title: Internally Randomized Control Trial of Radiation Exposure Using Ultra-low Radiation Imaging Versus Traditional C-arm Fluoroscopy for Patients Undergoing Single-level Minimally Invasive Transforaminal Lumbar Interbody Fusion.
abstract: METHODS
  Randomized controlled trial.
  
  
  OBJECTIVE
  To compare radiation exposure between ultra-low radiation imaging (ULRI) with image enhancement and standard-dose fluoroscopy for patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).
  
  
  BACKGROUND
  Although the benefits of MIS are lauded by many, there is a significant amount of radiation exposure to surgeon and operating room personnel. Our goal with this work was to see if by using ultra-low dose radiation settings coupled with image enhancement, this exposure could be minimized.
  
  
  METHODS
  An institutional review board approved, prospective, internally randomized controlled trial was performed comparing ultra-low dose settings coupled with image enhancement software to conventional fluoroscopic imaging. In this study, each patient served as their own control, randomly assigning one side of MIS-TLIF for cannulation and K-wire placement using each imaging modality. Further, the case was also randomly divided into screw placement and cage placement/final images to allow further comparisons amongst patients. Radiation production from the C-arm fluoroscope and radiation exposure to all operating room personnel were recorded.
  
  
  RESULTS
  Twenty-four patients were randomly assigned to undergo a single level MIS-TLIF. In no case was low radiation imaging abandoned, and no patient had a neurologic decline or required hardware repositioning. Everyone in the operating room-the physician, scrub nurse, circulator, and anesthesiologist-all benefited with 61.6% to 83.5% reduction in radiation exposure during cannulation and K-wire placement to screw insertion aided by ULRI. In every case but the anesthesiologist dose, this was statistically significant (P < 0.05). This benefit required no additional time (P = 0.78 for K-wire placement).
  
  
  CONCLUSIONS
  ULRI, when aided by image enhancement software, affords the ability for all parties in the operating room to substantially decrease their radiation exposure compared with standard-dose C-arm fluoroscopy without adding additional time or an increased complication rate.
  
  
  METHODS
  2.
authors.affiliation: Department of Neurological Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Timothy Y
authors.initials: TY
authors.lastname: Wang
authors.affiliation: Department of Neurological Surgery, Duke University Medical Center, Durham, NC.
authors.forename: S Harrison
authors.initials: SH
authors.lastname: Farber
authors.affiliation: Department of Neurological Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Scott S
authors.initials: SS
authors.lastname: Perkins
authors.affiliation: Department of Neurological Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Adam G
authors.initials: AG
authors.lastname: Back
authors.affiliation: Department of Neurological Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Byrd
authors.affiliation: Department of Neurological Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Debbie
authors.initials: D
authors.lastname: Chi
authors.affiliation: Neurosurgical Specialists, Norfolk, VA.
authors.forename: David
authors.initials: D
authors.lastname: Vincent
authors.affiliation: Department of Neurological Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Isaac O
authors.initials: IO
authors.lastname: Karikari
mesh_terms: D000328:Adult; D001863:Bone Screws; D005471:Fluoroscopy / Q000295:instrumentation / Q000379:methods; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery*; D008161:Lumbosacral Region / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011446:Prospective Studies; D011829:Radiation Dosage; D000069079:Radiation Exposure / Q000009:adverse effects; D013123:Spinal Fusion / Q000379:methods; D025321:Surgery, Computer-Assisted / Q000379:methods