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INTRODUCTION:  The utility of ChatGPT has recently caused consternation in the medical world. While it has been utilized to write manuscripts, only a few studies have evaluated the quality of manuscripts generated by AI (artificial intelligence). OBJECTIVE:  We evaluate the ability of ChatGPT to write a case report when provided with a framework. We also provide practical considerations for manuscript writing using AI. METHODS: We compared a manuscript written by a blinded human author (10 years of medical experience) with a manuscript written by ChatGPT on a rare presentation of a common disease. We used multiple iterations of the manuscript generation request to derive the best ChatGPT output. Participants, outcomes, and measures: 22 human reviewers compared the manuscripts using parameters that characterize human writing and relevant standard manuscript assessment criteria, viz., scholarly impact quotient (SIQ). We also compared the manuscripts using the "average perplexity score" (APS), "burstiness score" (BS), and "highest perplexity of a sentence" (GPTZero parameters to detect AI-generated content). RESULTS: The human manuscript had a significantly higher quality of presentation and nuanced writing (p<0.05). Both manuscripts had a logical flow. 12/22 reviewers were able to identify the AI-generated manuscript (p<0.05), but 4/22 reviewers wrongly identified the human-written manuscript as AI-generated. GPTZero software erroneously identified four sentences of the human-written manuscript to be AI-generated. CONCLUSION:  Though AI showed an ability to highlight the novelty of the case report and project a logical flow comparable to the human manuscript, it could not outperform the human writer on all parameters. The human manuscript showed a better quality of presentation and more nuanced writing. The practical considerations we provide for AI-assisted medical writing will help to better utilize AI in manuscript writing.

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Background and Purpose: Paragangliomas (PGLs) are rare neuroendocrine tumors with imaging features that can overlap with other entities. This study hypothesizes that given overexpression of somatostatin receptor (SSTR) 2, PGLs can be differentiated on Ga-68 DOTATATE positron emission tomography/computed tomography (PET/CT) from other benign or malignant lesions. Materials and Methods: Ninety-six patients with known tumors of the head and neck who underwent Ga-68 DOTATATE PET/CT from May 2017 to December 2021 were retrospectively reviewed from a single institution. Of these, 43 patients had histopathological confirmation and 66 positive lesions were discovered on PET/CT. For each lesion, the SUV max, the SUV lesion to liver ratio, and the SUV lesion to spleen ratio were analyzed. Results: PGLs (n = 37) showed the most intense uptake, and the mean of SUVmax was 69.3 (range 3.7-225.9). Metastatic PGL and metastasis from other neuroendocrine tumors (n = 13) demonstrated intermediate uptake, the mean of SUVmax was 15.16 (range 2.3-40.3). Meningiomas (n = 3) had intermediate uptake, and the mean of SUVmax was 12.37 (range 2.5-19.4). One patient with esthesioneuroblastoma had 5 lesions in the head and neck, and the mean of SUVmax was 18.9 (range 6.9-49.4). Schwannomas (n = 4) had very low uptake, and the mean of SUVmax was 1.75 (range 1.1-2.2). Other rare cases with low uptake included 1 each of osteosarcoma, acinic cell carcinoma, ectopic thyroid tissue, and plasmacytoma, and the mean of SUVmax was 4.75 (range 2.3-6.1). Conclusions: Ga-68 DOTATATE PET/CT can be a useful adjunct in differentiating tumors in the head and neck. PGLs demonstrate the highest uptake. Meningioma, esthesioneuroblastoma, and neuroendocrine tumor metastasis have intermediate uptake. Schwannomas and other rare tumors exhibit low uptake.

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BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a recognized cause of childhood and neonatal stroke with high morbidity and mortality and a challenging diagnosis in the pediatric population. OBJECTIVE: We hypothesize that measuring Hounsfield units (HU) of blood in venous sinuses is a more reliable method to diagnose CVST and that normalizing the measured HU in relation to the patient's hematocrit levels may further improve detection of CVST in the pediatric population. MATERIALS AND METHODS: We performed a retrospective chart review of 15 pediatric patients with acute CVST and 31 control patients. Regions of interest (ROIs) were plotted to measure HU values within the venous sinuses of each patient. Hounsfield unit to hematocrit (HU:Hct) ratios were also calculated. In patients with CVST, HU values were determined in thrombosed and non-thrombosed venous sinuses. Statistical analysis was performed to calculate the differences between patient and control groups and to determine optimal cutoff values for HU and HU:Hct measurements in diagnosing CVST on non-contrast brain computed tomography (CT). RESULTS: A statistically significant difference in sinus attenuation and HU:Hct ratio was found between thrombosed (66.2±5.3 HU, 1.96±0.4) and non-thrombosed sinuses (47.2±4.5 HU, 1.38±0.25) in the patient group (P<0.0001), with the average attenuation difference being 19 HU. A statistically significant difference was also found between thrombosed sinuses in the patient group and sinuses (48.9±3.13 HU, 1.3±0.12) in the control group (P<0.0001). CONCLUSION: Optimal cutoff values of 58 HU and HU:Hct ratios of 1.4 lead to sensitivities of 100% in diagnosing CVST.

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STUDY DESIGN: Cross-sectional analysis. OBJECTIVES: Given the lack of strong evidence/guidelines on appropriate treatment for lumbar spine disease, substantial variability exists among surgical treatments utilized, which is associated with differences in costs to treat a given pathology. Our goal was to investigate the variability in costs among spine surgeons nationally for the same pathology in similar patients. METHODS: Four hundred forty-five spine surgeons completed a survey of clinical and radiographic case scenarios on patients with recurrent lumbar disc herniation, low back pain, and spondylolisthesis. Those surveyed were asked to provide various details including their geographical location, specialty, and fellowship training. Treatment options included no surgery, anterior lumbar interbody fusion, posterolateral fusion, and transforaminal/posterior lumbar interbody fusion. Costs were estimated via Medicare national payment amounts. RESULTS: For recurrent lumbar disc herniation, no difference in costs existed for patients undergoing their first revision microdiscectomy. However, for patients undergoing another microdiscectomy, surgeons who operated <100 times/year had significantly lower costs than those who operated >200 times/year (P < .001) and those with 5-15 years of experience had significantly higher costs than those with >15 years (P < .001). For the treatment of low back pain, academic surgeons kept costs about 55% lower than private practice surgeons (P < .001). In the treatment of spondylolisthesis, there was significant treatment variability without significant differences in costs. CONCLUSIONS: Significant variability in surgical treatment paradigms exists for different pathologies. Understanding why variability in treatment selection exists in similar clinical contexts across practices is important to ensure the most cost-effective delivery of care among spine surgeons.

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BACKGROUND: There are a multitude of treatments for low-grade lumbar spondylolisthesis. There are no clear guidelines for the optimal approach. OBJECTIVE: To identify the surgical treatment patterns for spondylolisthesis among United States spine surgeons. METHODS: 445 spine surgeons in the United States completed a survey of clinical/radiographic case scenarios on patients with lumbar spondylolisthesis with neurogenic claudication with (S+BP) or without (S-BP) associated mechanical back pain. Treatment options included decompression, laminectomy with posterolateral fusion, posterior lumbar interbody fusion, or none of the above. The primary outcome measure was the probability of 2 randomly chosen surgeons disagreeing on the treatment method. RESULTS: There was 64% disagreement (36% agreement) among surgeons for treatment of spondylolisthesis with mechanical back pain (S+BP) and 71% disagreement (29% agreement) for spondylolisthesis without mechanical back pain (S-BP). For S+BP, disagreement was 52% for those practicing 5 to 10 years versus 70% among those practicing more than 20 years. Orthopedic surgeons had greater disagreement than did neurosurgeons (76% vs. 56%) for S+BP. Greater clinical equipoise was seen for S-BP than for S+BP regardless of surgeon characteristics. For spondylolisthesis without mechanical back pain, neurosurgeons were significantly more likely to select decompression-only than were orthopedic surgeons, who more commonly selected fusion. CONCLUSIONS: Clinical equipoise exists for the treatment of spondylolisthesis. Differences are greater when the patient presents without associated back pain. Surgeon case volume, practice duration, and specialty training influence operative decisions for a given pathologic condition. Recognizing this practice variation will hopefully lead to better evidence and practice guidelines for the optimal and most cost-effective treatment paradigms.

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Surgeons and radiologists have traditionally focused on frontal radiographs and the measurement of scoliosis curves as important tools in the management of spinal deformity. It has become evident, however, that the management of spinal deformity should use a multidimensional approach with an increased emphasis on standing lateral radiographs and the sagittal position of the spine. Furthermore, they have come to realize the critical role that the pelvis plays in the maintenance of posture. Failure to recognize pelvic compensation can lead to under-treatment and poor postoperative outcomes.

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STUDY DESIGN: Electronic survey. OBJECTIVE: To identify the surgical treatment patterns for low back pain (LBP), among U.S. spine surgeons. Specifically determine (1) differences in surgical treatment responses based on various demographic variables; (2) probability of disagreement based on surgeon subgroups. SUMMARY OF BACKGROUND DATA: Multiple surgical and nonsurgical treatments exist for LBP. Without strong evidence or clear guidelines for the indications and optimal treatments, there is substantial variability in surgical treatments used. METHODS: A total of 445 U.S. spine surgeons completed a survey of clinical and radiographic case scenarios on patients with mechanical LBP, no leg pain, and concordant discograms. Surgical treatment options included no surgery, anterior lumbar interbody fusion (ALIF), posterolateral fusion with pedicle screws, transforaminal/posterior lumbar interbody fusion (TLIF/PLIF), etc. Statistical significance was set at 0.01 to account for multiple comparisons. RESULTS: There was substantial clinical equipoise (∼75% disagreement) among surgeons on the approach to treat patients with LBP. Disagreement was highest in the southwest and lowest in the Midwest (82% vs. 69%, respectively); there was significantly lower disagreement among those in academic practices versus those in private/hybrid practices (56% vs.79%, respectively). Those in academic practices had approximately four times greater odds of choosing no surgery as compared to those in hybrid and private practices, who were more likely to choose ALIF or PLIF/TLIF. Those with fellowship training had approximately two times greater odds of selecting no surgery and four times greater odds of selecting ALIF as compared to those without fellowship training who were more likely to select TLIF/PLIF. CONCLUSION: Significant differences exist among U.S. spine surgeons in the treatment of LBP. These differences stem from geographical location of the practice, specialty, practice type, and fellowship training. Recognizing the substantial variability underlies the importance of additional studies aimed at identifying the proper indications and most cost-effective treatments for LBP. LEVEL OF EVIDENCE: 3.

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Deep brain stimulation (DBS) is an approved and effective therapy for patients suffering from advanced Parkinson's disease (PD). Several clinical trials have indicated significant motor function improvement in patients undergoing subthalamic nucleus stimulation. This therapy is, rarely, associated with complications, mostly related to infections, seizures or stimulation-induced side effects. We report a case of a 71-year-old man with a 10-year history of PD who underwent bilateral placement of subthalamic nucleus DBS. As a complication, the patient showed subjective postoperative cognitive decline, and subsequent MRI showed peri-lead oedema, which progressed to large cystic cavitation around the leads without indication of infection. The patient received steroid therapy and the cavitations regressed without surgical intervention.

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A number of new developments in cervical spine imaging have transpired since the introduction of 64-section computed tomographic (CT) scanners in 2004. An increasing body of evidence favors the use of multidetector CT as a stand-alone screening test for excluding cervical injuries in polytrauma patients with obtundation. A new grading scale that is based on CT and magnetic resonance (MR) imaging findings, the cervical spine Subaxial Injury Classification and Scoring (SLIC) system, is gaining acceptance among spine surgeons. Radiographic measurements described for the evaluation of craniocervical distraction injuries are now being reevaluated with the use of multidetector CT. Although most patients with blunt trauma are now treated nonsurgically, evolution in the understanding of spinal stability, as well as the development of new surgical techniques and hardware, has driven management strategies that are increasingly favorable toward surgical intervention. It is therefore essential that radiologists recognize findings that distinguish injuries with ligamentous instability or a high likelihood of nonfusion that require surgical stabilization from those that are classically stable and can be treated with a collar or halo vest alone. The purpose of this article is to review the spectrum of cervical spine injuries, from the craniocervical junction through the subaxial spine, and present the most widely used grading systems for each injury type.

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BACKGROUND CONTEXT: There are often multiple surgical treatment options for a spinal pathology. In addition, there is a lack of data that define differences in surgical treatment among surgeons in the United States. PURPOSE: To assess the surgical treatment patterns among neurologic and orthopedic spine surgeons in the United States for the treatment of one- and two-time recurrent lumbar disc herniation. STUDY DESIGN: Electronic survey. PATIENT SAMPLE: An electronic survey was delivered to 2,560 orthopedic and neurologic surgeons in the United States. OUTCOME MEASURES: The response data were analyzed to assess the differences among respondents over various demographic variables. The probability of disagreement is reported for various surgeon subgroups. METHODS: A survey of clinical and radiographic case scenarios that included a one- and two-time lumbar disc herniation was electronically delivered to 2,560 orthopedic and neurologic surgeons in the United States. The surgical treatment options were revision microdiscectomy, revision microdiscectomy with in situ fusion, revision microdiscectomy with posterolateral fusion using pedicle screws, revision microdiscectomy with posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF), anterior lumbar interbody fusion (ALIF) with percutaneous screws, ALIF with open posterior instrumentation, or none of these. Significance of p=.01 was used to account for multiple comparisons. RESULTS: Four hundred forty-five surgeons (18%) completed the survey. Surgeons in practice for 15+ years were more likely to select revision microdiscectomy compared with surgeons with fewer years in practice who were more likely to select revision microdiscectomy with PLIF/TLIF (p<.001). Similarly, those surgeons performing 200+ surgeries per year were more likely to select revision microdiscectomy with PLIF/TLIF than those performing fewer surgeries (p=.003). No significant differences were identified for region, specialty, fellowship training, or practice type. Overall, there was a 69% and 22% probability that two randomly selected spine surgeons would disagree on the surgical treatment of two- and one-time recurrent disc herniations, respectively. This probability of disagreement was consistent over multiple variables including geographic, practice type, fellowship training, and annual case volume. CONCLUSIONS: Significant differences exist among US spine surgeons in the surgical treatment of recurrent lumbar disc herniations. It will become increasingly important to understand the underlying reasons for these differences and to define the most cost-effective surgical strategies for these common lumbar pathologies as the United States moves closer to a value-based health-care system.

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BACKGROUND: Ectopic bone marrow production, known as extramedullary hematopoiesis, may result in symptoms due to compression on normal structures. We present the multimodality imaging findings and subsequent management of a rare case of symptomatic extramedullary hematopoiesis within the calvarium. METHODS: Case report. RESULTS: A 54-year-old male with a history of myelofibrosis and no previous diagnosis of a headache disorder presented to the emergency department with worsening severe bilateral headaches. A nonenhanced CT of the brain was performed and diffuse extra-axial nodular hyperdensities were visualized. MRI of the brain demonstrated diffuse extra-axial avidly enhancing nodular masses, dural thickening and marked susceptibility. No paravertebral masses, typical for extramedullary hematopoiesis, were present in the chest or abdomen. Although the clinical team considered a biopsy to confirm the diagnosis, we suggested a noninvasive confirmatory test. The subsequent Tc99m sulfur colloid scan corroborated the diagnosis. The patient was then referred to radiation oncology for treatment. CONCLUSION: In summary, extramedullary hematopoiesis is a hematologic compensatory disorder that rarely occurs within the CNS and may cause neurological compromise due to compression on underlying structures. The diagnosis can be made with noninvasive imaging and treated with low dose radiation therapy.

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CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is a recently described chronic inflammatory disorder involving the brainstem with characteristic imaging findings. Since it was originally described in 2002, only a handful of cases have been reported in the literature. We describe two additional cases of CLIPPERS with characteristic clinical and radiological findings. Besides the previously described MR findings, one of the cases also demonstrated multiple basal ganglia lacunar infarcts, a finding which has not been previously reported. We hypothesize that the lacunar infarcts are caused by this chronic infiltrative perivascular disease process.

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As computed tomography (CT) technology has evolved, multidetector CT has become an integral part of the initial assessment of many injured patients, and the spine is easily included in the total body screening performed in patients with severe blunt polytrauma. Despite all the advantages of multidetector CT, clearing the spine in which injury is suspected continues to be a daily challenge in clinical practice. The purpose of this review is to present the evidence and the controversies surrounding the practice of imaging in patients suspected of having spine injury. The discussion is centered on the increasing reliance on multidetector CT in the work-up of these patients but also considers the important contributions of clinical trials to select patient for appropriate imaging on the basis of risk and probability of injury. Available protocols, injury classification systems, and issues awaiting future research are addressed.

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This report describes the imaging findings in three patients who developed lumbar spine osteolysis after posterior spinal fusion using rhBMP-2. These cases demonstrate the variable course of osteolysis, as well as the importance of recognizing its radiological appearances to prevent confusion with infection following spinal fusion.

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Lumbar spinal fusion is a commonly performed procedure, and, despite changes in cage types and fixation hardware, radiologists have, over the years, become familiar with the imaging features of typical spinal fusion and many of the complications seen in patients after surgery, including pseudoarthrosis, hardware loosening, and recurrent or residual disk herniation. Recently, however, novel approaches and devices have been developed, including advances in minimally invasive surgery, the increasing use of osteoinductive materials, and a wide variety of motion-preserving devices. These new approaches and devices manifest with characteristic imaging features and the potential for unusual and unexpected complications. Several of these devices and approaches are experimental, but many, including those devices used in lateral approaches to fusion, as well as the use of bone morphogenic protein, disk arthroplasty, and interspinous spacers, are seen with increasing frequency in daily clinical practice. Given the recent advances in spinal fusion surgery, it is important that radiologists have a basic understanding of the rationale behind these procedures, the common imaging features of the devices, and the complications associated with their use.

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OBJECTIVE: CT angiography (CTA) using 64-MDCT enables timely evaluation of injuries associated with blunt neck trauma. The purpose of this article is to familiarize the reader with the most frequent CTA signs of blunt vascular injury. CONCLUSION: CTA is a valuable tool to detect blunt vascular injuries, especially using its multiplanar and 3D reconstruction capabilities.

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Fusion, with or without laminectomy, is the standard treatment for symptomatic lumbar degenerative disk disease when conservative management has failed. Yet even radiographically verified solid fusion may be accompanied by considerable long-term problems, including recurrent low back pain, spinal stenosis, hypertrophic facet disease, pseudarthrosis, and spondylolysis and spondylolisthesis at adjacent levels. Several studies have shown a relationship between solid fusion and the development of adjacent-level disk disease, which is thought to result from increased stress on, or hypermobility of, adjacent segments. Total disk replacement (TDR) was developed as a way to restore normal mobility of the diseased segments and improve clinical outcomes by decreasing the risk of adjacent-level degenerative disease and related complications. However, like fusion, TDR is associated with various complications; some of these (eg, migration, subsidence) may occur regardless of the device used, whereas others (eg, extrusion of the polyethylene inlay, vertical fractures) are device specific. Facet arthrosis, device wear, particle disease, adjacent-level degeneration, and heterotopic ossification also have been observed after TDR, but the frequency and importance of these findings remain uncertain. Given the increasing use of lumbar TDR to treat degenerative disk disease, it is important that radiologists be familiar with the most commonly used devices and the potential complications of their use.

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