Intraoperative 2D C-arm and 3D O-arm in children: a comparative phantom study

Intraoperative Fluoroscopy Radiation Using OEC 9900 Elite C-arm: Risk and Method for Decreasing Exposure

ABSTRACT

The use of intraoperative fluoroscopy in surgery produces scattered radiation that can expose all operating room personnel to measurable and, in some cases, substantial radiation doses. The goal of this work is to assess and document potential radiation doses to various staff positions in a simulated standard operating room environment. Adult-sized mannequins wearing standard lead protective aprons were placed at seven positions around large and small BMI cadavers. Doses were recorded in real time at thyroid level with Bluetooth-enabled dosimeters for a variety of fluoroscope settings and imaging views. A total of 320 images were acquired, resulting in 2,240 dosimeter readings from the seven mannequins. Doses were compared to cumulative air kerma (CAK) calculations provided by the fluoroscope. There was a strong correlation between the CAK and the recorded scattered radiation doses ( P < 0.001). Radiation doses could be reduced by manipulating C-arm manual technique settings [e.g., turning off the automatic exposure control (AEC) and using pulse (PULSE) or low dose (LD) settings]. Staff position and patient size also affected the recorded doses. The highest radiation doses were recorded across all settings for the mannequin positioned immediately adjacent to the C-arm x-ray tube. The larger BMI cadaver generated greater scattered radiation than the smaller BMI cadaver for all views and settings. This work provides suggestions for reducing exposure to operating room personnel beyond standard techniques of reducing beam-on time, increasing the distance from the radiation source, and use of shielding. Simple changes in C-arm settings (turning AEC off, avoiding DS setting, use of PULSE or LD settings) can markedly reduce dose to staff.

Comparison of Navigated Expandable Vertebral Cage with Conventional Expandable Vertebral Cage for Minimally Invasive Lumbar/Thoracolumbar Corpectomy

Background and Objectives: The thoracolumbar burst fracture is one of the most common spinal injuries. If the patient has severe symptoms, corpectomy is indicated. Currently, minimally invasive corpectomy with a navigated expandable vertebral cage is available thanks to spinal surgical technology. The aim of this study is to retrospectively compare clinical and radiographic outcomes of conventional and navigational minimally invasive corpectomy techniques. Materials and Methods: We retrospectively evaluated 21 patients who underwent thoracolumbar minimally invasive corpectomy between October 2016 and January 2021. Eleven patients had a navigated expandable cage (group N) and 10 patients had a conventional expandable cage (group C). Mean follow-up period was 31.9 months for group N and 34.7 months for group C, ranging from 12 to 42 months in both groups. Clinical and radiographic outcomes are assessed using values including visual analogue scale (VAS) for back pain and Oswestry disability index (ODI). This data was collected preoperatively and at 6, 12, and 24 months postoperatively. Results: Surgical time and intraoperative blood loss of both groups were not significantly different (234 min vs. 267 min, 656 mL vs. 786 mL). Changes in VAS and ODI were similar in both groups. However, lateral cage mal-position ratio in group N was lower than that of group C (relative risk 1.64, Odds ratio 4.5) and postoperative cage sinking was significantly lower in group N (p = 0.033). Conclusions: Clinical outcomes are not significantly different, but radiographic outcomes of lateral cage mal-position and postoperative cage sinking were significantly lower in the navigation group.

Comparison of Simultaneous Single-Position Oblique Lumbar Interbody Fusion and Percutaneous Pedicle Screw Fixation with Posterior Lumbar Interbody Fusion Using O-arm Navigated Technique for Lumbar Degenerative Diseases

Minimally invasive posterior or transforaminal lumbar interbody fusion (MI-PLIF/TLIF) are widely accepted procedures for lumbar instability due to degenerative or traumatic diseases. Oblique lateral interbody fusion (OLIF) is currently receiving considerable attention because of the reductions in damage to the back muscles and neural tissue. The aim of this study was to compare clinical and radiographic outcomes of simultaneous single-position OLIF and percutaneous pedicle screw (PPS) fixation with MI-PLIF/TLIF. This retrospective comparative study included 98 patients, comprising 63 patients with single-position OLIF (Group SO) and 35 patients with MI-PLIF/TLIF (Group P/T). Cases with more than 1 year of follow-up were included in this study. Mean follow-up was 32.9 ± 7.0 months for Group SO and 33.7 ± 7.5 months for Group P/T. Clinical and radiological evaluations were performed. Comparing Group SO to Group P/T, surgical time and blood loss were 118 versus 172 min (p < 0.01) and 139 versus 374 mL (p < 0.01), respectively. Cage height, change in disk height, and postoperative foraminal height were significantly higher in Group SO than in Group P/T. The fusion rate was 96.8% in Group SO, similar to the 94.2% in Group P/T (p = 0.985). The complication rate was 6.3% in Group SO and 14.1% in Group P/T (p = 0.191). Simultaneous single position O-arm-navigated OLIF reduces the surgical time, blood loss, and time to ambulation after surgery. Good indirect decompression can be achieved with this method.

Navigated Lateral Osteotomy for Adult Spinal Deformity: A Technical Note

BACKGROUND

Minimally invasive surgery is receiving considerable attention as a technique for reducing the complications of adult spinal deformity (ASD) surgery. For this technique, a new lateral osteotomy plays an important role to release fused vertebrae. We describe herein a novel navigated lateral osteotomy technique not requiring C-arm fluoroscopy to correct adult spinal deformities.

CASE DESCRIPTION

A 68-year-old woman with symptomatic ASD and a 4-year history of severe low back pain affecting daily life was referred to our hospital. Surgery was performed without C-arm fluoroscopy. A navigated osteotome was used to release the fused L1/2 mass. The patient was successfully treated with surgery, and low back pain was well controlled. In terms of clinical outcomes, Oswestry Disability Index improved from 64%-19% and Visual Analog Scale score for low back pain improved from 74 mm-19 mm on final follow-up at 2 years.

CONCLUSIONS

This novel navigated lateral osteotomy for ASD is a useful technique that enables minimally invasive surgery for fixed deformity. With this new technique, surgeons and operating room staff can avoid adverse effects of intraoperative radiation.

Irradiation level related to intraoperative imaging device in paediatric elastic stable intramedullary nailing: preliminary prospective study on 51 patients using PCXMC software

PURPOSE

Radiation-induced cancers due to imaging devices concern above all the growing child, however, to date, intraoperative irradiation doses are not well-documented in children. The goal of the study was to evaluate the intraoperative doses received by patients operated with the use of a C-arm in traumatology, as well as the lifetime attributable risk of cancer death (LAR) related to the irradiation of the imaging device.

METHODS

From 1 April 2017 to 31 March 2019, we started a multicentre study and prospectively recruited all consecutive children who needed elastic stable intramedullary nailing (ESIN) for long-bone fracture. We collected demographic and operative data, with dose reports including duration and doses. The main outcome was the effective dose (ED) in millisievert (mSv), calculated with PCXMC software, and the secondary outcome was the LAR expressed as a percentage.

RESULTS

In all, 51 patients operated on using 2D C-arm imaging were included in this study. The mean ED was 0.085 mSv (sd 0.10; 0.002 to 0.649). Overall LAR was 6.5 x 10^-4% (sd 6.7 x 10^-4%; 0.1 x 10^-4% to 28.3x10^-4%). Univariate linear regression showed a significant association between ED and irradiation time (p < 0.001). There was no significant association between ED and other outcomes (p > 0.05).

CONCLUSION

Treatment of long-bone fractures by ESIN found a low level of effective doses with utilization of the C-arm device in current practice. Further studies on a larger sample are needed to confirm these results.

LEVEL OF EVIDENCE

II.

High-Energy Fractures of the Pelvis and Acetabulum in Pediatric Patients

Fractures of the pelvis and acetabulum, although uncommon in the pediatric cohort, represent a range of injuries with similarities to those seen in the adult cohort but with key differences that are important for the treating physician to be aware of to allow for systematic evaluation and management of these potentially life-threatening injuries. As the pediatric skeleton matures, changes in anatomy and physiology influence injury pattern, diagnosis, treatment, and complications. High-energy fractures of the pediatric pelvis are particularly concerning given the reported mortality rates ranging from 3.2% to 18%, with severe fracture patterns being associated with visceral injury in up to 60% of patients. The unique complexity of pediatric patients requires a multidisciplinary team to fully address their care. A systematic approach to the initial evaluation and diagnosis of pediatric patients with fractures of the acetabulum or pelvic ring aids in choosing between surgical and nonsurgical management of these fractures and avoiding complications unique to the maturing skeleton. We present such an approach to assist the practitioner who infrequently treats these uncommon injuries.