Radiation Exposure in Minimally Invasive Lumbar Fusion Surgery

Abstract

Study Design. Randomized controlled trial. Objective. The aim of this study was to compare the dosemetrically determined radiation exposure of surgeon and patient during minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) using conventional 2D fluoroscopy (FLUORO) or 3D fluoroscopy-based navigation (NAV). Summary of Background Data. MIS TLIF was shown to exhibit higher radiation exposures compared to open techniques. In particular, the routinely exposed surgeon encounters the risks of increased radiation doses. With the additional use of intraoperative 3D navigation, major steps of the operation can be performed without exposing the operating room staff to ionizing radiation. Methods. Forty-four patients undergoing monosegmental MIS TLIF were randomized into the two intraoperative imaging technique groups (FLUORO or NAV). The primary endpoint was the radiation exposure of the surgeon; the secondary endpoints were the radiation exposure of the patient and C-arm readings. Results. After exclusion of three patients, 41 patients were analyzed. In general, the average radiation exposure of the surgeon was lower in the NAV group without being statistically significant. The radiation exposure of the patient was significantly higher in the NAV group at all dosemeter sites. The average fluoroscopy time was 63 ± 36 versus 109 ± 31 sec (FLUORO versus NAV group, P < 0.001). Conclusion. The additional use of intraoperative 3D fluoroscopy-based navigation compared to conventional 2D fluoroscopy alone showed a nonsignificant reduction of the radiation exposure of the surgeon in monosegmental MIS TLIF, while increasing the radiation exposure of the patient. Level of Evidence: 1

The Impact of Implementing a Radiation-Sparing Protocol for Percutaneous Kyphoplasty—A Prospective Dosemetric Study

“…Continuous fluoroscopy was not used at any time. Note the collimation from both sides at the beginning (1-5), and then the maximum collimation applied in the further course (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). The operating room staff kept distance to the radiation source for each X-ray exposure and stepped back behind mobile lead glass walls.…”

“…This was followed by positioning of the working cannulas in the posterior third of the corpus vertebrae (5), drilling of a working channel (6), insertion of the kyphoplasty balloon (7) with gradual inflation of the balloon (8-10). The cement distribution was monitored with single-shot fluoroscopic images after every 0.3 to 0.4 ml of cement injection per side in this case (11)(12)(13)(14)(15)(16), without evidence of intraspinal or prevertebral cement extravasation. Continuous fluoroscopy was not used at any time.…”

“…14 On this basis we assumed a lower detection limit of 0.044 mSv for film dosemeters, and 0.030 mSv for eye lens and ring dosemeters, as in previous studies. 15 Secondary outcome measures were fluoroscopy time, dose area product, number of fluoroscopic images per kyphoplasty, improvement of local pain (numeric pain rating scale) and complications such as cement extravasation. Furthermore, we calculated the maximum allowable annual number of operations according to the surgeon's average radiation exposure and the occupational dose limits of the ICRP.…”

What’s New in Spine Surgery

“…Both studies found significant improvements in pedicle screw accuracy, including reduced violation of the cephalad facet joint and intraoperative radiation dose, with robotic assistance, although revision rates for screw malpositioning were similar in the latter article. Klingler et al performed a randomized trial of fluoroscopically assisted MIS-TLIF and navigated TLIF and found that the type of navigation used in the study did not significantly reduce radiation exposure to the surgeon, while simultaneously increasing radiation exposure to the patient 24 . Therefore, the role of navigation and robotics is still being developed.…”

Minimally invasive transforaminal lumbar interbody fusion — A narrative review on the present status

“…In a randomised control study comparing dosimetric radiation exposure with 2D fluoroscopy and 3D navigation assisted single level MIS TLIF, Klingler et al 31 have found that the surgeon's exposure to radiation is lesser when 3D navigation is used but the difference is not statistically significant. However, the radiation exposure to the patient is significantly higher when 3D navigation was used.…”