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Review
. 2023 Jan 14:13:100199.
doi: 10.1016/j.xnsj.2023.100199. eCollection 2023 Mar.

Comparing radiation dose of image-guided techniques in lumbar fusion surgery with pedicle screw insertion; A systematic review

I J M H Caelers  1   2   3 , R C M Berendsen  4 , R Droeghaag  5 , N J J Pecasse  6 , K Rijkers  2   3 , W L W Van Hemert  5 , R A De Bie  1   7 , H Van Santbrink  1   2   3
Affiliations
Review

Comparing radiation dose of image-guided techniques in lumbar fusion surgery with pedicle screw insertion; A systematic review

I J M H Caelers et al. N Am Spine Soc J. .

Abstract

Background context: Fluoroscopic devices can be used to visualize subcutaneous and osseous tissue, a useful feature during pedicle screw insertion in lumbar fusion surgery. It is important that both patient and surgeon are exposed as little as possible, since these devices use potential harmful ionizing radiation.

Purpose: This study aims to compare radiation exposure of different image-guided techniques in lumbar fusion surgery with pedicle screw insertion.

Study design: Systematic review.

Methods: Cochrane, Embase, PubMed and Web of Science databases were used to acquire relevant studies. Eligibility criteria were lumbar and/or sacral spine, pedicle screw, mGray and/or Sievert and/or mrem, radiation dose and/or radiation exposure. Image-guided techniques were divided in five groups: conventional C-arm, C-arm navigation, C-arm robotic, O-arm navigation and O-arm robotic. Comparisons were made based on effective dose for patients and surgeons, absorbed dose for patients and surgeons and exposure. Risk of bias was assessed using the 2017 Cochrane Risk of Bias tool on RCTs and the Cochrane ROBINS-I tool on NRCTs. Level of evidence was assessed using the guidelines of Oxford Centre for Evidence-based Medicine 2011.

Results: A total of 1423 studies were identified of which 38 were included in the analysis and assigned to one of the five groups. Results of radiation dose per procedure and per pedicle screw were described in dose ranges. Conventional C-arm appeared to result in higher effective dose for surgeons, higher absorbed dose for patients and higher exposure, compared to C-arm navigation/robotic and O-arm navigation/robotic. Level of evidence was 3 to 4 in 29 studies. Risk of bias of RCTs was intermediate, mostly due to inadequate blinding. Overall risk of bias score in NRCTs was determined as 'serious'.

Conclusions: Ranges of radiation doses using different modalities during pedicle screw insertion in lumbar fusion surgery are wide. Based on the highest numbers in the ranges, conventional C-arm tends to lead to a higher effective dose for surgeons, higher absorbed dose for patients and higher exposure, compared to C-arm-, and O-arm navigation/robotic. The level of evidence is low and risk of bias is fairly high. In future studies, heterogeneity should be limited by standardizing measurement methods and thoroughly describing the image-guided technique settings.

Keywords: Absorbed dose; Effective dose; Exposure; Image-guided techniques; Lumbar fusion surgery; Patient; Pedicle screws; Radiation dose; Surgeon; Systematic review.

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Conflict of interest statement

Ethics approval and consent to participate: not applicable.

Figures

Figure 1
Figure 1
Ranges of EDS (mSv) per procedure for conventional C-arm group, C-arm navigation group and C-arm robotic group. The blue bar is the lowest value of the range and the orange bar is the highest value. Abbreviations: EDS = Effective Dose Surgeon, Carm conv = Conventional C-arm, Cnav = C-arm navigation, Crob = C-arm robotic.
Figure 2
Figure 2
Ranges of EDP (mSv) per procedure for conventional C-arm group, C-arm navigation group, C-arm robotic group and O-arm navigation group. The blue bar is the lowest value of the range and the orange bar is the highest value. Abbreviations: EDP = Effective Dose Patient, Carm conv = Conventional C-arm, Cnav = C-arm navigation, Crob = C-arm robotic, Onav = O-arm navigation.
Figure 3
Figure 3
Ranges of ADP (mGy) per procedure for conventional C-arm group, C-arm navigation group, O-arm navigation group and O-arm robotic group. The blue bar is the lowest valuer of the range and the orange bar is the highest value. Abbreviations: ADP = Absorbed Dose Patient, Carm conv = Conventional C-arm, Cnav = C-arm navigation, Onav = O-arm navigation, Orob = O-arm robotic.
Figure 4
Figure 4
Ranges of Exposure (mGycm2 or mGycm) per procedure for conventional C-arm group, C-arm navigation group and O-arm navigation group. The blue bar is the lowest value of the range and the orange bar is the highest value. Abbreviations: Carm conv = Conventional C-arm, Cnav = C-arm navigation, Onav = O-arm navigation.
Figure 5
Figure 5
Ranges of EDS (mSv) per pedicle screw for conventional C-arm group, C-arm navigation group and C-arm robotic group. The blue bar is the lowest value of the range and the orange bar is the highest value. Abbreviations: EDS = Effective Dose Surgeon, Carm conv = Conventional C-arm, Cnav = C-arm navigation, Crob = C-arm robotic.
Figure 6
Figure 6
Ranges of EDP (mSv) per pedicle screw for conventional C-arm group, C-arm navigation group, C-arm robotic group and O-arm navigation group. The blue bar is the lowest value of the range and the orange bar is the highest value. Abbreviations: EDP = Effective Dose Patient, Carm conv = Conventional C-arm, Cnav = C-arm navigation, Crob = C-arm robotic, Onav = O-arm navigation.
Figure 7
Figure 7
Ranges of ADP (mGy) per pedicle screw for conventional C-arm group, C-arm navigation group, O-arm navigation group and O-arm robotic group. The blue bar is the lowest value of the range and the orange bar is the highest value. Abbreviations: ADP = Absorbed Dose Patient, Carm conv = Conventional C-arm, Cnav = C-arm navigation, Onav = O-arm navigation, Orob = O-arm robotic.
Figure 8
Figure 8
Ranges of Exposure (mGycm2 or mGycm) per pedicle screw for conventional C-arm group, C-arm navigation group and O-arm navigation group. The blue bar is the lowest value of the range and the orange bar is the highest value. Abbreviations: Carm conv = Conventional C-arm, Cnav = C-arm navigation, Onav = O-arm navigation.
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