with resection of the amyloidoma outside the nerve capsule that is compressing the nerve, while resection of the lesion from within the capsule may result in permanent trigeminal nerve dysfunction.

Imaging of the temporal bone.

Classical descriptions of the temporal bone are based on its five embryologically distinct osseous components: the petrous, tympanic, mastoid, squamous, and styloid portions.

Intralabyrinthine schwannomas: diagnosis, management, and a new classification system.

OBJECTIVE: To outline the diagnosis and management of intralabyrinthine schwannomas and to propose a new classification system to further define them. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center at a university hospital. PATIENTS: Twenty-eight patients seen at the institution with intralabyrinthine schwannomas between 1996 and 2002 were included in the study. INTERVENTIONS: Diagnosis was made with magnetic resonance imaging in all but one case. Our ability to detect these tumors has been greatly enhanced by the introduction of high-resolution T2-weighted magnetic resonance imaging. Treatment options were observation with serial magnetic resonance imaging versus complete surgical removal via a translabyrinthine or transotic approach. Surgery was indicated for dizziness caused by the tumor or extralabyrinthine growth. MAIN OUTCOME MEASURES: Clinical features, audiology, radiology, and management outcomes were evaluated. RESULTS: Eight patients have undergone successful surgery with removal of their tumors and resolution of symptoms. One patient chose to have stereotactic radiotherapy. Of the 20 patients who were managed with observation and serial magnetic resonance imaging, only 1 has shown significant growth requiring surgical removal. CONCLUSION: Intralabyrinthine schwannomas are uncommon tumors that mimic the clinical features of many other neurotologic conditions. A high index of suspicion and precise imaging are often required to detect these tumors. Surgical treatment is indicated for specific indications and will be needed in the minority of patients with this disorder. The classification system that we propose is helpful in both the diagnosis and the management of these tumors.

Imaging findings of cochlear nerve deficiency.

BACKGROUND AND PURPOSE: High-resolution T2-weighted fast spin-echo MR imaging provides excellent depiction of the cisternal and intracanalicular segments of the vestibulocochlear and facial nerves. Absence or reduction in caliber of the cochlear nerve (deficiency) has been described in association with congenital sensorineural hearing loss (SNHL). Depiction of cochlear nerve integrity may be important for diagnosis and management of SNHL. METHODS: We retrospectively reviewed high-resolution T2-weighted fast spin-echo MR images of 22 patients examined for SNHL who had deficiency of the cochlear nerve. Images were evaluated for the presence and comparative size of the component nerves (facial, cochlear, superior vestibular, and inferior vestibular nerves), relative size of the internal auditory canal (IAC), and any associated inner ear abnormalities. The clinical history, results of the clinical examination, and audiometric findings were reviewed for each patient. RESULTS: Deficiency of the cochlear nerve was observed in 12 patients with congenital SNHL and in 10 patients with acquired SNHL. Hypoplasia of the IAC was observed in association with congenital deficiency of the cochlear nerve in 11 of 12 patients. Deficiency of the cochlear nerve was observed in association with acoustic schwannoma in two cases and with acquired labyrinthine abnormalities in seven cases. Hypoplasia of the IAC was not observed in association with acquired SNHL. CONCLUSION: Deficiency of the cochlear nerve can be shown by high-resolution T2-weighted fast spin-echo MR imaging. Deficiency may be observed in association with congenital or acquired SNHL and may be important in the assessment of patients for cochlear implantation. Hypoplasia of the IAC is an indicator of congenital cochlear nerve deficiency.

The silent sinus syndrome: clinical and radiographic findings.

OBJECTIVE. The purpose of this article is to acquaint the reader with the clinical and imaging features of the silent sinus syndrome, which is relatively unknown. Discussion of the presentation, treatment, and theory regarding pathogenesis of the syndrome follows. CONCLUSION. The silent sinus syndrome consists of painless facial asymmetry and enophthalmos caused by chronic maxillary sinus atelectasis. Although the diagnosis is usually suspected clinically, it is confirmed radiologically by characteristic imaging features that include maxillary sinus outlet obstruction, sinus opacification, and sinus volume loss caused by inward retraction of the sinus walls.

Imaging of the temporal bone.

Classical descriptions of the temporal bone are based on its five embryologically distinct osseous components: the petrous, tympanic, mastoid, squamous, and styloid portions.