Keeping Up Good Practices for the Spine Surgeon

The increased use of fluoroscopy in pedicle screw insertion places spine surgeons and operating room staff at measurable risk for ionizing radiation exposure. Radiogenic risks are inherent in the business.

An abstract presented at SRS 2006 Annual Meeting¹, concluded: “Serious questions regarding radiation safety during scoliosis surgery are raised. Long term risks of low level radiation are unknown. Acceptable levels of radiation are continually being revised downward. The surgeon employing fluoroscopy for pedicle screw placement should use maximum protection and be treated as a classified worker (radiologist), wearing a badge and having periodic examinations for radiation effects.”

Another study² found radiation dose rates to the spine surgeon were 10 to 12 times higher for fluoroscopically assisted thoracolumbar pedicle screw placement procedures than for other, non-spinal musculoskeletal procedures that involve the use of a fluoroscope.

All possible exposure reduction techniques available should be employed. The following is a checklist of good practices for shielding and other techniques to achieve as low as reasonably achievable (ALARA) when utilizing fluoroscopy:

• Lead glasses
• Thyroid shield
• Lead gown/apron/drapes
• Protective gloves
• Side shield
• Patient shield

All applicable local, state and federal regulations should always be strictly enforced.

The most widely available indicators of dose are the actual fluoroscopy time and the number of images made³. Additional precautions include well-trained techs; efficient fluoroscopy further reduces the radiation scatter.

After completing a radiation safety training program, dosimeter measurement film badge should be worn (preferably near the head) to record radiation exposure by all O-R personnel and subsequently handled according to hospital and state protocol.

Laser-targeted devices that fit on to the C-arm unit fluoroscopy system will increase accuracy and reduce the number of images necessary during a pedicle screw insertion.

Less use of fluoroscopy per procedure per patient will reduce accumulated radiation exposure. The use of PediGuard™, a smart electronic freehand drill providing real time audio and visual signals to the surgeon in response to electrical conductivity changes at its tip, indicating possible cortex perforation, cuts down appreciably for the need of continuous fluoroscopic imaging guidance. It also reduces the average radiation exposure by about 25-30 percent⁴ as shown by the preliminary results of an ongoing multi-site, randomized post-market study presented in October 2007 in a White Paper by Randal R. Betz, MD, Chief of Staff, Shriners Hospitals for Children, Philadelphia.

Minimizing radiation dose is a crucial issue for all surgeons, especially for those performing minimally invasive procedures. While the growing trend for these minimally invasive procedures comes with many advantages, its daily usage implies a serious radiation exposure for the surgeon.