Radiation Safety and Spine Surgery: Systematic Review of Exposure Limits and Methods to Minimize Radiation Exposure

BACKGROUND: Ionizing radiation is typically used during spine surgery for localization and guidance in instrumentation placement. Minimally invasive (MI) surgical procedures are increasingly popular and often require significantly more fluoroscopy, placing surgeons at risk for increased radiation exposure and radiation-induced complications. This study provides recommendations for minimizing risk of radiation-induced injury to spine surgeons and summarizes studies addressing radiation exposure in spine procedures. METHODS: The PubMed database was queried for relevant articles pertaining to radiation exposure in spine surgery. RESULTS: Discectomy, percutaneous pedicle screw placement, MI trans foraminal lumbar interbody fusion, MI lateral lumbar interbody fusion, and vertebroplasty/kyphoplasty procedures were assessed. The highest radiation doses were seen with MI pedicle screw placement. MI transforaminal lumbar inter body fusion, vertebroplasty and kyphoplasty, and percutaneous endoscopic lumbar discectomy. Use of lead aprons and thyroid shields reduces effective dose by several orders of magnitude. Proper operator positioning also minimizes radiation exposure. Lead gloves decrease dose to the surgeon's hand from scatter if the hand is out of the x-ray beam most of the time. If prolonged exposure of the hand cannot be avoided, the technician should collimate the surgeon's hand out of the beam or use instruments to position the hand farther horn the beam. In addition to using less fluoroscopy, pulsed fluoroscopy can decrease overall dose in a procedure. CONCLUSIONS: Spine surgeons should reduce their exposure to radiation to minimize risk of potential long-term complications. Strategies include mizing fluoroscopy use and dose, proper use of protective gear, and appropriate manipulation of fluoroscopic equipment.