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Kim JH, Jitpakdee K, Kotheeranurak V, Quillo-Olvera J, Choi KC, Kim YJ, Lee CR, Kim JS. Is navigation beneficial for transforaminal endoscopic lumbar foraminotomy? A preliminary comparison study with fluoroscopic guidance. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2808-2818. [PMID: 36920512 DOI: 10.1007/s00586-023-07624-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE The primary purpose of this study was to determine radiation exposure of the surgeon during transforaminal endoscopic lumbar foraminotomy (TELF). Secondary purpose of this study was to compare clinical and radiologic outcomes between TELF under C-arm fluoroscopic guidance (C-TELF) and O-arm navigation-guided TELF (O-TELF). METHODS The author reviewed patients' medical records who underwent TELF at our institute from June 2015 to November 2022. A total of 40 patients were included (18 patients with C-TELF and 22 with O-TELF). Basic demographic data were collected. Preoperative/postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) were recorded at the outpatient clinic. Radiologic features were compared on X-rays at each follow-up. The degree of foraminal expansion was measured/compared through MRI. In the C-TELF group, the amount of exposure was calculated with a dosimeter. RESULTS Average surgeon's effective dose in the C-TELF group was 0.036 mSv. In the case of the O-TELF group, there was no radiation exposure during operation. However, the operation time in the O-TELF group was about 37 min longer than that in the C-TELF group. There were significant improvements in VAS/ODI after operation in both groups. Complications were identified in three patients. CONCLUSION O-TELF showed similarly favorable clinical and radiologic outcomes to C-TELF in lumbar foraminal stenosis, including complication rate. Compared to C-TELF, O-TELF has an advantage of not wearing a lead apron since the operator is not exposed to radiation. However, the operation time was longer with O-TELF due to O-arm setting time. Because there are pros and cons, the choice of surgical method depends on the surgeon's preference.
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Affiliation(s)
- Jung-Hoon Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Khanathip Jitpakdee
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
- Department of Orthopaedics, Queen Savang Vadhana Memorial Hospital, Thai Red Cross Society, Si Racha, Chonburi, Thailand
| | - Vit Kotheeranurak
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Javier Quillo-Olvera
- The Brain and Spine Care, Minimally Invasive Spine Surgery Group, Hospital H+, Queretaro City, Mexico
| | - Kyung-Chul Choi
- Seoul Top Spine Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Young-Jin Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Cho-Rong Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Klingler JH, Hubbe U, Scholz C, Volz F, Roelz R, Beck J, Watzlawick R, Brönner J, Hoedlmoser H, Krüger MT, Hohenhaus M, Naseri Y. The Impact of Implementing a Radiation-Sparing Protocol for Percutaneous Kyphoplasty-A Prospective Dosemetric Study. Global Spine J 2023; 13:1541-1549. [PMID: 34530629 PMCID: PMC10448088 DOI: 10.1177/21925682211039497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES The purpose of this prospective study was to evaluate a protocol for radiation-sparing kyphoplasty by assessing dosemetrically recorded radiation exposures to both patient and surgeon. METHODS This prospective clinical study examines the radiation exposure to patient and surgeon during single-level kyphoplasty in 32 thoracolumbar osteoporotic vertebral body fractures (12 OF 2, 9 OF 3, 11 OF 4 types) using a radiation aware surgical protocol between May 2017 and November 2019. The radiation exposure was measured at different locations using film, eye lens and ring dosemeters. Dose values are reported under consideration of lower detection limits of each dosemeter type. RESULTS A high proportion of dosemeter readings was below the lower detection limits, especially for the surgeon (>90%). Radiation exposure to the surgeon was highest at the unprotected thyroid gland (0.053 ± 0.047 mSv), however only slightly above the lower detection limit of dosemeters (0.044 mSv). Radiation exposure to the patient was highest at the chest (0.349 ± 0.414 mSv) and the gonad (0.186 ± 0.262 mSv). Fluoroscopy time, dose area product and number of fluoroscopic images were 46.0 ± 17.9 sec, 124 ± 109 cGy×cm2, and 35 ± 13 per kyphoplasty, respectively. Back pain significantly improved from 6.8 ± 1.6 to 2.5 ± 1.7 on the numeric rating scale on the first postoperative day (P < 0.0001). CONCLUSIONS The implementation of a strict intraoperative radiation protection protocol allows for safely performed kyphoplasty with ultra-low radiation exposure for the patient and surgeon without exceeding the annual occupational dose limits. TRIAL REGISTRATION The study was registered in the German Clinical Trials Register (DRKS00011908, registration date 16/05/2017).
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Affiliation(s)
- Jan-Helge Klingler
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Volz
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralf Watzlawick
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Brönner
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Herbert Hoedlmoser
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Marie T. Krüger
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marc Hohenhaus
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Yashar Naseri
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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3
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Metaxas V, Efthymiou F, Dimitroukas C, Delis H, Gatzounis G, Zampakis P, Tzortzidis F, Papadakos D, Constantoyannis C, Panayiotakis G. Lumbar discectomy and fusion: Organs’ dose and effective dose estimation using Monte Carlo simulation. Appl Radiat Isot 2023; 196:110781. [PMID: 36996533 DOI: 10.1016/j.apradiso.2023.110781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/19/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
In this study, the effect of patient- and procedure-related parameters on organs' dose (OD), peak skin dose (PSD) and effective dose (ED) during lumbar discectomy and fusion (LDF) was assessed. Intra-operative parameters obtained from 102 LDFs were inserted into VirtualDose-IR software implementing sex-specific and BMI-adjustable anthropomorphic phantoms for dosimetric calculations. Fluoroscopy time (FT), kerma-area product (KAP), cumulative and incident air-kerma (Kair) were also recorded from the dosimetric report of the mobile C-arm. An increase in KAP, Kair, PSD and ED was found for male or higher BMI patients, multi-level or fusion or L5/S1 procedures. However, a significant difference was found only for PSD and incident Kair between normal and obese patients and for FT between discectomy and discectomy and fusion procedures. The spleen, kidneys and colon received the highest doses. The BMI have a significant impact only for kidneys, pancreas, and spleen doses when comparing obese to overweight and for urinary bladder when comparing overweight to normal patients. Multi-level and fusion procedures resulted in significantly higher doses for lungs, heart, stomach, adrenals, gallbladder and kidneys, while pancreas and spleen doses significantly increased only for multi-level procedures. Additionally, a significant increase was found only for urinary bladder, adrenals, kidneys, and spleen ODs when comparing L5/S1 and L3/L4 levels. The mean ODs were lower compared to the literature. These data may aid neurosurgeons in optimising exposure techniques during LDF to keep patients' dose as low as is practicably possible.
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Affiliation(s)
- Vasileios Metaxas
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece
| | - Fotios Efthymiou
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece
| | - Christos Dimitroukas
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece; Department of Medical Physics, University Hospital of Patras, 26504, Patras, Greece
| | - Harry Delis
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece
| | - George Gatzounis
- Department of Neurosurgery, University Hospital of Patras, 26504, Patras, Greece; Department of Neurosurgery, School of Medicine, University of Patras, 26504, Patras, Greece
| | - Petros Zampakis
- Department of Radiology, University Hospital of Patras, 26504, Patras, Greece; Department of Radiology, School of Medicine, University of Patras, 26504, Patras, Greece
| | - Fotios Tzortzidis
- Department of Neurosurgery, University Hospital of Patras, 26504, Patras, Greece
| | - Dimitrios Papadakos
- Department of Neurosurgery, University Hospital of Patras, 26504, Patras, Greece
| | - Constantine Constantoyannis
- Department of Neurosurgery, University Hospital of Patras, 26504, Patras, Greece; Department of Neurosurgery, School of Medicine, University of Patras, 26504, Patras, Greece
| | - George Panayiotakis
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece; Department of Medical Physics, University Hospital of Patras, 26504, Patras, Greece.
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Kolz JM, Wagner SC, Vaccaro AR, Sebastian AS. Ergonomics in Spine Surgery. Clin Spine Surg 2022; 35:333-340. [PMID: 34321393 DOI: 10.1097/bsd.0000000000001238] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
As physician burnout and wellness become increasingly recognized as vital themes for the medical community to address, the topic of chronic work-related conditions in surgeons must be further evaluated. While improving ergonomics and occupational health have been long emphasized in the executive and business worlds, particularly in relation to company morale and productivity, information within the surgical community remains relatively scarce. Chronic peripheral nerve compression syndromes, hand osteoarthritis, cervicalgia and back pain, as well as other repetitive musculoskeletal ailments affect many spinal surgeons. The use of ergonomic training programs, an operating microscope or exoscope, powered instruments for pedicle screw placement, pneumatic Kerrison punches and ultrasonic osteotomes, as well as utilizing multiple surgeons or microbreaks for larger cases comprise several methods by which spinal surgeons can potentially improve workspace health. As such, it is worthwhile exploring these areas to potentially improve operating room ergonomics and overall surgeon longevity.
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Affiliation(s)
- Joshua M Kolz
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Scott C Wagner
- Walter Reed National Military Medical Center, Bethesda, MD
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Li Q, Wu C, Huang Z, Cao J, Chang J, Yin G, Yu L, Cao X, Sui T. A comparison of robot-assisted and fluoroscopy-assisted kyphoplasty in the treatment of multi-segmental osteoporotic vertebral compression fractures. J Biomed Res 2022; 36:208-214. [PMID: 35635142 PMCID: PMC9179111 DOI: 10.7555/jbr.36.20220023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Osteoporotic vertebral compression fracture (OVCF) has become a major public health issue that becomes more pressing with increasing global aging. Percutaneous kyphoplasty (PKP) is an effective treatment for OVCF. Robot-assisted PKP has been utilized in recent years to improve accuracy and reduce complications. However, the effectiveness of robot-assisted PKP in the treatment of multi-segmental OVCF has yet to be proved. This study was designed to compare the efficacy of robot-assisted and conventional fluoroscopy-assisted multi-segmental PKP. A total of 30 cases with multi-segmental OVCF between April 2019 and April 2021 were included in this study. Fifteen cases were assigned to the robot-assisted PKP group (robot group) and 15 cases to the conventional fluoroscopy-assisted PKP group (conventional fluoroscopy group). The number of fluoroscopic exposures, fluoroscopic dose, operation time, cement leakage rate, visual analog scale (VAS) score, vertebral kyphosis angle (VKA), and height of fractured vertebral body (HFV) were compared between the 2 groups. The number of fluoroscopic exposures, fluoroscopic doses, and cement leakage rates in the robot group were lower than in the conventional fluoroscopy group (P<0.05) while the operative time in the robot group was longer than in the conventional fluoroscopy group (P<0.05). VAS score and VKA were decreased and HFV was increased after surgery in both groups (P<0.05). Therefore, robot-assisted PKP for the treatment of multi-segmental OVCF can reduce the number of fluoroscopic exposures, fluoroscopic doses, and cement leakage compared to conventional treatment. As such, robot-assisted PKP has good application prospects and is potentially more effective in the treatment of multi-segmental OVCF.
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Affiliation(s)
- Qingqing Li
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Chaoqin Wu
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Zhenfei Huang
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Jiang Cao
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Jie Chang
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Guoyong Yin
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Lipeng Yu
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
- Xiaojian Cao, Lipeng Yu, and Tao Sui, Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, China. Tel: +86-25-68303190, E-mails:
,
, and
| | - Xiaojian Cao
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
- Xiaojian Cao, Lipeng Yu, and Tao Sui, Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, China. Tel: +86-25-68303190, E-mails:
,
, and
| | - Tao Sui
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
- Xiaojian Cao, Lipeng Yu, and Tao Sui, Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, China. Tel: +86-25-68303190, E-mails:
,
, and
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6
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Arif S, Brady Z, Enchev Y, Peev N, Encheva E. Minimising radiation exposure to the surgeon in minimally invasive spine surgeries: A systematic review of 15 studies. Orthop Traumatol Surg Res 2021; 107:102795. [PMID: 33333283 DOI: 10.1016/j.otsr.2020.102795] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 09/22/2020] [Accepted: 09/29/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intraoperative imaging in minimally invasive spinal surgeries is associated with significant radiation exposure to surgeons, which overtime can lead to serious health hazards including malignancy. In this study, the authors conducted a systematic review to evaluate the efficacy of navigation assisted fluoroscopy methods on radiation exposure to the surgeon in minimally invasive spine surgeries, percutaneous endoscopic lumbar discectomy/percutaneous endoscopic transforaminal discectomy versus minimally invasive spine transforaminal lumbar interbody fusion (PELD/PETD versus MIS-TLIF). METHODS A systematic literature search was conducted using PUBMED/MEDLINE on 20th July, 2020. Inclusion criteria were applied according to study design, surgical technique, spinal region, and language. Data extracted included lumbar segment, average operation time (min), fluoroscopic time (s), and radiation dose (μSV), efficacy of modified navigation versus conventional techniques; on reducing operation, fluoroscopy times and effective radiation dose. RESULTS Fifteen studies (ten prospectives, and five retrospectives) were included for quantitative analysis. PELD recorded a shorter operation time (by 126.3min, p<0.001) and fluoroscopic time (by 22.9s, p=0.3) than MIS-TLIF. The highest radiation dose/case (μSV) for both techniques were recorded at the surgeon's: finger, chest, neck and eye. The effective dose for MIS-TLIF was 30μSV higher than PELD. Modified navigation techniques recorded a shorter operation time (by 15.9min, p=0.3); fluoroscopy time (by 289.8s, p=0.3); effective radiation dose (by 169.5μSV, p=0.3) than conventional fluoroscopy methods. DISCUSSION This systematic literature review showed that although navigation assisted fluoroscopy techniques are superior to conventional methods in minimising radiation exposure, lack of statistical significance warrants future randomised controlled trials, to solidify their efficacy in reducing radiation related hazards.
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Affiliation(s)
- Shahswar Arif
- Medical university of Varna, ul. "Professor Marin Drinov" 55, 9002 Center Varna, Bulgaria
| | - Zarina Brady
- Medical university of Varna, ul. "Professor Marin Drinov" 55, 9002 Center Varna, Bulgaria.
| | - Yavor Enchev
- Medical university of Varna, ul. "Professor Marin Drinov" 55, 9002 Center Varna, Bulgaria; Department of neurosurgery, medical university of Varna, university hospital "St. Marina", Varna, Bulgaria
| | - Nikolay Peev
- Department of neurosurgery, Royal Victoria hospital, Belfast health and social care trust, Belfast, Northern Ireland, United Kingdom
| | - Elitsa Encheva
- Medical university of Varna, ul. "Professor Marin Drinov" 55, 9002 Center Varna, Bulgaria
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7
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Klingler JH, Hoedlmoser H, Naseri Y. Radiation protection measures to reduce the eye lens dose in spinal surgery. Spine J 2021; 21:1243-1245. [PMID: 33865983 DOI: 10.1016/j.spinee.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 02/03/2023]
Abstract
The annual limit value for the eye lens dose for occupationally exposed personnel has recently been considerably reduced from 150mSv to 20mSv. We have therefore re-evaluated the effectiveness of radiation protection measures (lead glass goggles, mobile radiation shielding wall and distance to the radiation source) in an experimental setting to provide spinal surgeons with clearly understandable radiation dose data for their daily work.
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Affiliation(s)
- Jan-Helge Klingler
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
| | - Herbert Hoedlmoser
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Yashar Naseri
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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Kopparapu S, Lubelski D, Pennington Z, Khan M, Theodore N, Sciubba D. Comparison of operator and patient radiation exposure during fluoroscopy-guided vertebroplasty and kyphoplasty: a systematic review and meta-analysis. J Neurosurg Spine 2021; 35:117-126. [PMID: 33930867 DOI: 10.3171/2020.9.spine201525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Percutaneous vertebroplasty (PV) and balloon kyphoplasty (BK) are two minimally invasive techniques used to treat mechanical pain secondary to spinal compression fractures. A concern for both procedures is the radiation exposure incurred by both operators and patients. The authors conducted a systematic review of the available literature to examine differences in interventionalist radiation exposure between PV and BK and differences in patient radiation exposure between PV and BK. METHODS The authors conducted a search of the PubMed, Ovid Medline, Cochrane Reviews, Embase, and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text articles in English describing one of the primary endpoints in ≥ 5 unique patients treated with PV or BK of the mobile spine were included. Estimates of mean operative time, radiation exposure, and fluoroscopy duration were reported as weighted averages. Additionally, annual occupational dose limits provided by the United States Nuclear Regulatory Commission (USNRC) were used to determine the number needed to harm (NNH). RESULTS The meta-analysis included 27 articles. For PV, the mean fluoroscopy times were 4.9 ± 3.3 minutes per level without protective measures and 5.2 ± 3.4 minutes with protective measures. The mean operator radiation exposures per level in mrem were 4.6 ± 5.4 at the eye, 7.8 ± 8.7 at the neck, 22.7 ± 62.4 at the torso, and 49.2 ± 62.2 at the hand without protective equipment and 0.3 ± 0.1 at the torso and 95.5 ± 162.5 at the hand with protection. The mean fluoroscopy times per level for BK were 6.1 ± 2.5 minutes without protective measures and 6.0 ± 3.2 minutes with such measures. The mean exposures were 31.3 ± 39.3, 19.7 ± 4.6, 31.8 ± 34.2, and 174.4 ± 117.3 mrem at the eye, neck, torso, and hand, respectively, without protection, and 1, 9.2 ± 26.2, and 187.7 ± 100.4 mrem at the neck, torso, and hand, respectively, with protective equipment. For protected procedures, radiation to the hand was the limiting factor and the NNH estimates were 524 ± 891 and 266 ± 142 for PV and BK, respectively. Patient exposure as measured by flank-mounted dosimeters, entrance skin dose, and dose area product demonstrated lower exposure with PV than BK (p < 0.01). CONCLUSIONS Operator radiation exposure is significantly decreased by the use of protective equipment. Radiation exposure to both the operator and patient is lower for PV than BK. NNH estimates suggest that radiation to the hand limits the number of procedures an operator can safely perform. In particular, radiation to the hand limits PV to 524 and BK to 266 procedures per year before surpassing the threshold set by the USNRC.
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Affiliation(s)
| | | | | | - Majid Khan
- 2Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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9
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Erken HY, Yilmaz O. Collimation Reduces Radiation Exposure to the Surgeon in Endoscopic Spine Surgery: A Prospective Study. J Neurol Surg A Cent Eur Neurosurg 2021; 83:6-12. [PMID: 34030187 DOI: 10.1055/s-0041-1726111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND STUDY AIMS There are no previous studies in the literature comparing the radiation dose to which surgeons are exposed while using a standard fluoroscopy versus collimation during transforaminal percutaneous endoscopic lumbar diskectomy (PELD). The aim of this study is to compare this and to evaluate the effectiveness of collimation in reducing radiation exposure. METHODS In this study, the operating surgeon (single surgeon) placed a gamma radiation dosimeter on his chest outside of the lead apron during transforaminal PELD surgeries and measured the radiation exposure immediately after each surgery. As foraminoplasty using free-hand reamers is a longer procedure and requires more fluoroscopy shots, we divided the patients into two groups. The first group consisted of 24 patients (nonforaminoplasty group). The second group consisted of 13 patients (foraminoplasty group). We compared the radiation exposure to the operating surgeon using a standard fluoroscopy versus collimation for each group individually and overall. We randomized the patients within each group based on the order in which they had their respective procedures. RESULTS We analyzed 39 patients who underwent transforaminal PELD between May and December 2019. In both groups, as well as overall, the recorded radiation exposure to the surgeon was significantly lower in surgeries in which collimation was used. In the first group, the radiation dose was 0.083 versus 0.039 mSv per surgery (p = 0.019), whereas in the second group, it was 0.153 versus 0.041 mSv per surgery (p = 0.001), and overall it was 0.108 versus 0.039 mSv per surgery (p < 0.001). CONCLUSION The use of collimation during transforaminal PELD significantly reduces spine the surgeon's exposure to radiation. Therefore, spine surgeons should consider using collimation during transforaminal PELD.
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Affiliation(s)
- H Yener Erken
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Çanakkale Onsekiz Mart University, Canakkale, Turkey
| | - Onur Yilmaz
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Çanakkale Onsekiz Mart University, Canakkale, Turkey
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10
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Hu PL, Lin JS, Meng H, Su N, Yang Y, Fei Q. A novel "three-dimensional-printed individual guide template-assisted percutaneous vertebroplasty" for osteoporotic vertebral compression fracture: a prospective, controlled study. J Orthop Surg Res 2021; 16:326. [PMID: 34016139 PMCID: PMC8136164 DOI: 10.1186/s13018-021-02471-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conventional percutaneous vertebroplasty (PVP) are mainly guided by C-arm fluoroscopy, and it usually leads to excessive X-ray radiation exposure to patients, surgeons, and anesthetists. Moreover, multi-time fluoroscope may prolong the operation time. 3D-printed template could help minimize fluoroscopy shot times and fluoroscopy dosage during operation, and shorten operation time. We perform this study to compare the efficacy and accuracy of PVP assisted by "three-dimensional printed individual guide template" versus conventional PVP. METHOD Patients who suffered acute painful single segment osteoporotic vertebral compression fracture(OVCF) needed operative treatment were randomly assigned into three-dimensional printing individual guide template-assisted percutaneous vertebroplasty group (group A) or conventional PVP guided by C-arm fluoroscopy group (group B) at a 1:1 ratio. Fluoroscopy times for puncture points (FTPP), total radiation dosages (TRD), total fluoroscopy time (TFT), and total operation time (TOT) were recorded as the main evaluation factors to evaluate the two operation procedures. RESULTS A total of 36 acute painful single segment OVCF patients were successfully operated on, and each group has 18 patients. None of the patients presented symptomatic complications. The surgical success rate in group A was 94.4%(17/18), one patient in the group A was failed and then operated by conventional procedure. FTPP (1.8 ± 0.8 in group A vs 5.2 ± 1.9 in group B, P < 0.05), TRD (4.9 ± 0.9 mGy vs 7.9 ± 1.6 mGy, P < 0.05), TFT (16.7 ± 2.9 vs 26.6 ± 5.3, P < 0.05), and total operation time (19.4 ± 2.4 min vs 27.8 ± 4.0 min, P < 0.05) were presented statistically difference in the two groups. The incidence of cement leakage occurred in group A (3/18, 16.7%) was less than that occurred in group B (7/18, 38.9%) (P > 0.05). CONCLUSIONS Compared with the conventional PVP, "three-dimensional-printed individual guide template-assisted PVP" could minimize fluoroscopy shot times during operation and fluoroscopy dosage, shorten operation time, and is a more precise and feasible operation method. TRIAL REGISTRATION The present study was registered with the Chinese Clinical Trial Registry (ChiCTR) ( http://www.chictr.org.cn ), and its registration no. is ChiCTR1900024283.
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Affiliation(s)
- Pei Lun Hu
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Xicheng District, Beijing, People's Republic of China
| | - Ji Sheng Lin
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Xicheng District, Beijing, People's Republic of China
| | - Hai Meng
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Xicheng District, Beijing, People's Republic of China
| | - Nan Su
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Xicheng District, Beijing, People's Republic of China
| | - Yong Yang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Xicheng District, Beijing, People's Republic of China
| | - Qi Fei
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Xicheng District, Beijing, People's Republic of China.
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11
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Jenkins NW, Parrish JM, Sheha ED, Singh K. Intraoperative risks of radiation exposure for the surgeon and patient. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:84. [PMID: 33553377 PMCID: PMC7859810 DOI: 10.21037/atm-20-1052] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intraoperative radiological imaging serves an essential role in many spine surgery procedures. It is critical that patients, staff and physicians have an adequate understanding of the risks and benefits associated with radiation exposure for all involved. In this review, we briefly introduce the current trends associated with intraoperative radiological imaging. With the increased utilization of minimally invasive spine surgery (MIS) techniques, the benefits of intraoperative imaging have become even more important. Less surgical exposure, however, often equates to an increased requirement for intraoperative imaging. Understanding the conventions for radiation measurement, radiological fundamental concepts, along with deterministic or stochastic effects gives a framework for conceptualizing how radiation exposure relates to the risk of various sequela. Additionally, we describe the various options surgeons have for intraoperative imaging modalities including those based on conventional fluoroscopy, computer tomography, and magnetic resonance imaging. We also describe different ways to prevent unnecessary radiation exposure including dose reduction, better education, and use of personal protective equipment (PPE). Finally, we conclude with a reflection on the progress that has been made to limit intraoperative radiation exposure and the promise of future technology and policy.
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Affiliation(s)
- Nathaniel W Jenkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - James M Parrish
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Evan D Sheha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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12
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Guenthner G, Eddy A, Sembrano J, Polly DW, Martin CT. The effectiveness of a free-standing lead-shield in reducing spine surgeon radiation exposure during intraoperative 3-dimensional imaging. Spine J 2020; 20:1685-1691. [PMID: 32445800 DOI: 10.1016/j.spinee.2020.05.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Intraoperative three-dimensional (3D) computed tomography (CT) imaging has become increasingly popular in spine surgery. Previous spine surgeon radiation exposure research has focused largely on procedures using fluoroscopy, however, few studies have been performed on the subject since the introduction of the 3D imaging systems. As a result, concerns have re-emerged over surgeon radiation exposure and the effectiveness of operating room (OR) protocols for decreasing workplace radiation. Current radiation safety guidelines require surgeons wear full body protective lead while any type of radiation is being administered during surgery. As a result, local institutions do not allow for the use of free-standing lead shields for sole radiation protection in the operating room. However, there is no data available to demonstrate whether the additional personal lead is required, or if in fact the lead shield alone is sufficient. PURPOSE This study investigated the effectiveness of a free-standing lead shield in reducing spine surgeon radiation exposure in the operating room during intraoperative imaging. STUDY DESIGN/SETTING A prospective clinical research study at a large, tertiary care center. PATIENT SAMPLE Twenty-seven patients undergoing instrumented spinal procedures between June and August 2019. OUTCOME MEASURES Fluoroscopy time, total fluoroscopy dose delivered, 3D dose delivered, total 3D spins, number of HD spins, number of standard spins, number of fluoroscopic images, number of spine levels operated on, patient size setting, shield distance from patient, radiation dose in front of shield, radiation dose behind shield. METHODS Twenty-seven instrumented spinal procedures using the O-Arm Imaging System (Medtronic, Minneapolis, MN) were observed to determine radiation exposure to a spine surgeon standing behind a lead shield in the OR. Two thermoluminescent dosimeters were used to measure scatter radiation in front of and behind lead shields. Both fluoroscopy and intraoperative CT based radiation exposure was recorded. The dosimeter readings were compared to determine the degree of radiation attenuation by the lead shield. Regression analysis of the exposure values from behind the shield, shield distance from the patient, and radiation dose delivered by the imaging system was utilized to estimate the number of cases required to surpass annual exposure limits. Case numbers were calculated for the highest "worst case" and "average case" exposure values. The safe annual occupation exposure limit determined by the National Council on Radiation Protection is five roentgen equivalent man (rem) or 50,000 microsieverts (μSv). RESULTS Average surgeon radiation exposure per case was 0.694 μSv (SD: 0.501, Range: 0.105-2.167) behind the lead shield compared to 14.577 μSv (SD: 9.864, Range: 2.185-44.492) in front of the lead shield. The average radiation dose reduction by the lead shield was 13.962 μSv (SD: 9.49, Range: 2.08-42.72) per case, which is equivalent to an average of 95.65% (SD: 1.71) radiation attenuation by lead shielding. If surgeons stand behind lead shields in the OR, the annual number of 3D image-guided spinal procedures required to surpass exposure limits is 15,479 and 67,060 based on "worst case" and "average case" analyses, respectively. CONCLUSIONS Our study demonstrates standing behind intraoperative lead shields is very effective at decreasing radiation exposure to surgeons. Additionally, surgeon radiation doses behind lead shielding fall far below annual exposure limits. Surgeons should not need additional protective equipment when a lead shield is used.
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Affiliation(s)
- Guy Guenthner
- Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th St, Suite R200, Minneapolis, MN, USA
| | - Alexander Eddy
- Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th St, Suite R200, Minneapolis, MN, USA
| | - Jonathan Sembrano
- Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th St, Suite R200, Minneapolis, MN, USA
| | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th St, Suite R200, Minneapolis, MN, USA
| | - Christopher T Martin
- Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th St, Suite R200, Minneapolis, MN, USA.
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13
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Psarras M, Ploussi A, Carinou E, Brountzos E, Spiliopoulos SC, Palialexis K, Kelekis A, Filippiadis D, Seimenis I, Efstathopoulos EP. RADIATION DOSES TO THE EYE LENS AND FOREHEAD OF INTERVENTIONAL RADIOLOGISTS: HOW HIGH AND ON WHAT GROUNDS? RADIATION PROTECTION DOSIMETRY 2020; 190:150-157. [PMID: 32626896 DOI: 10.1093/rpd/ncaa097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/05/2020] [Accepted: 06/10/2020] [Indexed: 02/05/2023]
Abstract
The aim of the study was to measure and evaluate the radiation dose to the eye lens and forehead of interventional radiologists (IRs). The study included 96 procedures (lower-limb percutaneous transluminal angioplasties, embolisations/chemoembolisations and vertebroplasties) performed by 6 IRs. A set of seven thermoluminescence dosemeters was allocated to each physician. The highest dose per procedure was found for the left eye lens of the primary operator in vertebroplasties (1576 μSv). Left and right eye doses were linearly correlated to left and right forehead doses, respectively. A workload-based estimation of the annual dose to participating IRs revealed that the occupational dose limit for the eye lens can be easily exceeded. The left eye dose of ΙRs must be routinely monitored on a personalised basis. Τhe left eye dose measurement provides a reliable assessment of the ipsilateral forehead dose, along with valid estimations for the right eye and right forehead doses.
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Affiliation(s)
- M Psarras
- 2nd Department of Radiology, Medical Physics Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
| | - A Ploussi
- 2nd Department of Radiology, Medical Physics Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
| | - E Carinou
- Greek Atomic Energy Commission (GAEC), 15310, Agia Paraskevi, Attiki, Greece
| | - E Brountzos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
| | - S C Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
| | - K Palialexis
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
| | - A Kelekis
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
| | - D Filippiadis
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
| | - I Seimenis
- Medical Physics Laboratory, Medical School, National and Kapodistrian University of Athens, Athens, 115 27, Greece
| | - E P Efstathopoulos
- 2nd Department of Radiology, Medical Physics Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
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14
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Merter A, Karaeminogullari O, Shibayama M. Comparison of Radiation Exposure Among 3 Different Endoscopic Diskectomy Techniques for Lumbar Disk Herniation. World Neurosurg 2020; 139:e572-e579. [PMID: 32330613 DOI: 10.1016/j.wneu.2020.04.079] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lumbar disk herniation can be successfully treated by lumbar endoscopic spinal procedures. However, one of the most important disadvantages of the endoscopic methods used is radiation exposure. There are multiple endoscopic spinal procedures and this study aims to compare unilateral biportal endoscopic diskectomy (UBED), percutaneous endoscopic lumbar diskectomy (PELD), and microendoscopic diskectomy (MED) methods in terms of radiation exposure. METHODS A total of 75 people were included in this prospective and multicenter study. The demographic characteristics, operating times (minutes), levels of surgery, lumbar disk herniation types, radiation exposures (dose area product [DAP]), and fluoroscopy times (seconds) of the groups were compared. RESULTS Mean DAP values were 1.39 Gy·cm2 in the UBED group, 2.46 Gy·cm2 in the PELD group, and 1.01 Gy·cm2 in the MED group. The UBED group had no statistically significant difference with the MED and PELD groups in terms of DAP (P = 0.281 and P = 0.058, respectively), whereas the PELD group had statistically significantly higher DAP values than the MED group (P = 0.016). The maximum mean duration of fluoroscopy usage time was 34.9 seconds in the PELD group, 19.3 seconds in the UBED group, and 4.6 seconds in the MED group. The differences between the groups were significant (P ≤ 0.001). CONCLUSIONS The more the level of invasiveness is reduced in spinal surgery, the greater the exposure to radiation. In this study, the groups are listed as PELD > UBED > MED according to the duration and level of radiation exposure.
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Affiliation(s)
- Abdullah Merter
- Department of Orthopedics, Spine Section, School of Medicine, Ibn-i Sina Hospital, Ankara University, Ankara, Turkey.
| | - Oguz Karaeminogullari
- Department of Orthopedics, Spine Section, Bayindir Sogutozu Hospital, Ankara, Turkey
| | - Motohide Shibayama
- Department of Orthopedics, Spine Section, Aichi Spine Hospital, Aichi Prefecture, Japan
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15
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Metaxas VI, Messaris GA, Gatzounis GD, Panayiotakis GS. OPTIMISATION OF PATIENT DOSE AND IMAGE QUALITY IN FLUOROSCOPICALLY GUIDED CERVICAL SPINE SURGERY: A PHANTOM-BASED STUDY. RADIATION PROTECTION DOSIMETRY 2019; 184:237-247. [PMID: 30508126 DOI: 10.1093/rpd/ncy205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/28/2018] [Accepted: 10/31/2018] [Indexed: 06/09/2023]
Abstract
The purpose of the current study was to provide useful data, which may help neurosurgeons to manage the patient dose and image quality in spinal surgery procedures, utilising a phantom and a test object. The kerma area product, cumulative dose (CD) and entrance surface dose (ESD) rate on the phantom and image intensifier were measured, for selectable fields of view (FOVs), fluoroscopy modes, two geometric magnifications and various phantom thicknesses. The images were subjectively evaluated regarding low-contrast detectability and high-contrast resolution. Signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), high-contrast spatial resolution (HCSR) and figure of merit (FOM) values were also estimated. The ESD rates increased with increasing phantom thickness, when using electronic or geometric magnification, continuous or high-definition fluoroscopy (HDF). The observers' evaluation showed relatively slight changes in image quality when pulsed fluoroscopy was used. SNR, CNR and HCSR values decreased with increasing phantom thicknesses, while remained almost constant when using pulsed fluoroscopy. SNR and HCSR improved in HDF, while the CNR remained almost constant only for the FOVs 23 and 17 cm. By applying electronic magnification, this resulted in improved HCSR. FOM values decreased in HDF, with increasing phantom thickness and using electronic magnification. For the 'thinnest' patients, CD may overestimate skin dose by 25% than the actual values. Geometric magnification resulted in improved FOM, especially for low-dose fluoroscopy and FOV 23 cm. The knowledge of the increments in dose values, image quality and FOM indices concerning phantom thickness may help neurosurgeons to optimise spinal surgery procedures by selecting the appropriate operational parameters, which could contribute toward the establishment of a radiation protection culture.
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Affiliation(s)
- Vasileios I Metaxas
- Department of Medical Physics, School of Medicine, University of Patras, Patras, Greece
| | - Gerasimos A Messaris
- Department of Medical Physics, School of Medicine, University of Patras, Patras, Greece
| | - George D Gatzounis
- Department of Neurosurgery, School of Medicine, University of Patras, Patras, Greece
| | - George S Panayiotakis
- Department of Medical Physics, School of Medicine, University of Patras, Patras, Greece
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16
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Xu J, Lin J, Li J, Yang Y, Fei Q. "Targeted Percutaneous Vertebroplasty" Versus Traditional Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fracture. Surg Innov 2019; 26:551-559. [PMID: 31167616 DOI: 10.1177/1553350619853134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. In this randomized, nonblinded, controlled study, the feasibility and precision of "targeted percutaneous vertebroplasty" ("targeted PVP") for osteoporotic vertebral compression fracture (OVCF) was evaluated. Methods. A total of 42 patients, aged 50 to 87 years, with OVCF were randomly divided into 2 groups: A and B. Group A underwent "targeted PVP," and group B underwent traditional PVP with the guidance of C-arm fluoroscopy. Fluoroscopy times for skin puncture points (FTSPP), total radiation doses (TRD), total fluoroscopy times (TFT), and operation time were set as the main evaluation indicators. Results. FTSPP (1.52 ± 0.51 in group A vs 6.62 ± 2.58 in group B, U < .001), TRD (6.26 ± 1.51 in group A vs 11.32 ± 4.21 in group B, P < .001), TFT (16.57 ± 2.79 in group A vs 26.05 ± 6.18 in group B, P < .001), and operation time (20.05 ± 3.38 in group A vs 25.43 ±5.11 in group B, U < .001) were statistically different in the 2 groups. The incidence of cement leakage that occurred in group A (1/21, 4.76%) was significantly less than that in group B (9/21, 42.9%, P < 0.05). Conclusions. "Targeted PVP" may achieve (1) less skin positioning fluoroscopy times, less total fluoroscopy times and dose, shorter operation time, which is more precise than traditional PVP; (2) less incidence of cement leakage; and (3) visualization of the fractured vertebra, which is probably more valuable for the treatment of complicated OVCF patients.
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Affiliation(s)
- JunChuan Xu
- 1 Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - JiSheng Lin
- 1 Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jian Li
- 1 Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yong Yang
- 1 Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Qi Fei
- 1 Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
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17
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Zhao Y, Yan N, Yu S, Zhang T, Wang C, He S, Gu G. Reduced Radiation Exposure and Puncture Time of Percutaneous Transpedicular Puncture with Real-Time Ultrasound Volume Navigation. World Neurosurg 2018; 119:e997-e1005. [PMID: 30121413 DOI: 10.1016/j.wneu.2018.08.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/04/2018] [Accepted: 08/06/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The present study introduced ultrasound volume navigation (UVN) to reduce the radiation exposure and puncture time of percutaneous transpedicular puncture in percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP). METHODS We retrospectively reviewed the medical records of patients with osteoporotic vertebral compression fracture who had undergone PVP or PKP guided by UVN or fluoroscopy from September 2017 to December 2017. RESULTS We enrolled 10 patients (6 women, 4 men) with 24 pedicles involved in the present study. Significant reductions in fluoroscopy frequency (2.58 vs. 17.42; P < 0.01), exposure time (2.36 vs. 15.69 seconds; P < 0.01), and puncture time (4.13 vs. 19.21 minutes; P < 0.01) for each pedicle were observed in the UVN group compared with the fluoroscopy group. Obvious correlations among fluoroscopy frequency, exposure time, and puncture time for each pedicle were observed (P < 0.01). The visual analog scale scores and Oswestry Disability Index were both significantly improved after the procedures. All patients achieved excellent or good clinical outcomes. No complications were observed in any patient. CONCLUSIONS UVN could obviously reduce the radiation exposure and puncture time of percutaneous transpedicular puncture in PVP and PKP.
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Affiliation(s)
- Yongzhao Zhao
- Orthopedic Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ning Yan
- Orthopedic Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shunzhi Yu
- Orthopedic Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tianqi Zhang
- Orthopedic Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chuanfeng Wang
- Orthopedic Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shisheng He
- Orthopedic Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Guangfei Gu
- Orthopedic Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
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Intraoperative Computed Tomography Navigational Assistance for Transforaminal Endoscopic Decompression of Heterotopic Foraminal Bone Formation After Oblique Lumbar Interbody Fusion. World Neurosurg 2018; 115:29-34. [PMID: 29626680 DOI: 10.1016/j.wneu.2018.03.188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 11/21/2022]
Abstract
Transforaminal endoscopic spine surgery is an emerging technique in spine surgery, but it offers 2 distinct challenges to spine surgeons looking to adopt it: 1) targeting spine pathology and 2) understanding the endoscopic anatomy visualized through the endoscope. Intraoperative computed tomography (CT)-guided navigation is also an emerging technique in spine surgery that is becoming widely adopted for its benefits in assisting surgeons in localizing pathology and guided spine instrumentation placement. In this technical note, we describe a technique that uses intraoperative CT-guided navigation concomitantly with a transforaminal endoscopic approach to decompress a L4-L5 foraminal heterotopic bone formation after an oblique lumbar interbody fusion. The addition of intraoperative CT-guided navigation proved beneficial in targeting the pathology during the procedure and ensuring that the pathology was resolved by offering postoperative CT visualization of the decompressed neural foramen.
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19
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Falco MD, Masala S, Stefanini M, Bagalà P, Morosetti D, Calabria E, Tonnetti A, Verona-Rinati G. Effective-dose estimation in interventional radiological procedures. Radiol Phys Technol 2018. [DOI: 10.1007/s12194-018-0446-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Smith JR, Marsh RM, Silosky MS. Is lead shielding of patients necessary during fluoroscopic procedures? A study based on kyphoplasty. Skeletal Radiol 2018; 47:37-43. [PMID: 28821928 DOI: 10.1007/s00256-017-2756-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/31/2017] [Accepted: 08/02/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the benefits, risks, and limitations associated with wrapping a patient with lead shielding during fluoroscopy-guided kyphoplasty procedures as a way to reduce operator radiation exposure. MATERIALS AND METHODS An anthropomorphic phantom was used to mimic a patient undergoing a kyphoplasty procedure under fluoroscopic guidance. Radiation measurements of the air kerma rate (AKR) were made at several locations and under various experimental conditions. First, AKR was measured at various angles along the horizontal plane of the phantom and at varying distances from the phantom, both with and without a lead apron wrapped around the lower portion of the phantom (referred to here as phantom shielding). Second, the effect of an operator's apron was simulated by suspending a lead apron between the phantom and the measurement device. AKR was measured for the four shielding conditions-phantom shielding only, operator apron only, both phantom shielding and operator apron, and no shielding. Third, AKR measurements were made at various heights and with varying C-arm angle. RESULTS At all locations, the phantom shielding provided no substantial protection beyond that provided by an operator's own lead apron. Phantom shielding did not reduce AKR at a height comparable to that of an operator's head. CONCLUSIONS Previous reports of using patient shielding to reduce operator exposure fail to consider the role of an operator's own lead apron in radiation protection. For an operator wearing appropriate personal lead apparel, patient shielding provides no substantial reduction in operator dose.
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Affiliation(s)
- Joshua R Smith
- Department of Radiology, University of Colorado School of Medicine, 12700 E. 19th Avenue, Mail Stop C278, Aurora, CO, 80045, USA
| | - Rebecca M Marsh
- Department of Radiology, University of Colorado School of Medicine, 12700 E. 19th Avenue, Mail Stop C278, Aurora, CO, 80045, USA.
| | - Michael S Silosky
- Department of Radiology, University of Colorado School of Medicine, 12700 E. 19th Avenue, Mail Stop C278, Aurora, CO, 80045, USA
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21
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Riis J, Lehman RR, Perera RA, Quinn JR, Rinehart P, Tuten HR, Kuester V. A retrospective comparison of intraoperative CT and fluoroscopy evaluating radiation exposure in posterior spinal fusions for scoliosis. Patient Saf Surg 2017; 11:32. [PMID: 29299062 PMCID: PMC5740881 DOI: 10.1186/s13037-017-0142-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background Radiation exposure is a concern in the field of medicine. Deformity spine surgeons depend on modalities that have high exposure through scoliosis x-rays or computed tomography. The use of fluoroscopy has increased with the increased use of pedicle screws. Recently other 3-D imaging devices with navigation have also been brought onto the market to improve accuracy of screw placement. There is concern that because of the use of CT, the radiation dose to the patient is increased, however there is little literature that directly compares the amount of radiation using the 3-D devices to traditional fluoroscopy. Although we know intraoperative CT decreases the amount of radiation to the surgeon and operating room staff, there is limited comparison data for exposure to patients. Our study focused on a comparison of radiation exposure data for pediatric scoliosis patients receiving posterior spinal fusions using traditional fluoroscopy and the Medtronic O-arm in an effort to determine the method most likely to decrease radiation exposure in the pediatric population. Methods Retrospective review of data in patient charts from two pediatric surgeons practicing in both a University and private hospital setting. Data collected included age, weight, height, diagnosis, Cobb angle, fusion levels, number of screws, and number of hooks, O-arm spins, fluoro doses and O-arm doses. Effective dose was calculated using output measures and radiation doses were compared along a continuum that took into account the amount of correction as indicated by Cobb angle. Results A total of 57 patients, 25 using the O-arm and 32 using traditional fluoroscopy, were analyzed. Effective dose was calculated and then compared as a factor correlated to curve severity. At lower angles of correction we found no statistically significant difference between methods in terms of effective radiation dose. There was no statistically significant divergence until a Cobb angle correction of greater than 74 degrees, where the Oarm dose was shown to be lower by comparison. Conclusion We found that regardless of the methods used there is still a significant radiation dose that is utilized in scoliosis procedures. The two methods analyzed did not display statistically significant differences in effective dose for the average case. Safely managing radiation exposure for pediatric patients is of the utmost priority. Healthcare professionals, however, face repeated exposure to radiation over the course of a long career. In our data set the O-Arm system does not increase overall exposure for patients and decreases radiation doses for providers and thereby provides a safe alternative to traditional fluoroscopy without compromising accuracy of implant placement or patient care. Level of Evidence: III.
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Affiliation(s)
- Jacob Riis
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1201 East Main Street, Richmond, VA USA
| | - Rebecca R Lehman
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA USA
| | - Robert A Perera
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA USA
| | - John Ryan Quinn
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1201 East Main Street, Richmond, VA USA
| | - Patricia Rinehart
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1201 East Main Street, Richmond, VA USA
| | | | - Victoria Kuester
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1201 East Main Street, Richmond, VA USA
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Norheim EP, Black MH, Ngor EW, Shi JM, Safran MR, Navarro RA. Cervical spine disease in surgeons performing arthroscopy or laparoscopy. ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 2017; 74:206-214. [PMID: 29035681 DOI: 10.1080/19338244.2017.1392277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/06/2017] [Indexed: 06/07/2023]
Abstract
Minimal research exists regarding cervical spine disorders in surgeons who perform endoscopy. A confidential on-line survey regarding neck pain (NP), spine disease (SD), and radiculopathy/myelopathy (R/M) was sent to 722 surgeons from a managed, group-based health care system. 415 responded. 361 had endoscopy experience, of whom 24.4% had NP, 20.8% SD, and 3.9% R/M. Most respondents were less than 50 years of age (62.3%), and male (65.7%). Significant risk factors for NP included older age and female, whereas OB/Gyn specialty, increased age and job stress were for SD. After adjusting for age and gender, significant risk factors for NP and SD included greater surgeon experience. After also adjusting for job stress, significant risk factors for SD included increased surgeon experience and higher frequency of endoscopies. No association was found between use of digital OR. Endoscopy appears to place surgeons at higher risk of cervical disease. Level of Evidence: Level 3.
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Affiliation(s)
- Elizabeth P Norheim
- a Southern California Permanente Medical Group, Kaiser Permanente, Downey Medical Center, Spine Surgery , Downey , California , USA
| | | | - Eunis W Ngor
- b Kaiser Foundation Health Plan , Pasadena , California , USA
| | - Jiaxiao M Shi
- b Kaiser Foundation Health Plan , Pasadena , California , USA
| | - Marc R Safran
- c Stanford Hospital and Clinics , Stanford , California , USA
| | - Ronald A Navarro
- d Southern California Permanente Medical Group, Kaiser Permanente, South Bay Medical Center , Harbor City , California , USA
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Matityahu A, Duffy RK, Goldhahn S, Joeris A, Richter PH, Gebhard F. The Great Unknown-A systematic literature review about risk associated with intraoperative imaging during orthopaedic surgeries. Injury 2017. [PMID: 28648410 DOI: 10.1016/j.injury.2017.04.041] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Modern techniques in orthopaedic surgery using minimally invasive procedures, and increased use of fluoroscopic imaging present a potential increased risk to surgeons due to ionizing radiation exposure. This article is a systematic review of recent literature on radiation exposure of orthopaedic surgeons. MATERIALS AND METHODS Pubmed and Cochrane searches were performed on intraoperative radiation exposure covering English and German articles published between 1.1.2000 and 11.8.2014. Inclusion criteria were clinical studies and systematic literature reviews focusing on radiation exposure of orthopaedic surgeons during surgical procedures of the musculoskeletal system reporting either effective dose (whole body) or equivalent dose at the organ level. All included articles were reviewed with focus on the surgical specialty, the procedure type, the imaging system used, the radiation measurement method, the fluoroscopy time, the radiation exposure, the use of radiation protection, and any references to specific safety guidelines. RESULTS Thirty-four eligible publications were identified. However, the lack of well-designed studies focusing on radiation exposure of surgeons prevents pooling of data. Highest exposure and subsequent equivalent doses were reported from spinal surgery (up to 4.8mSv of equivalent dose to the hand) and intramedullary nailing (up to 0.142mSV of equivalent dose to the thyroid). Radiation exposure was reduced by 96.9% and 94.2% when wearing a thyroid collar and a lead apron. CONCLUSIONS With the increasing use of intraoperative imaging, there is a growing need for radiation awareness by the operating surgeon. Strict adherence to radiation protection should be enforced to protect in-training surgeons. Strategies to reduce exposure include C-arm position, distance, protective wear, and new imaging technologies. Radiation exposure is harmful and action should be taken to minimize exposure.
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Affiliation(s)
- Amir Matityahu
- San Francisco General Hospital-Orthopaedic Trauma Institute, San Francisco, CA, USA.
| | - Ryan K Duffy
- San Francisco General Hospital-Orthopaedic Trauma Institute, San Francisco, CA, USA
| | - Sabine Goldhahn
- AO Clinical Investigation and Documentation, AO Foundation, Dübendorf, Switzerland
| | - Alexander Joeris
- AO Clinical Investigation and Documentation, AO Foundation, Dübendorf, Switzerland
| | - Peter H Richter
- Department for Orthopaedic Trauma, Ulm University, Ulm, Germany
| | - Florian Gebhard
- Department for Orthopaedic Trauma, Ulm University, Ulm, Germany
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Narain AS, Hijji FY, Yom KH, Kudaravalli KT, Haws BE, Singh K. Radiation exposure and reduction in the operating room: Perspectives and future directions in spine surgery. World J Orthop 2017; 8:524-530. [PMID: 28808622 PMCID: PMC5534400 DOI: 10.5312/wjo.v8.i7.524] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/21/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
Intraoperative imaging is vital for accurate placement of instrumentation in spine surgery. However, the use of biplanar fluoroscopy and other intraoperative imaging modalities is associated with the risk of significant radiation exposure in the patient, surgeon, and surgical staff. Radiation exposure in the form of ionizing radiation can lead to cellular damage via the induction of DNA lesions and the production of reactive oxygen species. These effects often result in cell death or genomic instability, leading to various radiation-associated pathologies including an increased risk of malignancy. In attempts to reduce radiation-associated health risks, radiation safety has become an important topic in the medical field. All practitioners, regardless of practice setting, can practice radiation safety techniques including shielding and distance to reduce radiation exposure. Additionally, optimization of fluoroscopic settings and techniques can be used as an effective method of radiation dose reduction. New imaging modalities and spinal navigation systems have also been developed in an effort to replace conventional fluoroscopy and reduce radiation doses. These modalities include Isocentric Three-Dimensional C-Arms, O-Arms, and intraoperative magnetic resonance imaging. While this influx of new technology has advanced radiation safety within the field of spine surgery, more work is still required to overcome specific limitations involving increased costs and inadequate training.
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Metaxas VI, Messaris GA, Gatzounis GD, Tzortzidis FN, Konstantinou DT, Panayiotakis GS. Institutional (local) diagnostic reference levels in fluoroscopically guided spine surgery. Eur J Radiol 2017; 90:50-59. [DOI: 10.1016/j.ejrad.2017.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 01/23/2017] [Accepted: 02/13/2017] [Indexed: 11/29/2022]
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Fan G, Wang Y, Guo C, Lei X, He S. Knowledge deficiency of work-related radiation hazards associated with psychological distress among orthopedic surgeons: A cross-sectional study. Medicine (Baltimore) 2017; 96:e6682. [PMID: 28538368 PMCID: PMC5457848 DOI: 10.1097/md.0000000000006682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Knowledge and concern degree about work-related radiation hazards remained unknown among orthopedic surgeons. The aim of the cross-sectional study is to investigate whether the knowledge degree of work-related radiation is associated with psychological distress among orthopedic surgeons. This cross-sectional study sent electronic questionnaire via WeChat to orthopedic surgeons nationwide. Concern and knowing degree over radiation exposure was evaluated by a single self-reported question. Professional evaluation of concern degree was reflected by general psychological distress, which was assessed with the Kessler 10 scale (K10) and depressive symptoms with the Center for Epidemiologic Studies Depression Scale (CES-D). Only 43.23% (115/266) respondents knew well about radiation and a total of 78.20% (208/266) respondents considered radiation exposure as a great concern. Among those who reported concerns about radiation exposure, a total of 57.69% (120/208) respondents reported knowing little about radiation. Respondents who reported concerns over radiation exposure were significantly associated with higher scores on CES-D and K10 (P < .05). Among respondents who reported concerns over radiation exposure, those who have fewer knowledge about radiation, had higher CES-D and K10 scores than those who knew well about radiation (P < .05). Among respondents who reported no concerns over radiation exposure, those who knew little about radiation still had higher CES-D and K10 scores (P < .05). Fewer radiation knowledge tends to induce more radiation concerns associated with higher psychological distress in orthopedic surgeons. Radiation knowledge should be enhanced for surgeons who daily work with radiation-related fluoroscopy.
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Affiliation(s)
| | | | - Changfeng Guo
- Department of Emergency Medicine, Shanghai Tenth People's Hostipal, Tongji University School of Medicine, Shanghai, China
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Fan G, Zhang H, Gu X, Wang C, Guan X, Fan Y, He S. Significant reduction of fluoroscopy repetition with lumbar localization system in minimally invasive spine surgery: A prospective study. Medicine (Baltimore) 2017; 96:e6684. [PMID: 28538369 PMCID: PMC5457849 DOI: 10.1097/md.0000000000006684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The conventional location methods for minimally invasive spinal surgery (MISS) were mainly based on repeated fluoroscopy in a trial-and-error manner preoperatively and intraoperatively. Localization system mainly consisted of preoperative applied radiopaque frame and intraoperative guiding device, which has the potential to minimize fluoroscopy repetition in MISS. The study aimed to evaluate the efficacy of a novel lumbar localization system in reducing radiation exposure to patients.Included patients underwent minimally invasive transforaminal lumbar interbody fusion (MISTLIF) or percutaneous transforaminal endoscopic discectomy (PTED). Patients treated with novel localization system were regarded as Group A, and patients treated without novel localization system were regarded as Group B.For PTED, The estimated effective dose was 0.41 ± 0.13 mSv in Group A and 0.57 ± 0.14 mSv in Group B (P < .001); the fluoroscopy exposure time of PTED was 22.18 ± 7.30 seconds in Group A and 30.53 ± 7.56 seconds in Group B (P < .001); The estimated cancer risk of radiation exposure was 22.68 ± 7.38 (10) in Group A and 31.20 ± 7.96 (10) in Group B (P < .001). For MISTLIF, the estimated effective dose was 0.45 ± 0.09 mSv in Group A and 0.58 ± 0.09 mSv in Group B (P < .001); The fluoroscopy exposure time was 25.41 ± 5.52 seconds in Group A and 32.82 ± 5.03 seconds in Group B (P < .001); The estimated cancer risk was 24.90 ± 5.15 (10) in Group A and 31.96 ± 5.04 (10) in Group B (P < .001). There were also significant differences in localization time and operation time between the 2 groups either for MISTLIF or PTED.The lumbar localization system could be a potential protection strategy for minimizing radiation hazards.
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Wu R, Liao X, Xia H. Radiation Exposure to the Surgeon During Ultrasound-Assisted Transforaminal Percutaneous Endoscopic Lumbar Discectomy: A Prospective Study. World Neurosurg 2017; 101:658-665.e1. [PMID: 28342919 DOI: 10.1016/j.wneu.2017.03.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine the radiation dose to the surgeon during ultrasound-assisted transforaminal percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniation, and to investigate whether the usage of ultrasonography could reduce the radiation exposure to the surgeon. METHODS The stages of needle insertion and foraminal plasty for transforaminal PELD were performed under ultrasound guidance and confirmed by fluoroscopy according to the standard technique by 2 spinal surgeons separately in 25 transforaminal PELDs (25 levels). The radiation exposure dose of the surgeons' chest above and below the shielding and the fluoroscopy time were recorded. The effective dose and number of possible levels per year within the yearly occupational exposure limit (OEL) were calculated. The radiation dose per level and fluoroscopy time between ultrasound-assisted PELD and fluoroscopy-assisted PELD were compared. RESULTS The mean operation time and fluoroscopy time were 67.6 ± 14.6 minutes and 2.9 ± 0.7 seconds, respectively. The mean effective dose to the surgeons per level was 1.3 ± 0.6 μSv. One surgeon could perform PELDs at 38,462 levels per year without exceeding the OEL for whole-body radiation wearing a lead apron, and 1938 levels per year without using any shielding devices. Ultrasound-assisted PELD had significantly less radiation dose per level at the chest below and above apron, effective dose per level, and fluoroscopy time, compared with fluoroscopy-assisted PELD (all P < 0.05). CONCLUSIONS The method of ultrasound-assisted needle insertion and foraminal plasty in transforaminal PELD can reduce radiation exposure to the surgeons compared with fluoroscopy-assisted PELD.
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Affiliation(s)
- Ruihui Wu
- Department of Orthopedics, Southern Medical University, Guangzhou, P.R. China; Department of Orthopedics, First People's Hospital of Foshan, Foshan, P.R. China
| | - Xuqiang Liao
- Department of Orthopedics, First People's Hospital of Foshan, Foshan, P.R. China
| | - Hong Xia
- Department of Orthopedics, Southern Medical University, Guangzhou, P.R. China; Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, P.R. China.
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Metaxas VI, Messaris GA, Gatzounis GD, Panayiotakis GS. Patient Dose in Fluoroscopically Guided Cervical Discectomy and Fusion. RADIATION PROTECTION DOSIMETRY 2017; 174:575-582. [PMID: 27613745 DOI: 10.1093/rpd/ncw257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 08/10/2016] [Indexed: 06/06/2023]
Abstract
Cervical discectomy and fusion (CDF) is a minimally invasive procedure, where the accurate placement of the implants is accomplished using fluoroscopic guidance. Therefore, the evaluation of the radiation dose becomes mandatory. The purpose of the current study was to assess patient dose during fluoroscopically guided anterior and/or posterior CDF procedures. Thirty-three patients undergoing single or multiple-level CDF were studied using a mobile C-arm system. Data regarding fluoroscopy time (FT), air kerma area product (KAP) and cumulative dose (CD) were recorded. Patient entrance surface dose (ESD), thyroid absorbed dose and effective dose (ED) were calculated from KAP measurements, utilizing the CALDoseX software. The average FT was 0.12 min (range 0.02-0.48 min), resulting to a KAP value of 0.21 Gy cm2 (range 0.01-1.46 Gy cm2) and a CD value of 0.96 mGy (range 0.04-6.58 mGy). The ESD ranged between 0.08 and 13.58 mGy (average 1.95 mGy), the ED between 0.001 and 0.097 mSv (average 0.015 mSv), while the dose absorbed by the thyroid ranged between 0.01 and 1.12 mGy (average 0.194 mGy). The dose associated with the CDF procedure is very low, comparable to that delivered by a lateral X-ray radiograph of the cervical spine. However, higher doses can be revealed, due to the non-optimum use of the X-ray system and extended FTs, mainly affected by complex clinical conditions, as well as the experience of the neurosurgeon. Additional studies need to be conducted for further investigation of the patient dose from the CDF procedure.
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Affiliation(s)
- Vasileios I Metaxas
- Department of Medical Physics, School of Medicine, University of Patras, 265 04 Patras, Greece
| | - Gerasimos A Messaris
- Department of Medical Physics, School of Medicine, University of Patras, 265 04 Patras, Greece
| | - George D Gatzounis
- Department of Neurosurgery, School of Medicine, University of Patras, 265 04 Patras, Greece
| | - George S Panayiotakis
- Department of Medical Physics, School of Medicine, University of Patras, 265 04 Patras, Greece
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Iprenburg M, Wagner R, Godschalx A, Telfeian AE. Patient radiation exposure during transforaminal lumbar endoscopic spine surgery: a prospective study. Neurosurg Focus 2016; 40:E7. [PMID: 26828888 DOI: 10.3171/2015.11.focus15485] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to describe patient radiation exposure during single-level transforaminal endoscopic lumbar discectomy procedures at levels L2-5 and L5-S1. METHODS Radiation exposure was monitored in 151 consecutive patients undergoing single-level transforaminal endoscopic lumbar discectomy procedures. Two groups were studied: patients undergoing procedures at the L4-5 level or above and those undergoing an L5-S1 procedure. RESULTS For the discectomy procedures at L4-5 and above, the average duration of fluoroscopy was 38.4 seconds and the mean calculated patient radiation exposure dose was 1.5 mSv. For the L5-S1 procedures, average fluoroscopy time was 54.6 seconds and the mean calculated radiation exposure dose was 2.1 mSv. The average patient radiation exposure dose among these cases represents a 3.5-fold decrease compared with the senior surgeon's first 100 cases. CONCLUSIONS Transforaminal lumbar endoscopic discectomy can be used as a minimally invasive technique for the treatment of lumbar radiculopathy in the setting of a herniated lumbar disc without the significant concern of exposing the patient to harmful doses of radiation. One caveat is that both the surgeon and the patient are likely to be exposed to higher doses of radiation during a surgeon's early experience in minimally invasive endoscopic spine surgery.
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Affiliation(s)
| | - Ralf Wagner
- Ligamenta Spine Centre, Frankfurt am Main, Germany; and
| | | | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Abstract
STUDY DESIGN Prospective in vivo investigation of fluoroscopic radiation exposure during spinal surgery. OBJECTIVE To quantify the total amount of radiation dosage and identify techniques to maintain safe levels of fluoroscopic exposure in the operating room. SUMMARY OF BACKGROUND DATA No previous study has performed an in vivo examination of fluoroscopic radiation exposure to the spinal surgeon and operating room personnel. Previous similar studies were in vitro, used older versions of fluoroscopy, and increased fluoro times associated with pedicle screw placement. METHODS Thirty-five surgeries were evaluated in 18 males and 17 females (mean age 52.4 y; range, 26.0-79.4). Surgeries included 37 lumbar levels fused, 45 lumbar decompressions, 8 anterior cervical fusions, and 19 transforaminal lumbar interbody fusion procedures. Spinal instrumentation was implemented in all fusion procedures (104 lumbar pedicle screws, 14 iliac, 22 anterior cervical). Radiation dosimetry was obtained through unprotected badges placed on surgeon's chest, first assistant chest, cranial and caudal end of operating table. RESULTS Total fluoroscopic time was 37.01 minutes. Mean fluoroscopic time with lumbar spine instrumentation was greater than decompression alone (1.74 vs. 0.22 min). Total fluoroscopic radiation exposure was obtained for surgeon (1225 mrem), first assistant (369 mrem), cranial table (92 mrem), and caudal table (150 mrem). Mean dose/min (mrem/min) was calculated for surgeon (33.1), first assistant (9.97), cranial table (2.48), and caudal table (4.05). To remain below the maximum yearly permissible level of radiation, the estimated total number of minutes for the surgeon would be 453. CONCLUSIONS The results of this in vivo study indicate fluoroscopic dosage to the spine surgeon remains below the annual maximum limit of radiation exposure. Increasing distance from radiation source led to a significantly diminished in vivo dosimetry reading. Monitoring fluoroscopic time and maintaining a distance from the beam source, radiation exposure to the spine surgeon may be kept within current safety standards.
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Hazards of Ionizing Radiation and its Impact on Spine Surgery. World Neurosurg 2016; 92:353-359. [DOI: 10.1016/j.wneu.2016.05.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 12/28/2022]
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Fu Q, Fan G, Wu X, Gu G, Guan X, Zhang H, Gu X, He S. Letter to the Editor: Impact of body habitus on fluoroscopic radiation to the surgeon. J Neurosurg Spine 2016; 24:867-9. [PMID: 26824582 DOI: 10.3171/2014.12.spine141274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Grelat M, Greffier J, Sabatier P, Dauzac C, Lonjon G, Debono B, Le Roy J, Kouyoumdjïan P, Lonjon N. Assessment of the Radiation Exposure of Surgeons and Patients During a Lumbar Microdiskectomy and a Cervical Microdiskectomy: A French Prospective Multicenter Study. World Neurosurg 2016; 89:329-36. [DOI: 10.1016/j.wneu.2016.02.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 11/29/2022]
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Rhea EB, Rogers TH, Riehl JT. Radiation safety for anaesthesia providers in the orthopaedic operating room. Anaesthesia 2016; 71:455-61. [DOI: 10.1111/anae.13400] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2015] [Indexed: 11/29/2022]
Affiliation(s)
- E. B. Rhea
- University of Louisville School of Medicine; Louisville Ohio USA
| | - T. H. Rogers
- Department of Orthopaedic Surgery; University of Florida College of Medicine; Jacksonville Florida USA
| | - J. T. Riehl
- Baptist Hospital and the Andrews Research and Education Institute; Gulf Breeze Florida USA
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Fan G, Guan X, Zhang H, Wu X, Gu X, Gu G, Fan Y, He S. Significant Improvement of Puncture Accuracy and Fluoroscopy Reduction in Percutaneous Transforaminal Endoscopic Discectomy With Novel Lumbar Location System: Preliminary Report of Prospective Hello Study. Medicine (Baltimore) 2015; 94:e2189. [PMID: 26656348 PMCID: PMC5008493 DOI: 10.1097/md.0000000000002189] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Prospective nonrandomized control study.The study aimed to investigate the implication of the HE's Lumbar LOcation (HELLO) system in improving the puncture accuracy and reducing fluoroscopy in percutaneous transforaminal endoscopic discectomy (PTED).Percutaneous transforaminal endoscopic discectomy is one of the most popular minimally invasive spine surgeries that heavily depend on repeated fluoroscopy. Increased fluoroscopy will induce higher radiation exposure to surgeons and patients. Accurate puncture in PTED can be achieved by accurate preoperative location and definite trajectory.The HELLO system mainly consists of self-made surface locator and puncture-assisted device. The surface locator was used to identify the exact puncture target and the puncture-assisted device was used to optimize the puncture trajectory. Patients who had single L4/5 or L5/S1 lumbar intervertebral disc herniation and underwent PTED were included the study. Patients receiving the HELLO system were assigned in Group A, and those taking conventional method were assigned in Group B. Study primary endpoint was puncture times and fluoroscopic times, and the secondary endpoint was location time and operation time.A total of 62 patients who received PTED were included in this study. The average age was 45.35 ± 8.70 years in Group A and 46.61 ± 7.84 years in Group B (P = 0.552). There were no significant differences in gender, body mass index, conservative time, and surgical segment between the 2 groups (P > 0.05). The puncture times were 1.19 ± 0.48 in Group A and 6.03 ± 1.87 in Group B (P < 0.001). The fluoroscopic times were 14.03 ± 2.54 in Group A and 25.19 ± 4.28 in Group B (P < 0.001). The preoperative location time was 4.67 ± 1.41 minutes in Group A and 6.98 ± 0.94 minutes in Group B (P < 0.001). The operation time was 79.42 ± 10.15 minutes in Group A and 89.65 ± 14.06 minutes in Group B (P = 0.002). The hospital stay was 2.77 ± 0.95 days in Group A and 2.87 ± 1.02 days in Group B (P = 0.702). There were no significant differences in the complication rate between the 2 groups (P = 0.386).The highlight of HELLO system is accurate preoperative location and definite trajectory. This preliminary report indicated that the HELLO system significantly improves the puncture accuracy of PTED and reduces the fluoroscopic times, preoperative location time, as well as operation time. (ChiCTR-ICR-15006730).
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Affiliation(s)
- Guoxin Fan
- From the Orthopedic Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
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Grelat M, Zairi F, Quidet M, Marinho P, Allaoui M, Assaker R. Évaluation de l’exposition aux radiations du chirurgien lors d’un TLIF mini-invasif : comparaison entre fluoroscopie et navigation O-arm. Neurochirurgie 2015; 61:255-9. [DOI: 10.1016/j.neuchi.2015.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 02/01/2015] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
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Bakr O, Morshed S, Marmor M. Effect of C-Arm Year Model on Radiation Scatter. J Med Device 2015. [DOI: 10.1115/1.4029419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Since the 1980’s C-arm fluoroscopy has been an integral part of orthopaedic trauma surgery. The advancement in C-arm technology has resulted in different generations of C-arms co-existing in the operating rooms. The purpose of this study was to compare the radiation scatter patterns of different generation C-arms. Three generation of C-arms were tested: GE OEC 9800 Plus (1999/2000), Siemens Arcadis Orbic 3D (2004), Philips BV Pulsera 2.3 (2008). Radiation scatter was measured using six real-time dosimetry badges set up on either side of the surgical table (Mizuho OSI, flat-top). Distance of C-arm was normalized at 20 in. and 10 in. from Image Intensifier. Each device was set to the automatic brightness control (ABC) setting. A phantom limb was irradiated for 120 s and radiation scatter was summed for both AP and lateral positions. At their typical operating room settings there was a reduction in radiation scatter using the newer generation C-arms. Results for total radiation, normalized to Philips, are as follows: Philips 1 (100%), GE 2.4 (240%), and Siemens 1.4 (140%). Newer generation C-arms can be expected to generate lower radiation scatter. Special care should be taken to attempt a lower dose setting, especially when utilizing older generation C-arms to minimize radiation scatter to practitioner.
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Affiliation(s)
- Omar Bakr
- 2550, 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110 e-mail:
| | - Saam Morshed
- 2550, 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110 e-mail:
| | - Meir Marmor
- 2550, 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110 e-mail:
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Falco MD, Masala S, Stefanini M, Fiori R, Gandini R, Bagalà P, Morosetti D, Calabria E, Tonnetti A, Verona-Rinati G, Santoni R, Simonetti G. Patient skin dose measurements using a cable free system MOSFETs based in fluoroscopically guided percutaneous vertebroplasty, percutaneous disc decompression, radiofrequency medial branch neurolysis, and endovascular critical limb ischemia. J Appl Clin Med Phys 2015; 16:5020. [PMID: 25679159 PMCID: PMC5689972 DOI: 10.1120/jacmp.v16i1.5020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 10/16/2014] [Accepted: 09/16/2014] [Indexed: 11/23/2022] Open
Abstract
The purpose of this work has been to dosimetrically investigate four fluoroscopically guided interventions: the percutaneous vertebroplasty (PVP), the percutaneous disc decompression (PDD), the radiofrequency medial branch neurolysis (RF) (hereafter named spine procedures), and the endovascular treatment for the critical limb ischemia (CLI). The X-ray equipment used was a Philips Integris Allura Xper FD20 imaging system provided with a dose-area product (DAP) meter. The parameters investigated were: maximum skin dose (MSD), air kerma (Ka,r), DAP, and fluoroscopy time (FT). In order to measure the maximum skin dose, we employed a system based on MOSFET detectors. Before using the system on patients, a calibration factor Fc and correction factors for energy (CkV) and field size (CFD) dependence were determined. Ka,r, DAP, and FT were extrapolated from the X-ray equipment. The analysis was carried out on 40 patients, 10 for each procedure. The average fluoroscopy time and DAP values were compared with the reference levels (RLs) proposed in literature. Finally, the correlations between MSD, FT, Ka,r, and DAP values, as well as between DAP and FT values, were studied in terms of Pearson's product-moment coefficients for spine procedures only. An Fc value of 0.20 and a very low dependence of CFD on field size were found. A third-order polynomial function was chosen for CkV. The mean values of MSD ranged from 2.3 to 10.8cGy for CLI and PVP, respectively. For these procedures, the DAP and FT values were within the proposed RL values. The statistical analysis showed little correlation between the investigated parameters. The interventional procedures investigated were found to be both safe with regard to deterministic effects and optimized for stochastic ones. In the spine procedures, the observed correlations indicated that the estimation of MSD from Ka,r or DAP was not accurate and a direct measure of MSD is therefore recommended.
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Srinivasan D, Than KD, Wang AC, La Marca F, Wang PI, Schermerhorn TC, Park P. Radiation safety and spine surgery: systematic review of exposure limits and methods to minimize radiation exposure. World Neurosurg 2014; 82:1337-43. [PMID: 25088230 DOI: 10.1016/j.wneu.2014.07.041] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 07/29/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ionizing radiation is typically used during spine surgery for localization and guidance in instrumentation placement. Minimally invasive (MI) surgical procedures are increasingly popular and often require significantly more fluoroscopy, placing surgeons at risk for increased radiation exposure and radiation-induced complications. This study provides recommendations for minimizing risk of radiation-induced injury to spine surgeons and summarizes studies addressing radiation exposure in spine procedures. METHODS The PubMed database was queried for relevant articles pertaining to radiation exposure in spine surgery. RESULTS Discectomy, percutaneous pedicle screw placement, MI transforaminal lumbar interbody fusion, MI lateral lumbar interbody fusion, and vertebroplasty/kyphoplasty procedures were assessed. The highest radiation doses were seen with MI pedicle screw placement, MI transforaminal lumbar interbody fusion, vertebroplasty and kyphoplasty, and percutaneous endoscopic lumbar discectomy. Use of lead aprons and thyroid shields reduces effective dose by several orders of magnitude. Proper operator positioning also minimizes radiation exposure. Lead gloves decrease dose to the surgeon's hand from scatter if the hand is out of the x-ray beam most of the time. If prolonged exposure of the hand cannot be avoided, the technician should collimate the surgeon's hand out of the beam or use instruments to position the hand farther from the beam. In addition to using less fluoroscopy, pulsed fluoroscopy can decrease overall dose in a procedure. CONCLUSIONS Spine surgeons should reduce their exposure to radiation to minimize risk of potential long-term complications. Strategies include minimizing fluoroscopy use and dose, proper use of protective gear, and appropriate manipulation of fluoroscopic equipment.
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Affiliation(s)
| | - Khoi D Than
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Anthony C Wang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank La Marca
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Page I Wang
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
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Nguyen-Kim L, Fargeot C, Beaussier H, Payen S, Chiras J. Evaluation of operator radioprotection using a new injection device during vertebroplasty. Interv Neuroradiol 2013; 19:173-9. [PMID: 23693040 DOI: 10.1177/159101991301900205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 02/08/2013] [Indexed: 11/15/2022] Open
Abstract
This study aimed to evaluate the protection granted by a simple device (X'TENS(®), Thiebaud, France) and to provide operators with information on the performance of this new device, which has not yet been assessed. Our assumption is that this device efficiently reduces the radiation dose to the operator. In a prospective clinical study, the radiation dose the operator's hand receives has been assessed using a specific sensor (UNFOR Instrument). Each patient included in the study was to receive at least two injections of cement during the procedure. Exposure was measured with and without the range extender. The data collected were then processed using a Wilcoxon matched pairs test. During 14 interventions, 20 vertebrae were treated with both procedures. Eleven women and three men were included. Seven patients underwent vertebroplasty for metastatic lesions and seven for osteoporotic lesions, bone fractures or vertebral compressions. The average injection time was 1.35 minutes with the device and 1.20 without (p=0.75). The dose to the hand per ml injected was 111.37 vs. 166.91 (p<0.05). Theoretically, the protection granted by the range extender depends on the length of the device. Our results are consistent with the inverse-square law. However, the variations in our results indicate that a proper and rigorous use is mandatory for the device to be effective. Given that radioprotection during fluoroscopy procedures is a frequently raised issue, the need for information for a safer practice increases likewise.
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Affiliation(s)
- L Nguyen-Kim
- Pharmacy Department, AGEPS, AP-HP, Paris, France.
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Li YY, Huang TJ, Cheng CC, Wu MH, Lee CY. Comparing radiation exposure during percutaneous vertebroplasty using one- vs. two-fluoroscopic technique. BMC Musculoskelet Disord 2013; 14:38. [PMID: 23339360 PMCID: PMC3557160 DOI: 10.1186/1471-2474-14-38] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 01/15/2013] [Indexed: 11/25/2022] Open
Abstract
Background Percutaneous vertebroplasty (PV) requires relatively lengthy fluoroscopic guidance, which might lead to substantial radiation exposure to patients or operators. The two-fluoroscopic technique (two-plane radiographs obtained using two fluoroscopes) during PV can provide simultaneous two-planar projections with reducing operative time. However, the two-fluoroscopic technique may expose the operator or patient to increased radiation dose. The aim of this study was to quantify the amount of radiation exposure to the patient or operator that occurs during PV using one- vs. two-fluoroscopic technique. Methods Two radiation dosimeters were placed on the right flank of each patient and on the upper sternum of each operator during 26 single-level PV procedures by one senior surgeon. The use of two-fluoroscopic technique (13 patients) and one-fluoroscopic technique (13 patients) were allocated in a consecutive and alternative manner. The operative time and mean radiation dose to each patient and operator were monitored and compared between groups. Results Mean radiation dose to the patient was 1.97 ± 1.20 mSv (95% CI, 0.71 to 3.23) for the one-fluoroscopic technique group vs. 0.95 ± 0.34 mSv (95% CI, 0.85 to 1.23) for the two-fluoroscopic technique group (P =0.031). Mean radiation dose to the operator was 0.27 ± 0.12 mSv (95% CI, 0.17–0.56) for the one-fluoroscopic technique group vs. 0.25 ± 0.14 mSv (95% CI, 0.06–0.44) for the two-fluoroscopic technique group (P = 0.653). The operative time was significantly different between groups: 47.15 ± 13.48 min (range, 20–75) for the one-fluoroscopic technique group vs. 36.62 ± 8.42 min (range, 21–50) for the two-fluoroscopic technique group (P =0.019). Conclusion Compared to the one-fluoroscopic technique, the two-fluoroscopic technique used during PV provides not only shorter operative times but also reduces the radiation exposure to the patient. There was no significant difference between the two techniques with regards to radiation exposure to the operator.
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Affiliation(s)
- Yen-Yao Li
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, No6 W Sec, Chia-pu Rd, Putz City, Chiayi County, 613, Taiwan.
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Xu W, Xu L, Chen M, Mao YT, Xie ZG, Wu SL, Dong QR. The effects of low dose X-irradiation on osteoblastic MC3T3-E1 cells in vitro. BMC Musculoskelet Disord 2012; 13:94. [PMID: 22682502 PMCID: PMC3414775 DOI: 10.1186/1471-2474-13-94] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 06/08/2012] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND It has been indicated that moderate or high dose of X-irradiation could delay fracture union and cause osteoradionecrosis, in part, mediated by its effect on proliferation and differentiation of osteoblasts. However, whether low dose irradiation (LDI) has similar roles on osteoblasts is still unknown. In this study, we investigated whether and to what extent LDI could affect the proliferation, differentiation and mineralization of osteoblasts in vitro. METHODS The MC3T3-E1 cells were exposed to single dose of X-irradiation with 0, 0.1, 0.5, 1.0 Gy respectively. Cell proliferation, apoptosis, alkaline phosphatase (ALP) activity, and mineralization was evaluated by methylthiazoletetrazolium (MTT) and bromodeoxyuridine (BrdU) assay, flow cytometry, ALP viability kit and von Kossa staining, respectively. Osteocalcin (OCN) and core-binding factor α1 (Cbfα1) expressions were measured by real time-PCR and western blot, respectively. RESULTS The proliferation of the cells exposed to 2.0 Gy was significantly lower than those exposed to ≤1.0 Gy (p < 0.05) from Day 4 to Day 8, measured by MTT assay and BrdU incorporation. For cells exposed to ≤1.0 Gy, increasing dosages of X-irradiation had no significant effect on cell proliferation and apoptosis. Importantly, LDI of 0.5 and 1 Gy increased ALP activities and mineralized nodules of MC3T3-E1 cells. In addition, mRNA and protein expressions of OCN and Cbfα1 were also markedly increased after treatment with LDI at 0.5 and 1 Gy. CONCLUSIONS LDI have different effects on proliferation and differentiation of osteoblasts from those of high dose of X-irradiation, which might suggest that LDI could lead to promotion of fracture healing through enhancing the differentiation and mineralization of osteoblasts.
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Affiliation(s)
- Wei Xu
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
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Fransen P. Fluoroscopic exposure during percutaneous balloon compression of the Gasserian ganglion. J Neurointerv Surg 2012; 5:494-5. [DOI: 10.1136/neurintsurg-2012-010370] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kim S, Sopko D, Toncheva G, Enterline D, Keijzers B, Yoshizumi TT. Radiation dose from 3D rotational X-ray imaging: organ and effective dose with conversion factors. RADIATION PROTECTION DOSIMETRY 2012; 150:50-54. [PMID: 21926088 DOI: 10.1093/rpd/ncr369] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The purpose of this study was to measure organ doses and the effective dose (ED) using a three-dimensional rotational X-ray (3D-RX) system and to determine the ED conversion factor from the dose area product (DAP) for skull, spine and biliary protocols. A commercial 3D-RX imaging system was used to simulate the protocols with the adult female anthropomorphic phantom. Twenty MOSFET detectors were used to measure the absorbed doses at various organ locations. The ED was calculated for each protocol and the corresponding DAP was obtained. The skin dose was the highest for all the protocols. The second highest organ doses were those of the brain for the skull, the intestine for the spine and the kidney for the biliary protocol. The ED was 0.4-0.9, 4.2-8.4 and 3.2-4.6 mSv, and the ED conversion factor was 0.06-0.09, 0.18-0.31 and 0.13-0.23 mSv Gy(-1) cm(-2) for each protocol, respectively. This data may be used to estimate the patient ED for those protocols in the 3D-RX.
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Affiliation(s)
- Sangroh Kim
- Medical Physics Graduate Program, Duke University, Durham, NC 27705, USA
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Yang CD, Chen YW, Tseng CS, Ho HJ, Wu CC, Wang KW. Non-invasive, fluoroscopy-based, image-guided surgery reduces radiation exposure for vertebral compression fractures: A preliminary survey. FORMOSAN JOURNAL OF SURGERY 2012. [DOI: 10.1016/j.fjs.2011.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Musculoskeletal disorders among spine surgeons: results of a survey of the Scoliosis Research Society membership. Spine (Phila Pa 1976) 2011; 36:E1715-21. [PMID: 21508887 DOI: 10.1097/brs.0b013e31821cd140] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Survey of surgeon members of the Scoliosis Research Society. OBJECTIVE To assess the prevalence of musculoskeletal disorders (MSDs) among spine surgeons. SUMMARY OF BACKGROUND DATA Spinal deformity surgery is characterized by long duration and repetitive, forceful tasks. The purpose of this study is to describe the type and prevalence of MSDs among orthopedic spine surgeons. METHODS A modified version of the physical discomfort survey was sent to surgeon members of the Scoliosis Research Society via standard mail and e-mail. A total of 3 attempts to contact potential respondents were made, with 62% (561/904 × 100) responding. Mean respondent age was 54 years. Mean annual total caseload was 147, of which 62 were of spinal deformity. A total of 84% of the respondents had an active surgical practice. RESULTS The most common self-reported diagnoses included neck pain/strain/spasm (38%, 215/561), lumbar disc herniation/radiculopathy (31%, 172/561), cervical disc herniation/radiculopathy (28%, 155/561), rotator cuff disease (24%, 134/561), varicose veins or peripheral edema (20%, 112/561), and lateral epicondylitis (18%, 99/561). For lumbar disc disease, 7.1% (40/561 × 100) and for cervical disc disease, 4.6% (26/561 × 100) of spine surgeons underwent surgery. Among active spine surgeons, multiple linear regression analysis revealed that total caseload correlated with neck pain (P = 0.01) and lower extremity edema (P = 0.03), while the number of deformity cases correlated with wrist pain (P = 0.003) and hand pain (P = 0.03). Age was correlated with shoulder (P = 0.03), elbow (P = 0.04), and hand pain (P = 0.02). Number of years in practice did not correlate with MSDs. CONCLUSION Compared with disease estimates in the general population, spine surgeons have a higher prevalence of MSDs. Our cohort underwent surgical intervention for lumbar (7.1%) and cervical (4.6%) disc disease at rates far exceeding disease estimates in the general population. Increased awareness among spine surgeons may lead to earlier treatment and, ultimately, enhanced preventive measures.
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Radiation exposure to the surgeon during open lumbar microdiscectomy and minimally invasive microdiscectomy: a prospective, controlled trial. Spine (Phila Pa 1976) 2011; 36:255-60. [PMID: 20736891 DOI: 10.1097/brs.0b013e3181ceb976] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a prospective in vivo study comparing radiation exposure to the surgeon during 10 minimally invasive lumbar microdiscectomy cases with 10 traditional open discectomy cases as a control. OBJECTIVE Radiation exposure to the eye, chest, and hand of the operating surgeon during minimally invasive surgery (MIS) and open lumbar microdiscectomy were measured. The Occupational Exposure Guidelines were used to calculate the allowable number of cases per year from the mean values at each of the 3 sites. SUMMARY OF BACKGROUND DATA Fluoroscopy is a source of ionizing radiation and as such, is a potential health hazard with continued exposure during surgery. Presently, radiation exposure to the surgeon during MIS lumbar microdiscectomy is unknown. METHODS Radiation exposure to the surgeon (millirads [mR]) per case was measured by digital dosimeters placed at the level of the thyroid/eye, chest, and dominant forearm. Other data collected included operative side and level, side of the surgeon, side of the x-ray source, total fluoroscopy time, and energy output. RESULTS The average radiation exposure to the surgeon during open cases was thyroid/eye 0.16 ± 0.22 mR, chest 0.21 ± 0.23 mR, and hand 0.20 ± 0.14 mR. During minimally invasive cases exposure to the thyroid/eye was 1.72 ± 1.52 mR, the chest was 3.08 ± 2.93 mR, and the hand was 4.45 ± 3.75 mR. The difference between thyroid/ eye, chest, and hand exposure during open and minimally invasive cases was statistically significant (P = 0.010, P = 0.013, and P = 0.006, respectively). Surgeons standing in an adjacent substerile room during open cases were exposed to 0.2 mR per case. CONCLUSION MIS lumbar microdiscectomy cases expose the surgeon to significantly more radiation than open microdiscectomy. One would need to perform 1623 MIS microdiscectomies to exceed the exposure limit for whole-body radiation, 8720 cases for the lens of the eye, and 11,235 cases for the hand. Standing in a substerile room during x-ray localization in open cases is not fully protective.
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Abstract
STUDY DESIGN We studied the radiation doses to which patients were exposed during 17 vertebroplasty operations. OBJECTIVE The radiation doses during vertebroplasty were measured to determine maximum skin dose (MSD), a measure of the likelihood of radiation-induced skin effects. SUMMARY OF BACKGROUND DATA Vertebroplasty is performed with use of fluoroscopic guidance for needle placement and to monitor bone cement injection. This procedure requires relatively long duration of fluoroscopic guidance, and so, it demands dose measurements for patients. METHODS From May 2006 to April 2008, 16 patients (7 men and 9 women; mean age 70.19 years, range 30-87 years) underwent a total of 17 vertebroplasty procedures. Total dose-area product (DAP), duration of fluoroscopy, and the parameters for anteroposterior (AP) and lateral (LAT) fluoroscopic and fluorography projections were recorded for each procedure. Gafchromic films were placed on the patients' skin to measure entrance surface dose and to evaluate the MSD. RESULTS The MSD and DAP were higher in the LAT plane than in the AP plane. These results were expected because the fluoroscopy time was longer, and the number of fluorography runs was higher in the LAT plane than in the AP plane.The MSD values for the AP plane ranged between 0.184 Gy and 1.834 Gy, whereas those for the LAT plane ranged between 0.417 Gy and 2.362 Gy. The frequency distribution of values for both planes showed that most MSD values were in the range of 0 to 0.5 Gy and 0.5 to 1 Gy for the AP plane and 0.5 to 1 Gy and 1 to 1.5 Gy for the LAT plane. There was great variability in the MSD at each value for the parameters among individual instances. CONCLUSION When evaluating the MSD to a patient, a distinction should be made between AP and LAT projections, because an overall mean MSD value underestimates the contribution of x-ray absorption on the LAT plane. The use of radiochromic films to estimate radiation damage to the skin has been shown to have the limitation of relying on DAP values only.
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