Radiology Performed Fluoroscopy-Guided Lumbar Punctures Decrease Volume of Diagnostic Study Interpretation - Impact on Resident Training and Potential Solutions

Abstract

Objectives: Lumbar punctures performed in radiology departments have significantly increased over the last few decades and are typically performed in academic centers by radiology trainees using fluoroscopy guidance. Performing fluoroscopy-guided lumbar punctures (FGLPs) can often constitute a large portion of a trainee's workday and the impact of performing FGLPs on the trainee's clinical productivity (i.e. dictating reports on neuroradiology cross-sectional imaging) has not been studied. The purpose of the study was to evaluate the relationship between the number of FGLPs performed and cross-sectional neuroimaging studies dictated by residents during their neuroradiology rotation (NR).

Material and methods: The number of FGLPs and myelograms performed and neuroimaging studies dictated by radiology residents on our neuroradiology service from July 2008 to December 2017 were retrospectively reviewed. The relationship between the number of FGLPs performed and neuroimaging studies (CT and MRI) dictated per day by residents was examined.

Results: Radiology residents (n = 84) performed 3437 FGLPs and myelograms and interpreted 33402 cross-sectional studies. Poisson regression demonstrated an exponential decrease in number of studies dictated daily with a rising number of FGLPs performed (P = 0.0001) and the following formula was derived: Number of expected studies dictated per day assuming no FGLPs × e-0.25 x number of FGLPs = adjusted expected studies dictated for the day.

Conclusion: We quantified the impact performing FGLPs can have on the number of neuroimaging reports residents dictate on the NR. We described solutions to potentially decrease unnecessary FGLP referrals including establishing departmental guidelines for FGLP referrals and encouraging bedside lumbar punctures attempts before referral. We also emphasized equally distributing the FGLPs among trainees to mitigate procedural burden.

Keywords: Fluoroscopy; Lumbar; Puncture; Residents; Training.

Figure 1:

Mean number of fluoroscopy-guided lumbar punctures (FGLP) and myelograms (FGLP-M) performed per day by resident year (R) with positive standard deviation error bars.

Figure 2:

Proportion of the total days on rotation, studies dictated (CT, MR, and CT and MR), and FGLP and/or FGLP-M procedures performed by resident year (R).

Figure 3:

Daily cross-sectional neuroimaging studies versus lumbar punctures for all residents. The scatterplot demonstrates the relationship between the number of cross-sectional neuroimaging studies (CT+MR) dictated and fluoroscopy-guided lumbar punctures or myelograms performed by all residents (1^st year through 4^th year). To facilitate visibility of individual data points, the data are jittered at each level. Means and standard deviations are overlaid in red. The Poisson logarithmic relationship described in Eq 1 bx = b0*e^(r*^x) with our calculated values of bo = 9.25 and r = −0.249259 is overlaid as a dashed line.