Radiation exposure and reduction in the operating room: Perspectives and future directions in spine surgery

Abstract

Intraoperative imaging is vital for accurate placement of instrumentation in spine surgery. However, the use of biplanar fluoroscopy and other intraoperative imaging modalities is associated with the risk of significant radiation exposure in the patient, surgeon, and surgical staff. Radiation exposure in the form of ionizing radiation can lead to cellular damage via the induction of DNA lesions and the production of reactive oxygen species. These effects often result in cell death or genomic instability, leading to various radiation-associated pathologies including an increased risk of malignancy. In attempts to reduce radiation-associated health risks, radiation safety has become an important topic in the medical field. All practitioners, regardless of practice setting, can practice radiation safety techniques including shielding and distance to reduce radiation exposure. Additionally, optimization of fluoroscopic settings and techniques can be used as an effective method of radiation dose reduction. New imaging modalities and spinal navigation systems have also been developed in an effort to replace conventional fluoroscopy and reduce radiation doses. These modalities include Isocentric Three-Dimensional C-Arms, O-Arms, and intraoperative magnetic resonance imaging. While this influx of new technology has advanced radiation safety within the field of spine surgery, more work is still required to overcome specific limitations involving increased costs and inadequate training.

Keywords: Intraoperative imaging; Ionizing radiation; DNA damage; Genomic instability; Shielding; Distance; Dose reduction; Spinal navigation

Core tip: Intraoperative radiation exposure is a significant concern for patients, surgeons, and operative room staff during spine surgery. All surgeons should practice general radiation safety techniques including shielding, distance, and fluoroscopic dose reduction. New imaging modalities and spinal navigation systems have also been developed to mitigate radiation exposure risk. These modalities include CT-based techniques such as Isocentric Three-Dimensional C-arms and O-Arms. Intraoperative magnetic resonance imaging has also been adapted from the neurosurgical field and is another developing imaging technique. Further research is required to overcome the limitations of these novel technologies in regards to costs and training requirements.