title: Patient and surgeon radiation exposure during spinal instrumentation using intraoperative computed tomography-based navigation.
abstract: BACKGROUND
  Imaging modalities used to visualize spinal anatomy intraoperatively include X-ray studies, fluoroscopy, and computed tomography (CT). All of these emit ionizing radiation.
  
  
  OBJECTIVE
  Radiation emitted to the patient and the surgical team when performing surgeries using intraoperative CT-based spine navigation was compared.
  
  
  METHODS
  This is a retrospective cohort case-control study.
  
  
  METHODS
  Seventy-three patients underwent CT-navigated spinal instrumentation and 73 matched controls underwent spinal instrumentation with conventional fluoroscopy.
  
  
  METHODS
  Effective doses of radiation to the patient when the surgical team was inside and outside of the room were analyzed. The number of postoperative imaging investigations between navigated and non-navigated cases was compared.
  
  
  METHODS
  Intraoperative X-ray imaging, fluoroscopy, and CT dosages were recorded and standardized to effective doses. The number of postoperative imaging investigations was compared with the matched cohort of surgical cases. A literature review identified historical radiation exposure values for fluoroscopic-guided spinal instrumentation.
  
  
  RESULTS
  The 73 navigated operations involved an average of 5.44 levels of instrumentation. Thoracic and lumbar instrumentations had higher radiation emission from all modalities (CT, X-ray imaging, and fluoroscopy) compared with cervical cases (6.93 millisievert [mSv] vs. 2.34 mSv). Major deformity and degenerative cases involved more radiation emission than trauma or oncology cases (7.05 mSv vs. 4.20 mSv). On average, the total radiation dose to the patient was 8.7 times more than the radiation emitted when the surgical team was inside the operating room. Total radiation exposure to the patient was 2.77 times the values reported in the literature for thoracolumbar instrumentations performed without navigation. In comparison, the radiation emitted to the patient when the surgical team was inside the operating room was 2.50 lower than non-navigated thoracolumbar instrumentations. The average total radiation exposure to the patient was 5.69 mSv, a value less than a single routine lumbar CT scan (7.5 mSv). The average radiation exposure to the patient in the present study was approximately one quarter the recommended annual occupational radiation exposure. Navigation did not reduce the number of postoperative X-rays or CT scans obtained.
  
  
  CONCLUSIONS
  Intraoperative CT navigation increases the radiation exposure to the patient and reduces the radiation exposure to the surgeon when compared with values reported in the literature. Intraoperative CT navigation improves the accuracy of spine instrumentation with acceptable patient radiation exposure and reduced surgical team exposure. Surgeons should be aware of the implications of radiation exposure to both the patient and the surgical team when using intraoperative CT navigation.
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
authors.forename: Daniel
authors.initials: D
authors.lastname: Mendelsohn
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
authors.forename: Jason
authors.initials: J
authors.lastname: Strelzow
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Dea
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Ford
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
authors.forename: Juliet
authors.initials: J
authors.lastname: Batke
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Pennington
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada.
authors.forename: Kaiyun
authors.initials: K
authors.lastname: Yang
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada.
authors.forename: Tamir
authors.initials: T
authors.lastname: Ailon
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Boyd
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
authors.forename: Marcel
authors.initials: M
authors.lastname: Dvorak
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada.
authors.forename: Brian
authors.initials: B
authors.lastname: Kwon
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada.
authors.forename: Scott
authors.initials: S
authors.lastname: Paquette
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
authors.forename: Charles
authors.initials: C
authors.lastname: Fisher
authors.affiliation: Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada. Electronic address: John.Street@vch.ca.
authors.forename: John
authors.initials: J
authors.lastname: Street
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D008297:Male; D008875:Middle Aged; D016273:Occupational Exposure; D011829:Radiation Dosage; D000069079:Radiation Exposure; D012189:Retrospective Studies; D013131:Spine / Q000601:surgery*; D066231:Surgeons; D025321:Surgery, Computer-Assisted; D014057:Tomography, X-Ray Computed
keywords: CT based navigation; Complications; Efficacy; Pedicle Screw Accuracy; Pedicle screw; Radiation exposure; Risk; Safety; Spine instrumentation; Spine navigation