Radiation Exposure in Posterior Lumbar Fusion: A Comparison of CT Image-Guided Navigation, Robotic Assistance, and Intraoperative Fluoroscopy

Abstract

Study Design: Retrospective clinical review. Objective: To assess the use of intraoperative computed tomography (CT) image-guided navigation (IGN) and robotic assistance in posterior lumbar surgery and their relationship with patient radiation exposure and perioperative outcomes. Methods: Patients ≥18 years old undergoing 1- to 2-level transforaminal lateral interbody fusion in 12-month period were included. Chart review was performed for pre- and intraoperative data on radiation dose and perioperative outcomes. All radiation doses are quantified in milliGrays (mGy). Univariate analysis and multivariate logistic regression analysis were utilized for categorical variables. One-way analysis of variance with post hoc Tukey test was used for continuous variables. Results: A total of 165 patients were assessed: 12 IGN, 62 robotic, 56 open, 35 fluoroscopically guided minimally invasive surgery (MIS). There was a lower proportion of women in open and MIS groups ( P = .010). There were more younger patients in the MIS group ( P < .001). MIS group had the lowest mean posterior levels fused ( P = .015). Total-procedure radiation, total-procedure radiation/level fused, and intraoperative radiation was the lowest in the open group and highest in the MIS group compared with IGN and robotic groups (all P < .001). Higher proportion of robotic and lower proportion of MIS patients had preoperative CT ( P < .001). Estimated blood loss ( P = .002) and hospital length of stay ( P = .039) were lowest in the MIS group. Highest operative time was observed for IGN patients ( P < .001). No differences were observed in body mass index, Charlson Comorbidity Index, and postoperative complications ( P = .313, .051, and .644, respectively). Conclusion: IGN and robotic assistance in posterior lumbar fusion were associated with higher intraoperative and total-procedure radiation exposure than open cases without IGN/robotics, but significantly less than MIS without IGN/robotics, without differences in perioperative outcomes. Fluoro-MIS procedures reported highest radiation exposure to patient, and of equal concern is that the proportion of total radiation dose also applied to the surgeon and operating room staff in fluoro-MIS group is higher than in IGN/robotics and open groups.

Regarding “Radiation Exposure in Posterior Lumbar Fusion: A Comparison of CT Image-Guided Navigation, Robotic Assistance, and Intraoperative Fluoroscopy” by Wang et al

“…The authors reveal that in the open surgery fluoroscopy-guided subgroup 1.32 ± 0.47 levels were fused, and they stated that the fluoroscopy time of 3 surgeons who performed the majority of these cases ranged from 12.27 to 24.24 seconds per procedure. 1 In our open surgery fluoroscopy-guided subgroup 1.5 ± 0.86 levels were fused per procedure, and we found a mean fluoroscopy time of 11.02 ± 5.18 seconds per fused level. These findings are very likely due to circumstance that generally only 1 or 2 lateral and 1 anteroposterior images are taken per pedicular screw.…”

“…The study published by Wang et al is highly interesting in our opinion and it highlights a crucial aspect of spinal surgery in terms of patient safety. 1 Furthermore, it is beyond all doubt essential to assess the radiation exposure of conventional fluoroscopy-guided surgery to robotic navigational guidance and intraoperative computed tomography (CT) image-guided navigation. As stated by Wang et al and shown by various authors, the application of these techniques yields improved accuracy of pedicle screw positioning.…”

“…As stated by Wang et al and shown by various authors, the application of these techniques yields improved accuracy of pedicle screw positioning. 1 However, there are some aspects of this study that need to be discussed, and we would like to compare our findings on radiation exposure in intraoperative computed tomography (iCT) versus fluoroscopy-assisted surgery to this study. 2…”

Intraoperative CT-assisted sacroiliac screws fixation for the treatment of posterior pelvic ring injury: a comparative study with conventional intraoperative imaging

“…This discrepancy may be attributed to the fact that our surgical team just implemented this technique not long ago and was not yet skilled. The duration of the MIT procedures was significantly correlated with the surgeon's experience 25 . Therefore, the same surgical team was selected to control the relevant confounding factors for the outcomes.…”

Machine Vision Navigation in Spine Surgery

“…Fluoroscopy had the highest radiation dosage (82.02 mGy) followed by robotic assistance (59.84 mGy) and CT image-guided navigation (50.21 mGy). This level of radiation exposure creates a potentially significant hazard to those individuals who perform a high volume of complex spinal surgery with fluoroscopy (4,5).…”