1. 2018;21;53-60Reducing Radiation Exposure in Lumbar Transforaminal Epidural Steroid Injections with Pulsed Fluoroscopy: A Randomized, Double-blind, Controlled Clinical Trial
   Randomized Trial
   Andrea Nicol, MD, Talal W. Khan, MD, Walter Orr, MPH, Michael Tollette, MD, Michael Brimacombe, PhD, Brian Hamm, MD, Smith Manion, MD, Dawood Sayed, MD, Andrew M. Sack, MD, and Edward Braun, MD.

BACKGROUND: Fluoroscopy-guided lumbar transforaminal epidural steroid injections (L-TFESI) result in radiation exposure that carries risks to patients, physicians, and procedural staff.

OBJECTIVE: We aim to evaluate the feasibility of using pulsed fluoroscopy to safely reduce radiation exposure during L-TFESI.

STUDY DESIGN: This is a prospective, double-blind, randomized controlled trial.

SETTING: This study took place in a single-center, academic, outpatient interventional pain management clinic.

METHODS: Patients undergoing L-TFESI were randomly assigned to either continuous mode fluoroscopy (high-dose), pulsed fluoroscopy with 8 pulses per second (medium-dose), or pulsed fluoroscopy with one pulse per second (low-dose). Data on radiation doses and other clinical and demographic factors were also collected.

RESULTS: In total, 231 cases were analyzed in the high-dose group (n = 81), medium-dose group (n = 72), and low-dose group (n = 78). Mean radiation effective dose (µSv) was 121 in the high-dose group, 57.9 in the medium-dose group, and 34.8 in the low-dose group (P < 0.001). The incidence of inadequate image quality in the pulsed groups was 6% (9/150). The body mass index (BMI, mean ± SD) was significantly higher in patients with inadequate image quality (37.3 ± 7.2) than with adequate quality (30.5 ± 7.2, P = 0.005).

LIMITATIONS: Radiation doses were measured using the meter on C-arm fluoroscopes rather than by direct measurement.

CONCLUSIONS: The use of pulsed fluoroscopy during L-TFESI resulted in radiation dose reduction of up to 72.1% without causing any significant adverse events. Pulsed fluoroscopy should be considered as an initial fluoroscopic setting for L-TFESI to reduce radiation exposure.

KEY WORDS: Radiation, epidural, fluoroscopy, injection, exposure, pulse