Decreasing Radiation Emission in Minimally Invasive Spine Surgery Using Ultra-Low-Radiation Imaging with Image Enhancement: A Prospective Cohort Study

Abstract

Visualization of the anatomy in minimally invasive surgery (MIS) of the spine is limited and dependent on radiographic imaging, leading to increased radiation exposure to patients and surgical staff. Ultra-low-radiation imaging (ULRI) with image enhancement is a novel technology that may reduce radiation in the operating room. The aim of this study was to compare radiation emission between standard-dose and ULRI fluoroscopy with image enhancement in patients undergoing MIS of the spine. This study prospectively enrolled 60 consecutive patients who underwent lateral lumbar interbody fusion, lateral lumbar interbody fusion with percutaneous pedicle screws, or MIS transforaminal lumbar interbody fusion. Standard-dose fluoroscopy was used in 31 cases, and ULRI with image enhancement was used in 29 cases. All imaging emission and radiation doses were recorded. Radiation emission per level was significantly less with ULRI than with standard-dose fluoroscopy for lateral lumbar interbody fusion (36.4 mGy vs. 119.8 mGy, P<0.001), per screw placed in lateral lumbar interbody fusion (15.4 mGy per screw vs. 47.1 mGy per screw, P<0.001), and MIS transforaminal lumbar interbody fusion (24.4 mGy vs. 121.6 mGy, P= 0.003). These differences represented reductions in radiation emission of 69.6%, 67.3%, and 79.9%. Total radiation doses per case were also significantly decreased for the transpsoas approach by 68.8%, lateral lumbar interbody fusion with percutaneous pedicle screws by 65.8%, and MIS transforaminal lumbar interbody fusion by 81.0% (P ≤ 0.004). ULRI with image enhancement has the capacity to significantly decrease radiation emission in minimally invasive procedures without compromising visualization of anatomy or procedure safety.