Comparison of operator and patient radiation exposure during fluoroscopy-guided vertebroplasty and kyphoplasty: a systematic review and meta-analysis

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  • 1 Departments of Neurosurgery and
  • | 2 Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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OBJECTIVE

Percutaneous vertebroplasty (PV) and balloon kyphoplasty (BK) are two minimally invasive techniques used to treat mechanical pain secondary to spinal compression fractures. A concern for both procedures is the radiation exposure incurred by both operators and patients. The authors conducted a systematic review of the available literature to examine differences in interventionalist radiation exposure between PV and BK and differences in patient radiation exposure between PV and BK.

METHODS

The authors conducted a search of the PubMed, Ovid Medline, Cochrane Reviews, Embase, and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text articles in English describing one of the primary endpoints in ≥ 5 unique patients treated with PV or BK of the mobile spine were included. Estimates of mean operative time, radiation exposure, and fluoroscopy duration were reported as weighted averages. Additionally, annual occupational dose limits provided by the United States Nuclear Regulatory Commission (USNRC) were used to determine the number needed to harm (NNH).

RESULTS

The meta-analysis included 27 articles. For PV, the mean fluoroscopy times were 4.9 ± 3.3 minutes per level without protective measures and 5.2 ± 3.4 minutes with protective measures. The mean operator radiation exposures per level in mrem were 4.6 ± 5.4 at the eye, 7.8 ± 8.7 at the neck, 22.7 ± 62.4 at the torso, and 49.2 ± 62.2 at the hand without protective equipment and 0.3 ± 0.1 at the torso and 95.5 ± 162.5 at the hand with protection. The mean fluoroscopy times per level for BK were 6.1 ± 2.5 minutes without protective measures and 6.0 ± 3.2 minutes with such measures. The mean exposures were 31.3 ± 39.3, 19.7 ± 4.6, 31.8 ± 34.2, and 174.4 ± 117.3 mrem at the eye, neck, torso, and hand, respectively, without protection, and 1, 9.2 ± 26.2, and 187.7 ± 100.4 mrem at the neck, torso, and hand, respectively, with protective equipment. For protected procedures, radiation to the hand was the limiting factor and the NNH estimates were 524 ± 891 and 266 ± 142 for PV and BK, respectively. Patient exposure as measured by flank-mounted dosimeters, entrance skin dose, and dose area product demonstrated lower exposure with PV than BK (p < 0.01).

CONCLUSIONS

Operator radiation exposure is significantly decreased by the use of protective equipment. Radiation exposure to both the operator and patient is lower for PV than BK. NNH estimates suggest that radiation to the hand limits the number of procedures an operator can safely perform. In particular, radiation to the hand limits PV to 524 and BK to 266 procedures per year before surpassing the threshold set by the USNRC.

ABBREVIATIONS

ALARA = as low as reasonably achievable; BK = balloon kyphoplasty; DAP = dose area product; ICRP = International Commission on Radiological Protection; NCRP = National Council on Radiation Protection and Measurements; NNH = number needed to harm; PV = percutaneous vertebroplasty; SIR = Society of Interventional Radiology; USNRC = United States Nuclear Regulatory Commission.

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Contributor Notes

Correspondence Daniel Sciubba: Johns Hopkins University School of Medicine, Baltimore, MD. dsciubb1@jhmi.edu.

INCLUDE WHEN CITING Published online April 30, 2021; DOI: 10.3171/2020.9.SPINE201525.

Disclosures Dr. Khan reports being a consultant for Stryker and Medwaves. Dr. Theodore reports being a consultant for Globus Medical, receiving royalties from Globus Medical and DePuy Synthes, owning stock in Globus Medical, and being on the scientific advisory board of Globus Medical. Dr. Sciubba reports being a consultant for Augmedics, Baxter, DePuy Synthes, and Stryker and receiving grant support unrelated to the present study from Baxter Medical, the North American Spine Society, and Stryker.

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