Doria-Medina Roberto, Hubbe Ulrich, Scholz Christoph, Sircar Ronen, Brönner Johannes, Hoedlmoser Herbert, Klingler Jan-Helge
Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany.
Mirion Technologies (AWST) GmbH, 81739 Munich, Germany.
J Clin Med. 2023 Aug 4;12(15):5125. doi: 10.3390/jcm12155125.
Transforaminal lumbar interbody fusion (TLIF) is one of the most frequently performed spinal fusion techniques, and this minimally invasive (MIS) approach has advantages over the traditional open approach. A drawback is the higher radiation exposure for the surgeon when conventional fluoroscopy (2D-fluoroscopy) is used. While computer-assisted navigation (CAN) reduce the surgeon's radiation exposure, the patient's exposure is higher. When we investigated 2D-fluoroscopically guided and 3D-navigated MIS TLIF in a randomized controlled trial, we detected low radiation doses for both the surgeon and the patient in the 2D-fluoroscopy group. Therefore, we extended the dataset, and herein, we report the radiation-sparing surgical technique of 2D-fluoroscopy-guided MIS TLIF.
Monosegmental and bisegmental MIS TLIF was performed on 24 patients in adherence to advanced radiation protection principles and a radiation-sparing surgical protocol. Dedicated dosemeters recorded patient and surgeon radiation exposure. For safety assessment, pedicle screw accuracy was graded according to the Gertzbein-Robbins classification.
In total, 99 of 102 (97.1%) pedicle screws were correctly positioned (Gertzbein grade A/B). No breach caused neurological symptoms or necessitated revision surgery. The effective radiation dose to the surgeon was 41 ± 12 µSv per segment. Fluoroscopy time was 64 ± 34 s and 75 ± 43 radiographic images per segment were performed. Patient radiation doses at the neck, chest, and umbilical area were 65 ± 40, 123 ± 116, and 823 ± 862 µSv per segment, respectively.
Using a dedicated radiation-sparing free-hand technique, 2D-fluoroscopy-guided MIS TLIF is successfully achievable with low radiation exposure to both the surgeon and the patient. With this technique, the maximum annual radiation exposure to the surgeon will not be exceeded, even with workday use.
经椎间孔腰椎椎体间融合术（TLIF）是最常施行的脊柱融合技术之一，这种微创（MIS）方法相较于传统开放手术具有优势。一个缺点是使用传统荧光透视（二维荧光透视）时外科医生的辐射暴露更高。虽然计算机辅助导航（CAN）可减少外科医生的辐射暴露，但患者的暴露量更高。当我们在一项随机对照试验中研究二维荧光透视引导和三维导航的MIS TLIF时，我们在二维荧光透视组中检测到外科医生和患者的辐射剂量都很低。因此，我们扩展了数据集，在此报告二维荧光透视引导的MIS TLIF的辐射节省手术技术。
按照先进的辐射防护原则和辐射节省手术方案，对24例患者进行了单节段和双节段MIS TLIF。专用剂量仪记录患者和外科医生的辐射暴露情况。为进行安全性评估，根据格茨贝恩 - 罗宾斯分类法对椎弓根螺钉的准确性进行分级。
总共102枚椎弓根螺钉中有99枚（97.1%）位置正确（格茨贝恩分级为A/B级）。没有穿破导致神经症状或需要翻修手术。外科医生每节段的有效辐射剂量为41±12微希沃特。荧光透视时间为每节段64±34秒，共进行75±43张射线照片。患者颈部、胸部和脐部区域每节段的辐射剂量分别为65±40、123±116和823±862微希沃特。
使用专门的辐射节省徒手技术，二维荧光透视引导的MIS TLIF能够成功实现，且外科医生和患者的辐射暴露都很低。采用这种技术，即使在工作日使用，外科医生的年度最大辐射暴露也不会超标。
