Intraoperative risks of radiation exposure for the surgeon and patient

Abstract

Intraoperative radiological imaging serves an essential role in many spine surgery procedures. It is critical that patients, staff and physicians have an adequate understanding of the risks and benefits associated with radiation exposure for all involved. In this review, we briefly introduce the current trends associated with intraoperative radiological imaging. With the increased utilization of minimally invasive spine surgery (MIS) techniques, the benefits of intraoperative imaging have become even more important. Less surgical exposure, however, often equates to an increased requirement for intraoperative imaging. Understanding the conventions for radiation measurement, radiological fundamental concepts, along with deterministic or stochastic effects gives a framework for conceptualizing how radiation exposure relates to the risk of various sequela. Additionally, we describe the various options surgeons have for intraoperative imaging modalities including those based on conventional fluoroscopy, computer tomography, and magnetic resonance imaging. We also describe different ways to prevent unnecessary radiation exposure including dose reduction, better education, and use of personal protective equipment (PPE). Finally, we conclude with a reflection on the progress that has been made to limit intraoperative radiation exposure and the promise of future technology and policy.

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© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2021;9(1):84 | http://dx.doi.org/10.21037/atm-20-1052
Intraoperative risks of radiation exposure for the surgeon and
patient
Nathaniel W. Jenkins, James M. Parrish, Evan D. Sheha, Kern Singh
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: All
authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII)
Final approval of manuscript: All authors.
Correspondence to: Kern Singh, MD. Professor, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite
#300, Chicago, IL 60612, USA. Email: kern.singh@rushortho.com.
Abstract: Intraoperative radiological imaging serves an essential role in many spine surgery procedures.
It is critical that patients, staff and physicians have an adequate understanding of the risks and benefits
associated with radiation exposure for all involved. In this review, we briefly introduce the current trends
associated with intraoperative radiological imaging. With the increased utilization of minimally invasive
spine surgery (MIS) techniques, the benefits of intraoperative imaging have become even more important.
Less surgical exposure, however, often equates to an increased requirement for intraoperative imaging.
Understanding the conventions for radiation measurement, radiological fundamental concepts, along with
deterministic or stochastic effects gives a framework for conceptualizing how radiation exposure relates to
the risk of various sequela. Additionally, we describe the various options surgeons have for intraoperative
imaging modalities including those based on conventional fluoroscopy, computer tomography, and magnetic
resonance imaging. We also describe different ways to prevent unnecessary radiation exposure including
dose reduction, better education, and use of personal protective equipment (PPE). Finally, we conclude with
a reflection on the progress that has been made to limit intraoperative radiation exposure and the promise of
future technology and policy.
Keywords: Intraoperative imaging; ionizing radiation; DNA damage; genomic instability; shielding; distance;
dose reduction; spine surgery
Submitted Jan 27, 2020. Accepted for publication Jun 11, 2020.
doi: 10.21037/atm-20-1052
View this article at: http://dx.doi.org/10.21037/atm-20-1052
Introduction
The World Health Organization recognizes that excessive
exposure to ionizing radiation increases the risk of
harmful sequelae, such as cancer (1). Radiation exposure is
particularly relevant among the surgical specialties that rely
on various modalities of radiologic imaging and localization.
Various examples of these technologies include uoroscopy
for imaging, intraoperative computed tomography (CT)
for localization, radiopaque dye for visualization in vascular
procedures, conrmation of alignment, or instrumentation
placement in orthopaedic procedures (2). While general
orthopaedic procedures frequently require imaging of the
limbs or peripheral structures when placing implants, spine
surgery routinely requires surgeons to place these devices in
close proximity to structures of the central nervous system
and neighboring vascular structures. In spine surgery, the
most common procedure requiring use of ionizing radiation
is the placement of posterior pedicle screws as erroneous
screw placement can have catastrophic results.
Ensuring the proper positioning of surgical devices requires
intraoperatively attained radiographic images. Increased
exposure to various spectra of the electromagnetic spectrum
84
Review Article on Current State of Intraoperative Imaging

Jenkins et al. Intraoperative radiation exposure
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2021;9(1):84 | http://dx.doi.org/10.21037/atm-20-1052
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is a necessary part of nearly all radiological imaging (3).
Spine surgeons first made use of biplanar fluoroscopy
which was used as an early radiological imaging modality.
The radiation emitted during intraoperative fluoroscopic
imaging places surgeons at risk for increased exposure
to ionizing radiation and other resultant sequelae (4).
As we will later discuss, some side effects include burns,
cataracts, carcinogenesis, and hair loss (5). Over the past
two decades, the utilization of intraoperative radiation-
emitting devices has risen with the increasing adoption
of minimally-invasive surgical techniques (6-8). With less
anatomic exposure, imaging is often required to verify the
position of anatomy and instrumentation (9).
While MIS offers numerous purported advantages such
as reduced hospital stays, decreased blood loss, a lower
risk of infection and lower pain scores (10,11), its practice
requires frequent use of uoroscopy for localization and
placement of pedicle screws and interbody implants as
the anatomic landmarks utilized in traditional, open spine
surgery techniques are not directly visualized. Moreover,
it has been observed that reducing fluoroscopy time
and exposure are among the most difcult MIS skills to
master (12). Despite these concerns, fluoroscopy remains
the conventional intraoperative imaging modality used in
MIS spine surgery despite its known risks (13-19).
Reducing radiation exposure to the patient, operating
room staff, and surgeon may be accomplished through
judicious use of intraoperative fluoroscopy, the use of
emerging technologies and increasing emphasis on the
use of personal protective equipment (PPE) (20). While
opportunities to decrease radiation exposure while using
traditional fluoroscopic methods are numerous, they are
faced with signicant barriers to implementation. Detailed
mitigation and safety procedures can be cumbersome,
are likely to be met with cultural resistance, and require
signicant healthcare workforce buy-in (21).
Many assert that new technologies are the likely solution
for reducing intraoperative radiation exposure (18,22,23).
Proven technologies such as frameless image guidance and
navigation systems have undergone changes to improve
accuracy and streamline registration procedures. Other
novel technologies are becoming increasingly utilized
such as intraoperative computed tomography (CT) based
guidance, IR-navigation that uses preoperative CT imaging,
and three-dimensional (3D) fluoroscopy (24). Despite
these advances, the strongest supporting evidence for these
methods is based on small cohorts.
Finally, while institutions are required to provide
education and appropriate PPE, there is a disconnect
between compliance and recommendations (25). Even
though required PPE items such as lead gowns, shields,
gloves, or glasses, may be institutionally supplied, education
regarding the use of such equipment, and lack of availability
are among the most common reasons for a lack of
adherence.
The objective of this review is to outline the physical and
pathological origins of intraoperative radiation, to describe
the various sources of intraoperative radiation exposure and
the barriers that must be overcome to prevent radiation
exposure, and nally to review future directions that may be
most applicable to mitigating intraoperative radiation risks.
Radiation emission and pathophysiological
effects
Conceptualizing the pathophysiology associated
with ionizing radiation exposure requires a cursory
understanding of how radiation exposure is measured,
what types of exposure exist, as well as the associated
short- and long-term physical effects. X-radiation (X-ray)
is electromagnetic radiation that is commonly used in
intraoperative imaging (fluoroscopy, CT). Radiation
exposure was classically measured by the roentgen, which
measures the intensity of X-ray radiation to which one was
exposed. More contemporary units of measurement include
the average energy absorbed by unit mass (Gray or Rad)
and effective dose (Sievert). The Gray (Gy) is dened as the
absorption of one joule of radiation energy per kilogram of
matter while the Rad is a unit of absorbed radiation dose (1
rad =0.01 Gy). Alternatively, the Sivert is an effective dose, a
measure of the overall detrimental health effects of ionizing
radiation. It is calculated by weighting the concentration of
energy imparted on each organ using factors that account
for radiation-related mutagenic potential in reference
populations and the radiation type. To better understand
the difference between absorbed and effective dose, we
can consider that a single radiograph from the posterior-
anterior chest delivers an absorbed dose to the posterior
chest of 0.14 Gy (9,26). When converted and weighted
an effective dose, this is 0.03 mSv. A lumbar radiograph
delivers approximately 1.5 mSv and a lumbar CT roughly
15 mSv to the patient (26).
There are three main sources of radiation in the
operating room: direct radiation, scattered radiation, and
leakage radiation (27). Direct radiation is emitted from the
beam source toward the target to produce the radiograph.

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Scattered radiation is the phenomenon of deected photons
from the X-ray beam that have interacted with the patient.
This phenomenon is known as Compton scattering and
occurs when an X-ray interacts with matter and deflects
instead of being absorbed. The majority of these scattered
X-rays are along the initial beam trajectory but they may
also scatter in any direction. The magnitude of scattered
radiation exposure depends on the strength of the X-ray
source, the distance from the target being imaged, and the
mass of the target. Leakage radiation is any radiation that
escapes the X-ray tube housing which is not originating
from the beam path. The magnitude of radiation from
a source, be it direct, scattered or leaked, is inversely
proportional to the square of the distance of the source
to the surgeon or patient (27). For example, considering
a point source of radiation that emits in all directions, it
is understandable that, at greater distances away from the
source the radiation is distributed over a larger and larger
spherical surface.
The biological effects of ionizing radiation are classified
into either deterministic or stochastic. Deterministic effects
are the immediate changes to tissues such as skin erythema,
hematopoietic damage, and fibrosis (27). Deterministic
effects are the result of a large number of cells in an organ or
tissue that are killed as the result of large radiation doses (28).
Deterministic effects are only observed once a high
threshold dose has been achieved. For example, during
the 2011 Fukushima Daiichi nuclear disaster in Ōkuma,
Fukushima Prefecture of Japan, workers were exposed to
an unforeseen supply of radioactive water and this resulted
in their hospitalization for the consequent radiation burns
(29,30). This threshold dose is much greater than those
used in diagnostic imaging.
Ionizing radiation produces both direct and indirect
damage to DNA including, base alteration, crosslinking,
and strand breaks (31). The stochastic effect is cellular
damage to DNA arising from low dose ionizing radiation
exposure, such as those in the OR. The stochastic effect is
the probability of experiencing an effect, which is directly
proportional to the radiation dose (i.e., 10 Gy has a higher
probability than 1 Gy). For stochastic effects, the severity
does not change with increases in dose. The only element
that changes is the likelihood that damage will occur.
Hence, there is no radiation dose threshold for cellular
damage, as any amount of ionizing radiation imparts
destructive energy on human cells that could ultimately
result in malignant conditions.
Current standards on radiation safety are described
by the US National Council on Radiation Protection &
Measurements (NCRP) and the International Commission
on Radiological Protection (ICRP). ICRP recommends a
dose limit for medical interventional procedures of a whole-
body effective dose of 20 mSv/year averaged over 5 years (28).
Further guidance is specied that this is not to exceed 50 mSv
in any single year, an extremity dose of 500 mSv/year, or
a skin dose of 500 mSv/year averaged over 1-cm2 (28).
Furthermore, no dose is advised at any time during
pregnancy of 5 mSv, and no dose to the lens of the eye of
20 mSv/year averaged over 5 years, not to exceed 50 mSv in
any single year (28). These recommended limits are meant
to avoid deterministic effects and to ensure that stochastic
effects are kept at an acceptable level (28). Notably, NRCP
has a higher recommended occupational dose limit of
50 mSv/year (32).
Physician exposure
Intraoperative surgeon exposure is predominantly
encountered due to scatter radiation. Long term effects of
exposure to ionizing radiation have been studied by tracking
survivors of the Hiroshima atomic bomb (33). These studies
based on this cohort have shown that 1 Sv of exposure
imparts a 60% increase in developing solid malignancy (33).
Exposure effects can be systemic or local. Localized
effects, for example, can include sequelae that develop after
radiation exposure to the lens of the eye, resulting in the
formation of cataracts. A consensus has not been reached on
the threshold exposure that will result in cataract formation.
This is in part due to the fact that cataracts may be caused
by deterministic or stochastic effects (34). Ainsbury
et al. evaluated data from atomic bomb survivors, clinical
exposures, and occupational exposures, such as pilots and
astronauts, and determined that the exposure threshold for
posterior subcapsular cataracts was 0.5 Gy (28,35). To put
this in measurement in perspective, one study found that
spine surgery patients were exposed to an average of 1,091
Gy with the use of conventional uoroscopy (36).
In a survey of female orthopaedic, urology, and plastic
surgeons (n=1,203) who were exposed to uoroscopy, Chou
et al., reported that orthopaedic surgeons in this cohort
had twice the expected rate of total cancers and 2.9 times
the rate of expected breast cancers (37). Interestingly, the
reported rate of cancer from urology and plastic surgeons
was not statistically different from their expected rate.

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© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2021;9(1):84 | http://dx.doi.org/10.21037/atm-20-1052
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Intraoperative imaging modalities: spine surgery
sources of radiation
Spinal imaging and navigation systems play an irreplaceable
role in accurate instrumentation placement. There are
various options available for intraoperative imaging, each
with its own set of unique advantages and disadvantages.
Traditional fluoroscopy is typically the easiest to adopt
and has the fewest barriers to implementation, while other
techniques—e.g., navigation, robotics—which promise
equivalent or increased accuracy with decreased radiation
exposure may be cost-prohibitive, involve a change in
workow or specialized training requiring adoption by OR
staff, and often come with a new set of potential pitfalls and
a corresponding learning curve for the surgeon.
Intraoperative navigation
Spinal navigation systems typically function through the
synchrony of multiple peripheral units. For example,
radiographic imaging data is often collected of the relevant
anatomy, uploaded into a computer which, in turn, constructs
a 3D image. The computer also integrates several other
components such as optical cameras, specialized surgical
instrumentation, and tools which can all be tracked relative
to surgical eld reference points (38,39). The computer can
then guide instrumentation insertion without the need for
continuously gathering uoroscopic imagery (40).
Early navigation systems primarily use preoperative
imaging, which entails a registration process (39). The
registration process ensures that references on the
preoperative CT or MRI are matched with physical points
in the surgical field. This process is often cumbersome
and time-intensive. Likewise, operative positioning of
the patient can move anatomic relationships that are
not reflected in preoperative imaging (41-44). Hence,
navigation systems that make use of 3D intraoperative
images have been developed and these can provide
automated registration throughout the operation. These
systems not only save time, but also avoid navigation errors
that can arise with preoperative image guidance systems,
such as inaccurate point or surface matching (45).
The resulting images can be utilized for either active or
passive navigation. Active navigation systems can prevent
movement beyond boundaries, or they can even perform
certain tasks. Passive navigation systems provide location
and imaging information without limiting movement. Given
the variety of options and uses for pre- and postoperative
imaging modalities, designing and using these systems in
a way that optimizes image quality and reduces radiation
exposure is more of a concern than ever before. Modalities
utilized include CT or MRI. Due to their prevalence, ease
of use and familiarity, there has been substantially more
research investigating CT-based systems (46). CT based
systems have demonstrated notable reductions in the
frequency of misplaced spine surgery instrumentation.
Isocentric C-arms
C-arms can be contrasted against legacy two-dimensional
fluoroscopy primarily because the C-arm allows an X-ray
tube to rotate over a 190º arc about an isocentric point of
interest. This rotation along with a wide aperture allows
for the acquisition of 100 two-dimensional images, that are
attained at equidistant angles. After acquiring, the images
are reconstructed into a 3D image with volumes in excess
of 15-cm (47-49). While several studies have observed
that intraoperative isocentric devices that are comparable
to CT insofar as diagnostic capability (42,50), others have
noted that C-arms may be limited in the cervical-thoracic
region (51). C-arm devices can also function as standard
fluoroscopic imaging systems and they can be used for
registering patient anatomic landmarks with navigation
systems (49).
As with any imaging modality, radiation exposure is
an important consideration in patient care. However,
intraoperative radiation exposure also means that the
hospital staff will be at risk for exposure during each
surgery. The Iso-C3D is promising in this regard because it
has been determined to produce images with comparable
quality to postoperative CT scans, albeit with a reduced
radiation signature. Thus, the Iso-C3D can be used to
replace postoperative CT and reduce radiation exposure for
the patient.
To lessen ionizing radiation exposure and fluoroscopy
time, researchers have utilized Iso-C3D arms instead of
standard fluoroscopy (42,52,53). One study compared
the two methods of measurement amongst 18 minimally
invasive transforaminal lumbar interbody fusion procedures
(MIS TLIF) on cadavers (52). Overall, uoroscopy time was
lower despite a longer setup in the Iso-C3D group. Radiation
exposure, which was measured in millirems (mREM),
was not discernible in the Iso-C3D group, whereas it was
12.4 mREM in the standard group (52). A similar study
involved 4 cadaveric lumbar pedicle screw placements while
comparing Iso-C3D and standard fluoroscopy (53). This
study also demonstrated less radiation exposure in the Iso-

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C3D group. The use of Iso-C3D is not only advantageous due
to reduced radiation, it has also demonstrated increased
accuracy when placing pedicle screws.
One disadvantage of the Iso-C3D is that its 190º rotation
limits the device to image three to five vertebral levels at
a time (46). Spine surgeries that require scanning of more
levels may require more than one sequential scan. Beyond
interrupting the task flow of the surgery and increasing
operative duration, it also increases the amount of radiation
exposure (50).
O-Arms
In comparison to C-arms, O-arms have a full 360º image
acquisition capability due to their circular gantry. O-arms
have an anatomical registration system that is similar to
C-arms.
They are also typically capable of acquiring more images
over a shorter period of time than are C-arms. In their
standard 3D volumetric imaging mode, O-arms will acquire
roughly 400 images over 360º in 14 seconds (45). The time
and number of images is roughly doubled in high denition
modes. O-arms were the first to offer a standard or high
denition mode.
Despite these advantages, there is disagreement
on the utility of O-arm imaging in terms of reducing
radiation. The findings of multiple studies demonstrate
that despite decreased radiation exposure to the surgeon
and clinical staff, who have the advantage of being able to
leave the room or cover behind a mobile shield, there is
overall increased radiation towards the patient (18,54-58).
Comparisons between C-arm and O-arm imaging have
replicated these results in cadaveric studies, most notably
in the analysis of 160 pedicle screw placements (58). It
was found that clinicians and operating room staff were
not exposed to any radiation in O-arm imaging, whereas
60.75 mREM of radiation exposure was attributed to C-arm
imaging. Conversely, the cadavers were exposed to much
higher radiation in the O-arm group as compared to the
C-arm group (58). An additional study found similar results
when comparing O-arm and C-arm fluoroscopy amongst
posterior pedicle screw insertions (18). In a cohort of
73 patients, those whose procedure involved O-arm
imaging had a radiation exposure that was 8.74 times that
of the operating room clinicians and staff. Overall, these
patients also had a higher mean effective dose radiation of
1.09 mSv when compared to patients who underwent the
same procedure with C-arm uoroscopy after MIS or open
procedures. These ndings demonstrate that clinicians must
consider the radiation risks to the patient when choosing
O-arm imaging, despite the benet to the clinicians.
Intraoperative MRI
Intraoperative MRI enhances the ability to visualize soft
tissue in the spine, which is why it is often used in tumor
removal (59). Although intraoperative MRI is an established
and well-researched technique in neurological surgery
and tumor removal, it has not been researched as heavily
in degenerative spine surgery. Researchers have studied
intraoperative MRI in transforaminal endoscopic lumbar
discectomy for patients with disk herniation and have
found that MRI can aid in locating surgical entry point and
instrumental trajectory as it relates to the intervertebral disk
space (60). It has also been noted that intraoperative MRI
can help to identify neural and vascular tissue, as well as
insufficient decompression, which overall reduces surgical
complications (60). To our knowledge, there are no studies
evaluating intraoperative MRI with MIS, although one
interventional neurology study found that intraoperative MRI
is approximately double the cost of intraoperative CT (61).
Procedure-related exposure
Differences in radiation exposure by procedure: MIS vs.
open
Despite minimizing exposure of the patient during surgery,
as previously mentioned, MIS is even more dependent
than open surgery is on intraoperative imaging (62). MIS
presents many potential advantages, such as less patient-
reported pain durations and severity levels, less tissue
trauma, less bleeding, and smaller wounds. Faster recovery
times have been attributed to these and other aspects.
However, due to the nature of MIS and its overall approach
to lessen adjacent tissue damage, there is minimal spine
exposure which results in less visibility. For this reason,
radiological imaging plays a signicant role in MIS.
Radiation exposure is an unfortunate, yet essential
aspect of the most common tools used to visualize surgical
instrumentation. Due to the necessary verification of
instrumentation with radiologic imaging in MIS, ionizing
radiation is an unavoidable necessity for both surgeons
and patients. The presence of this workplace hazard
makes it desirable to monitor intraoperative exposure.
Hence, exposure and variations in exposure are often

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© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2021;9(1):84 | http://dx.doi.org/10.21037/atm-20-1052
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measured throughout procedures through fluoroscopic
monitoring. This is most applicable during the placement
of percutaneous screws in MIS (3). With the concern and
actual effects of radiation exposure that have now been
realized, several investigators have attempted to measure
the intraoperative radiation exposure for both surgeons and
patients during various spine procedures (3,63-66). Indeed,
one Italian institution described their orthopaedic surgeons
to have increased their risk of cancer by ve times (13).
Fusion procedures
A recent meta-analysis determined that, compared to open
spine fusion surgeries, MIS TLIF can expose patients
to as much as 2.4 times more radiation (67). One study
measured radiation exposure to both surgeons and patients
undergoing minimally invasive spine fusions and observed
total radiation exposure for patients was 3.47±2.12 Rad
which broke down to 0.46 Rad/screw. The mean radiation
to the surgeon was estimated to be 8.61 μSv, which was
divided up to 1.06 μSv/screw. When compared to TLIF
or A/P fusion procedures, XLIF procedures exposed the
surgeon and patient to nearly twice as much ionizing
radiation, Farber et al. did note that when compared to
using fluoroscopy in the general setting, low-dose pulse
setting for uoroscopy could signicantly reduce the level
of exposure (1.40±0.65 vs. 0.79±0.65 μSv/screw, P=0.0002).
One technique, although part of a cadaveric study, used
preoperative C-arm fluoroscopy to demonstrate reduced
intraoperative radiation to below detectable levels (52).
Other spine procedures
Other investigators have measured radiation exposure
for vertebroplasty, kyphoplasty, pedicle screw insertion,
microdiscectomy, and endoscopic procedures (10,14,68-73).
In general, MIS techniques appear to impose more of a
radiation exposure risk than do open techniques. Radiation
exposure has been compared between open versus MIS
microdiscectomies (74). Compared to the open technique,
MIS microdiscectomies were again observed to have a
statistically signicant increase in radiation exposure for the
surgeon, including areas such as the chest, eyes, hand, and
thyroid. Others have investigated endoscopic procedures.
In one investigation with percutaneous endoscopic lumbar
discectomies, the authors observed similar surgeon radiation
exposure levels (0.1718 μSv/level) to those reported in
common MIS procedures (66).
Prevention
Barriers to exposure safety
Current barriers facing trainees and practicing physicians
are multifaceted, ranging from education, protective
equipment, and local/institutional safety policies. While
the previously mentioned safety policies are put forth
by national (NRCP) and international (IRCP) radiation
safety organizations, these recommendations have a varied
application at the trainee and physician levels throughout
orthopaedic surgery (28,32,75).
In one cohort of 26 orthopaedic trainees, just over 50%
of the trainees felt they received adequate radiation safety
training (76). Overall, the cohort reported high compliance
with lead apron use (96%), while in contrast, their
dosimeters were rarely used (27%) (76). The two greatest
barriers to using protective equipment were perceived
impracticality and lack of availability (76). In another survey
of 50 general surgery trainees from the United Kingdom,
only 16% reported they had read literature regarding
radiation safety, 22% utilized a thyroid shield, and a slim
6% were aware of the principle “As Low As Reasonably
Achievable (ALARA)” (77).
The American Academy of Orthopaedic Surgeons
(AAOS) recommends a three-pronged approach to reducing
radiation exposure to surgeons, patients, and associated staff
which include: educating users on safe techniques to reduce
exposure, utilization of protective equipment and dose-
measuring methods, as well as the regular maintenance of
imaging equipment and shielding. Institutional policies vary
widely and, unfortunately, there are no current standardized
educational curriculums on radiation safety for orthopaedic
residency training (78).
PPE
Standard radiation protection, such as lead aprons,
skirts, thyroid, and eye shields, should be worn during all
procedures and may be supplemented with more specialized
equipment to further mitigate radiation exposure (16). A
mobile shielding device has been observed to reduce the
exposure dose to a surgeon by 75–86.1% in vertebroplasties
(14,79). Wearing lead gloves while performing
percutaneous vertebroplasty procedures has also been
reported to reduce radiation exposure by 75%, reducing
the treatment associated dose to the hand from 1.81 to
0.49 mSv (71). Although this may seem like a minuscule
improvement, for a surgeon who performs hundreds of

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procedures a year, this can safely increase the number
of procedures performed without increasing exposure
to the hand when compared to performing procedures
without lead gloves. All imaging modalities benefit from
further protection. While using a cone-beam CT for 3D
image guidance, having the surgeon stand behind a lead
shield 10 feet away has been observed to reduce scatter
radiation to the torso from 5 rem to 3.6 rem/spin (55).
Ahn et al. demonstrated that without the use of protective
radiation shielding, a surgeon would be limited to 291
percutaneous endoscopic lumbar discectomies annually (i.e.,
prior to exceeding the maximum annual dose limit) (66).
In this same study, the addition of a lead collar and apron,
the radiation dose was reduced by 96.9% and 94.2%,
respectively (66). Another study that evaluated the radiation
dose from C-arm fluoroscopy during a simulated spine
procedure, recommended the best steps to take to reduce
exposure were to: increase the distance from the source,
wear all protective equipment (apron, thyroid shield, and
goggles), avoid direct exposure to the hands, and avert one’s
head if no eye protection is available (16).
Fluoroscopic dose reduction
The principals inherent to ALARA are essential to safe
radiation exposure practices. The foundational tenets
include decreasing the dose, increasing the distance to the
source, decreasing the time exposed, or a combination of
all three. There is a plethora of research that has evaluated
and demonstrated the success of this principle in reducing
radiation exposure. Acquisition of uoroscopic images may
be modied to reduce exposure to the patient and surgeon.
Switching from a continuous uoroscopic mode to a pulsed
mode has been shown to reduce radiation dose (80,81).
Physicians must attempt to balance useful image quality
while adhering to the ALARA principle. In one cohort of
50 patients undergoing MIS TLIF, Clark et al. successfully
implemented a low dose pulsed fluoroscopy protocol that
decreased fluoroscopy time and radiation dose without
compromising image quality (82). Another study reported
that in 158 patients undergoing spinal interventions a
56.7% reduction in radiation exposure was achieved
through the use of pulsed low dose uoroscopy (81). Using
pulsed and low dose settings does pose a risk for producing
lower image quality (81), although some radiological studies
have demonstrated no perceivable difference (83,84).
One development that has allowed for the focusing
of radiation, beam collimation, allows the operator to
concentrate the radiation on a point of interest while
avoiding inadvertent targets. This is achieved by the
application of lead shutters that restrict the X-ray beam
to only the anatomy of interest. Obvious advantages are
reducing radiation doses to the patient and surgeon. Using
cadavers and Monte Carlo risk and outcome simulation,
Yamashita et al. demonstrated that the collimation of C-arm
uoroscopy reduced 65% of the radiation exposure to the
surgeon’s hand and thyroid (85). Artner et al. used low dose
CT-guided injections to demonstrate that low dose settings
can also be applied to CT-guided procedures (38). An 85%
dose reduction was observed when using a low dose mode
while maintaining the safety and precision of epidural and
periradicular injections (38). In addition to changes in
mode settings, modications in how the surgeon manually
manipulates the acquisition of images may reduce radiation
exposure. Freezing the last image on the monitor, known as
“image hold”, allows the surgeon to plan the next maneuver
while avoiding additional inadvertent radiation to the
patient and OR staff (86). Intermittent fluoroscopy is the
method of only activating the X-ray beam for a few seconds
at a time to visualize structures (86). Taken together, even in
radiologically intensive operative techniques, surgeons have
many options available that can assist in the delicate balance
between image quality and radiation exposure safety.
Conclusions
The critical balance to optimize care while limiting
radiation exposure for patients, hospital staff, and
community members is a challenge that continues to
evolve. Prototypes such as hybrid operating rooms are
soon expected to be equipped with automated C-arms
with 3D cone-beam CTs. These are hypothesized to offer
the automation of signicant portions of image collection
processes and to potentially eliminate the exposure burden
currently imposed on hospital staff (69). Robotic surgery
also may offer new methods to limit radiation exposure
for hospital staff. While there is much promise with these
systems, it is also important to be cognizant of potential
limitations such as cost, maintenance requirements,
and operative time durations. Until such time that
technological progress changes the current paradigm of
intraoperative radiation, the fundamentals of decreasing
exposure—distance, dose reduction, and shielding—
remain essential pillars for practitioners who utilize
ionizing radiation as an integral part of their surgical
practice.

Jenkins et al. Intraoperative radiation exposure
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2021;9(1):84 | http://dx.doi.org/10.21037/atm-20-1052
Page 8 of 11
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned
by the Guest Editor (Dr. Sheeraz Qureshi) for the series
“Current State of Intraoperative Imaging” published in
Annals of Translational Medicine. The article was sent for
external peer review organized by the Guest Editor and the
editorial ofce.
Conflicts of Interest: All authors have completed the ICMJE
uniform disclosure form (available at http://dx.doi.
org/10.21037/atm-20-1052). The series “Current State of
Intraoperative Imaging” was commissioned by the editorial
office without any funding or sponsorship. KS reports
personal fees and other from Zimmer Biomet, other from
Stryker, other from RTI Surgical, other from Lippincott
Williams and Wilkins, other from Avaz Surgical LLC,
other from Vital 5 LLC, personal fees from K2M, non-
nancial support and other from TDi LLC, non-nancial
support from Minimally Invasive Spine Study Group, non-
nancial support from Contemporary Spine Surgery, non-
financial support from Orthopedics Today, non-financial
support from Vertebral Columns, grants from Cervical
Spine Research Society, outside the submitted work. The
authors have no other conicts of interest to declare.
Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Attribution-NonCommercial-NoDerivs 4.0 International
License (CC BY-NC-ND 4.0), which permits the non-
commercial replication and distribution of the article with
the strict proviso that no changes or edits are made and the
original work is properly cited (including links to both the
formal publication through the relevant DOI and the license).
See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Jenkins NW, Parrish JM, Sheha ED,
Singh K. Intraoperative risks of radiation exposure for the
surgeon and patient. Ann Transl Med 2021;9(1):84. doi:
10.21037/atm-20-1052