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Advanced Practice Providers in Spinal CSF Leak Programs: A Multi-Institutional Study of Current Roles and Perceived
Ajay A Madhavan1, Michelle L Kodet2, Peter G Kranz2
1From the Division of Neuroradiology (A.A.M., P.G.K.T.J.A., E.H.W.), Department of Radiology, Duke Health, 2301 Erwin Rd, Durham, NC 27710; Division of Neuroradiology, Department of Radiology (M.L.K., I.T.M.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Kaiser Permanente Santa Clara Medical Center (M.D.M.), Radiology, 700 Lawrence Expy, Santa Clara, CA, US 95051-5329; University of Colorado Denver School of Medicine (A.C.), Department of Radiology and Biomedical Imaging, 12401 East 17th Avenue, Mail Stop L954, Aurora, CO, US 80045; Weill Cornell Medicine, Departments of Radiology (G.S.), 525 East 68th Street, Box 141, New York, US 10065; Hospital for Special Surgery, Radiology (J.L.C.), 535 E 70th St, 3rd Floor Radiology, New York, NY, US 10021-4898, 212-606-1085; UCSF, Neuroradiology (V.S.), 505 Parnassus Avenue, Room L352, San Francisco, CA, US 94143; Cedars-Sinai Medical Center (W.I.S., R.T.), Neurosurgery, 8631 WThird St Suite 800E, Los Angeles, CA, US 90048, 310-423-7900; MedStar Georgetown University Hospital (A.S.), 3800 Reservoir Rd, NW, CG201, Washington, DC, US 20007; University of Utah, Radiology (M.E.P., L.S.), 50 N Medical Dr., Salt Lake City, UT, US 84132; Mount Sinai Hospital, Radiology (A.H.D.), 1 Gustave L. Levy Pl, Box 1234, New York, NY, US 10128 and Stanford University, Department of Anesthesiology (I.C.), 211 Quarry Rd, Stanford, CA 94305. ajay.madhavan@duke.edu.
Background And Purpose:
Advanced practice providers (APPs), including nurse practitioners and physician assistants, are increasingly integrated into radiology practices. However, their utilization and clinical responsibilities in dedicated spinal CSF leak programs have not been characterized. Using a multicenter survey, we investigated APP training, clinical responsibilities, perceived impact, and challenges of APP integration at US spinal CSF leak programs.
Materials And Methods:
A survey was distributed to physicians at US institutions with dedicated spinal CSF leak programs and APP involvement. Candidate institutions were identified through the International Society for Spinal CSF Leak and American Society of Spine Radiology. Survey questions addressed program characteristics, APP training and structure, clinical responsibilities, perceived impact, and challenges. Responses were summarized descriptively.
Results:
Twelve institutions completed the survey. Eight (67%) reported caring for more than 250 spinal CSF leak patients annually. APPs included nurse practitioners at 4 centers (33%), physician assistants at 3 (25%), and both at 5 (42%); 7 centers (58%) had APPs dedicated exclusively to spinal CSF leak care. APP training was primarily informal and on-the-job at all institutions. Common primary APP responsibilities included obtaining outside imaging, patient intake and symptom review, procedure and sedation orders, informed consent, post-procedural follow-up, pain management, and treatment of rebound intracranial hypertension. Shared APP and physician responsibilities commonly included outside record review, determining evaluation urgency, preliminary imaging review, sedation assessment, and multidisciplinary coordination. Procedural responsibilities such as lumbar puncture, intrathecal contrast administration, myelography planning, and CSF leak treatment were primarily performed by physicians in most programs. At least 75% of respondents strongly agreed that APP participation improved continuity of care, patient communication/accessibility, clinic efficiency, patient satisfaction, physician administrative burden, and multidisciplinary coordination. Common barriers included funding/support, billing/reimbursement, and limited procedural privileges.
Conclusions:
APPs are widely integrated into dedicated spinal CSF leak programs, with substantial involvement in pre-procedural evaluation, care coordination, and post-procedural management, while advanced myelography and CSF leak treatment remain predominantly physician-directed. APP participation was perceived to improve patient care and clinical workflow. These findings provide a framework for APP integration into specialized spinal CSF leak programs.