title: Does less invasive spine surgery result in increased radiation exposure? A systematic review.
abstract: BACKGROUND
  Radiation exposure to patients and spine surgeons during spine surgery is expected. The risks of radiation exposure include thyroid cancer, cataracts, and lymphoma. Although imaging techniques facilitate less invasive approaches and improve intraoperative accuracy, they may increase radiation exposure.
  
  
  OBJECTIVE
  We performed a systematic review to determine whether (1) radiation exposure differs in open spine procedures compared with less invasive spine procedures; (2) radiation exposure differs in where the surgeon is positioned in relation to the C-arm; and (3) if radiation exposure differs using standard C-arm fluoroscopy or fluoroscopy with computer-assisted navigation.
  
  
  METHODS
  A PubMed search was performed from January 1980 to July 2013 for English language articles relating to radiation exposure in spine surgery. Twenty-two relevant articles met inclusion criteria. Level of evidence was assigned on clinical studies. Traditional study quality evaluation of nonclinical studies was not applicable.
  
  
  RESULTS
  There are important risks of radiation exposure in spine surgery to both the surgeon and patient. There is increased radiation exposure in less invasive spine procedures, but the use of protective barriers decreases radiation exposure. Where the surgeon stands in relation to the image source is important. Increasing the distance between the location of the C-arm radiation source and the surgeon, and standing contralateral from the C-arm radiation source, decreases radiation exposure. The use of advanced imaging modalities such as CT or three-dimensional computer-assisted navigation can potentially decrease radiation exposure.
  
  
  CONCLUSIONS
  There is increased radiation exposure during less invasive spine surgery, which affects the surgeon, patient, and operating room personnel. Being cognizant of radiation exposure risks, the spine surgeon can potentially minimize radiation risks by optimizing variables such as the use of barriers, knowledge of position, distance from the radiation source, and use of advanced image guidance navigation-assisted technology to minimize radiation exposure. Continued research is important to study the long-term risk of radiation exposure and its relationship to cancer, which remains a major concern and needs further study as the popularity of less invasive spine surgery increases.
authors.affiliation: Division of Spine Surgery, Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 West 10th Avenue, Columbus, OH, 43210, USA, elizabeth.yu@osumc.edu.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Yu
authors.forename: Safdar N
authors.initials: SN
authors.lastname: Khan
mesh_terms: D005471:Fluoroscopy; D006801:Humans; D019060:Minimally Invasive Surgical Procedures; D016273:Occupational Exposure / Q000009:adverse effects; D060051:Occupational Injuries / Q000209:etiology / Q000517:prevention & control; D009873:Operating Rooms; D019637:Orthopedic Procedures / Q000009:adverse effects / Q000379:methods; D061214:Patient Safety; D011829:Radiation Dosage; D011832:Radiation Injuries / Q000209:etiology / Q000517:prevention & control; D011834:Radiation Monitoring; D011835:Radiation Protection; D015641:Radiography, Interventional / Q000009:adverse effects / Q000379:methods; D012307:Risk Factors; D013131:Spine / Q000000981:diagnostic imaging / Q000601:surgery*; D025321:Surgery, Computer-Assisted / Q000009:adverse effects / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome; D000078329:Workforce