Advanced Practice Providers in Spinal CSF Leak Programs: A Multi-Institutional Study of Current Roles and Perceived Impact on Patient Care

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.