Radiation a Peril for Spine Surgeons

Used to be, morbidity and mortality conferences involved only the noble goals of improving patient care and outcome, and of course limiting physician liability.

But recently, there has been a quiet trend building where spine surgeons’ inherent risks and health complications are the topic of discussion at surgical M&M meetings. Many of the surgeons are focusing on fluoroscopy as the primary culprit.

While the benefits of fluoroscopic diagnostic imaging are immense, all agree the technology has revolutionized surgical procedures, the risks of adverse health effects are currently being examined by concerned surgeons.

The thyroid gland is a vulnerable target

The incidence of thyroid cancer and other cancers appears to be increasing among surgeons who use fluoroscopy, which involves the use of X-rays, a form of ionizing radiation. It has been posited that there is a causative relationship between the two. The thyroid gland is especially susceptible to injury from this type of electromagnetic radiation. Everyone knows about the atomic bomb survivors in Nagasaki and Hiroshima and the 1986 Chernobyl accident and the significant increase in the incidence of thyroid diseases and cancer experienced by these unique populations.

Although the radiation dose received by the patient during a single procedure is generally low, the spine surgeons and operating-room staff are on the receiving end of cumulative amounts of ionizing radiation, the most energetic and potentially hazardous form of radiation.

Theodore A. Wagner, MD, University of Washington, presented a research abstract at a 2006 Scoliosis Research Society (SRS) meeting titled, “SRS Surgeon Members' Risk for Thyroid Cancer: Is it Increased?” The study looked only at head and neck cancers and was primarily based on a survey of SRS member surgeons.
It began, “In the past three years, three of our senior spine surgeons have been diagnosed with thyroid cancer, raising concern about occupation-related health risks for spine deformity surgeons.”

Dr. Wagner noted that of the three surgeons, one has had successful treatment; one was still being treated for an active tumor and the third sadly died. “The survey’s bottom line revealed that the incidence of thyroid cancer among our member physicians in their third and fourth decades of practice was 18 times higher than expected in a normal population and we feel that this is in direct correlation to the accumulated radiation.”

The research points to the successive additional doses generated by C-arms and plain X-rays in operating rooms or treatment areas. “Surgeons need to learn to minimize radiation exposure for themselves and the patient; they need to use radiation judiciously to avoid excess exposure,” said Dr. Wagner in a recent interview. “It’s the people who are getting the cancers that are certainly asking a lot of questions and the young doctors need to learn that—and I think they’re paying attention.”

Significant risk for pedicle screw users

Dr. Wagner pointed to the spine surgeons who “do pedicle screws” as one of the groups with significant exposure, but he was quick to point out that exposure risks are a concern for all surgeons. “Radiation is radiation,” he said, “and if a surgeon has been doing pedicle screws for 15 years, that’s a lot of nails and a lot of instrumentation.” Dr. Wagner said he thought the highest risk population were those that did pediatrics fracture work and intramedullary nailing before 1990. “But since 1990, the spine surgeons have had an equal or greater exposure,” he said.

Dr. Wagner’s study group includes Sue-Min Lai, PhD and Marc Asher, MD, both from the University of Kansas Medical Center. They hope to present further findings and their conclusions at this year’s September 2008 Annual SRS meeting to be held in Salt Lake City, Utah, with an article to be published as well.

And it’s the older surgeons, when asked about the dangers of radiation exposure, who are mostly concerned about the Young Turks who are just beginning their surgical practices. Dr. Courtney W. Brown, Panorama Orthopedics & Spine Center, Golden, CO, past president of the Scoliosis Research Society, said that the younger docs, whose “bread and butter” involves the use of radiation on a de rigueur basis, are the population of surgeons that can change the dangerous tide. “There always has to be a concern about lifetime radiation exposure, especially for the younger surgeons because they will be using minimally invasive procedures for years and they should be the ones to change the future.”

With a preponderance of scientific evidence showing that even low doses of ionizing radiation are likely to pose a health risk, how can spine surgeons minimize their risk?

Ounces of protection worth pounds of cure

One young spine surgeon, Milan G. Mody, MD, 36, from the Willis-Knighton Health System & LSU Health Sciences Center, Shreveport, where is he an assistant professor and Chief of Spine Service, has a self-proclaimed “huge interest in the subject of radiation.”

Dr. Mody decks himself out in protective clothing with all the ionizing radiation-proof bells and whistles available to him for the operating room, even if some of his residents think he looks like the Michelin Man wrapped in lead. “Before I scrub, I put on my protection in less than one minute; it becomes part of your routine, it’s like washing your hands,” he said. “I tell people I want to make spine surgery safer for the patient and the surgeon.”

Dr. Mody said he typically dons a lead apron, uses a thyroid shield and wears fluoroscopic protective lead gloves to attenuate direct and scatter radiation to his hands. He also wears the newer lightweight lead goggles. “The eyes are very, very important—we tend to forget that.” He routinely uses PediGuardTM, a freehand pedicle screw pilot hole preparation device providing audio and visual feedback to the surgeon to indicate possible cortex perforation in real time, allowing a decrease in the need for fluoroscopy.

Dr. Mody was happy to also report that his hospital has installed a $5,000 laser targeting device that fits on to the C-arm fluoroscopy system “so the tech knows where he will end up and it also translates into less exposure for the surgeon.”

At Dr. Mody’s institution, he said the radiation effects were not discussed openly at M&M meetings: “We don’t discuss radiation in an open forum or at a formal forum. We usually discuss the issue in hallways and elevators amongst ourselves, but I teach the issue to residents about lifetime dosing and the radiation they’re getting in the O-R.”

“I’ve had a lot of residents who don’t understand the dangers,” Dr. Mody explained. “Some say to me that they’ve ‘already had their kids,’ and they think it’s overkill but if you think about the fact that a lifetime for a surgeon is 30 or 35 years or so, especially with the thyroid cancer deaths we’ve had in our surgical community, I’ll take the kidding over death any day.”