Here are 50key points on radiation exposure during spine surgery from studies and expert articles on the topic.
C-arm fluoroscopy vs. portable X-ray or CT [Study published in The Spine Journal]
1. For single lateral/posterior-anterior entrance, patient radiation exposure was on average 116 mR/102 mR for the C-arm.
2. In the same procedure, patient radiation exposure was 3,435 mR/2,160 mR for the X-ray radiography
3. The patient radiation exposure was 4,360 mR/5,2220 mR for the O-arm.
2. Surface exposure for lateral/posterior-anterior approaches for the O-arm was equivalent to 38/41 C-arm exposures and 1.5/2.4 X-ray radiography exposures.
3. The overall radiation exposure to the operating room staff was less than 4.4 for a single acquisition of all modalities.
4. In the lateral C-arm acquisition, there was a 7.7-fold increase in radiation exposure was measured on the X-ray tube side compared to the detector side.
5. The anesthesiologist scatter radiation level for a single acquisition was highest for the O-arm.
6. The second highest was the X-ray radiology, followed by the C-arm.
7. For radiologic technologists, scatter radiation level was highest for X-ray, followed by the O-arm and then fluoroscopy.
8. The surgeon and surgeon assistant had higher levels of scatter radiation for C-arm, followed by O-arm and then X-ray radiography.
Fluoroscopy guidance vs. robotic guidance [Study published in the Jounral of Neurosurgery: Spine]
9. A study published in early 2014 shows using robotic guidance shortened procedure time and radiation exposure by 74 percent when compared with fluoroscopy guidance and 50 percent when compared with navigated augmentation.
10. Fluoroscopy use was limited to 1.58 seconds per screw with the robotic guidance system in a five-center analysis of 3,270 pedicle screws placed using robotic guidance for adolescent idiopathic scoliosis.
11. Per center the average exposure per screw was between 1.12 and 3.73 seconds per screw. The average fluoroscopy use per patient was 30.8±17.9 seconds.
12. In a different study of 33 patients who underwent robotic-guided vertebral body augmentation, two surgeons simultaneously injecting cement at two levels under pulsed fluoroscopy. The average preoperative computed tomographic dose was 50 mSv with average operative time of 118 minutes.
13. The average robotic guidance took 36 minutes and the average operative radiation time was 46.1 seconds per level.
14. The researchers found average surgeon and staff exposure time per augmented level was 37.6 seconds with an execution and accuracy rate of 99 percent for the robotic procedure.
Guidance vs. freehand technique [Study published in Spine]
15. When comparing posterior lumbar spine instrumentation cases with a navigation versus freehand technique, the accumulated radiation dose for the surgeon was significantly higher in the non-navigated group — up to 9.96 times.
16. The radiation dose for the patient was higher with the freehand technique — 1884.8 cGy•cm2 during non-navigated techniques versus 887 cGy•cm2 during navigated techniques.
17. In an article published in Spine in March, researchers reported results of a study evaluating whether freehand pedicle screw fixation in pediatric spinal deformity correction reduced surgeon radiation exposure. The study found to place a single screw, average fluoroscopy time was 2.6±1.7 seconds with average fluoroscopic time at 40.5±21. Researchers recorded less radiation exposure than the minimum reportable dose in each surgery.
Lateral procedures [Study published in Spine]
18. In following current safety guidelines, around 2,700 lateral lumbar interbody fusion procedures can be performed with intraoperative fluoroscopy before exceeding dose limits.
19. The average fluoroscopy time for LLIF procedures is 88.7±36.8 seconds and dose to the skin is 25.2±21.1 mGy.
20. The average exposure to the eye — 2.64 ± 2.76 mrem.
21. The average exposure to the thyroid — 2.19 ± 2.07 mrem.
22. The average exposure to the chest — 0.44 ± 0.49 mrem.
23. The average exposure to the axilla — 4.20 ± 7.76 mrem.
24. The average exposure to the gluteal — 2.31 ± 4.50 mrem.
25. Except for in the gluteal region, dosimeter readings from unprotected areas were higher than those from the chest dosimeter.
26. After 13 procedures, the hand was exposed to 190 mrem.
Percutaneous endoscopic lumbar discectomy [Study published in Spine]
27. For patients undergoing transforaminal PELDs, the average operation time is 29.8 minutes and average fluoroscopy time is 2.5 minutes.
28. Radiation dose per operated level at in the neck was 0.0785 mSv.
29. Radiation dose per operated level at in the chest was 0.1718 mSv.
30. Radiation dose per operated level at in the right upper arm was 0.0461 mSv.
31. Radiation dose per operated level at in the left ring finger was 0.7318 mSv.
32. Radiation dose per operated level at in the right ring finger was 0.6694 mSv.
33. The lead collar reduced the radiation dose by 96.9 percent.
34. The lead apron reduced the radiation dose by 94.2 percent.
35. A surgeon can perform 5,379 PELD operations per year using the lead apron before exceeding whole-body radiation limit recommendations.
36. A surgeon can perform 291 PELD operations per year using the lead apron before exceeding whole-body radiation limit recommendations.
37. Surgeons are able to perform 1,910 PELD operations before exceeding the exposure limit for the eyes — 150 mSv.
38. Surgeons are able to perform 683 PELD operations before exceeding the exposure limit for the hands — 500 mSv.
Tips to reduce radiation exposure from A. Jay Khanna, MD [From Becker's Spine Review article — read the full article here]
39. Monitor and minimize the number of seconds of fluoroscopy used for each case.
40. Use the "hands-off" technique when acquiring images.
41. Ensure that you are wearing a high quality lead apron and thyroid shield.
42. Use lead glasses during procedures that are fluoroscopy intensive.
43. Maximize distance from the image intensifier.
44. Use the "low dose" mode.
45. Ask the fluoroscopy technician to collimate and center all images.
46. If possible, stand on the "correct" side of the table.
47. Wear your radiation badge.
48. Consider avoiding the use of fluoroscopy to perform of large volumes of procedures that are very radiation-dependent.
49. Consider the use of image guidance systems instead of fluoroscopy when performing procedures that are radiation-dependent.
50. Encourage those who are not scrubbed into the case (anesthesiologist, circulating nurse, implant representatives, neuromonitoring staff, etc.) to avoid the direct radiation path if possible. You can use someone who is scrubbed into the case to "set the pick" between them and the radiation source so that there is an additional barrier.