Vijayasree Arvind, MD
Physician Owner
Cardinal Pain Center
Dallas, Texas
Lisa Patino, LVN
LVN and Research Coordinator
Cardinal Pain Center
Dallas, Texas
Kavya Arvind, Medical Student Researcher
Medical Student
Cardinal Pain Center
Dallas, Texas
Ezra Aguilar, Student
Student Researcher
Cardinal Pain Center
Dallas, Texas
Anup Arvind, Medical Student
Medical Student Researcher
Cardinal Pain Center
Dallas, Texas
Interventional Pain Management involves routine use of fluoroscopy to promote accuracy of needle placement, delivery of medications to appropriate locations and enhance patient safety using multimodal views of fluoroscopy to minimize complications. Fluoroscopy has become mandatory for most procedures based either on the definition of the procedure or the requirement of insurance companies.
The most commonly used fluoroscopy in interventional pain management is with C-arm fluoroscopes with image intensification. Fluoroscopic exposure to radiation causes enhanced risk to physicians, medical personnel assisting during procedures and patients alike. Hence keen awareness and efforts to minimize radiation exposure is mandatory.
We compared the radiation dosages and fluoroscopy duration in most common interventional pain procedures such as lumbar translaminar epidural steroid injections and lumbar transforaminal epidural Steroid injections. Bilateral single level or unilateral two level transforaminal epidural steroid injections were compared to single level translaminar epidural steroid injection. The cases were performed in a 3 month period by one physician in a private practice setting, thereby limiting the variability in doses due to physician expertise or performance method.
Fluoroscopy doses and times were compared in 25 patients each of patient categories, who underwent translaminar and transforaminal lumbar epidural steroid injections
Methods:
The data was reviewed from the fluoroscopy machine from January 2022 to April 2022 in the procedure suite. Mean fluoroscopy time (FT), mean radiation dose per procedure, and utilization of pulsed fluoroscopy were analyzed.
Results:
Data of a total of 25 cases of translaminar epidural steroid injections were collected. The average fluoroscopy exposure time for translaminar lumbar epidural steroid injection was 0.115 minute and the transforaminal approach average time was 0.24 minutes.
The average radiation dose for lumbar translaminar approach was 5.51 mGy and for the trasnsforaminal approach was 9.59mGy.
The data was analyzed using a two-sample independent t-test for statistical significance. There was sufficient evidence to suggest that there is a statistically significant difference between both the radiation doses and radiation times between the transforaminal and translaminar approaches to lumbar epidural steroid injections since the p-value of the t-test was less than 0.05. The transforaminal approach had a statistically significant greater average radiation dose and delivery time.
Conclusion:
Since the transforaminal approach involved higher radiation doses and times incurred both by the patients and physician, every effort should be taken to judiciously limit exposure. Risk and benefits of choosing different approaches for interventional procedures need to be carefully evaluated.
In particular, clinicians or medical staff that use fluoroscopic imaging outside of dedicated radiology or interventional departments have low adherence and training to radiation safety guidelines. As radiation exposure becomes more prevalent, a thorough understanding of radiation exposure risks and dose reduction techniques will be of utmost importance.
The image intensifier or x-ray plate should be as close to the patient as possible, with the x-ray tube positioned as far away as possible. Utilization pulsed fluoroscopy also reduce the radiation exposure significantly. Scattered radiation can be reduced by one fourth if the staff members double the distance from the source. Since scattered radiation follow the inverse square law distance plays a pivotal role in exposure.
References: Radiation Exposure to the Physician in Interventional Pain Management
Laxmaiah Manchikanti, MD*, Kim A. Cash, RT, Tammy L. Moss, RT, and Vidyasagar Pampati, MSc