1. 2022;25;E67-E72Radiation Doses for Different Approaches of Fluoroscopy-Guided Epidural Injections: An Observational Clinical Study
   Retrospective Study
   Osman Hakan Gunduz, MD, Savas Sencan, MD, Ekim Can Ozturk, MD, and Rekib Sacaklidir, MD.

BACKGROUND: Although fluoroscopy-guided interventional therapies have declined in recent years, radiation exposure remains a critical issue for both patients and medical staff. Radiation exposure varies according to the physicians’ experience, procedure time, patients’ body mass index (BMI), imaging techniques, and the type of procedure performed.

OBJECTIVE: The purpose of this study is to report procedure times and calculate the radiation doses for 4 different approaches of fluoroscopy-guided epidural injections per procedure and BMI to provide radiations doses for potential use in future dose reduction strategies.

STUDY DESIGN: Retrospective, observational study.

SETTING: A university hospital, pain management center.

METHODS: A retrospective evaluation was performed of patients who received epidural steroid injections between January 2015 and December 2020 in a university hospital interventional pain management center. This observational study was conducted with patients aged >= 18 who underwent 3,711 epidural injections including cervical interlaminar, lumbar interlaminar, lumbar transforaminal, and caudal approaches. If more than one level or bilateral injections were performed, total dose and times were divided by the number of sites injected to attain procedure time and mean dose per injection. Provided doses for each patient were also divided by patients’ BMI to obtain dose per BMI.

RESULTS: The highest radiation dose per procedure was found in caudal epidural injection with 0.218 mGy·m2, and the lowest dose was found in cervical interlaminar epidural injection with 0.057 mGy·m2. The radiation dose per procedure was 0.123 mGy·m2 for lumbar transforaminal and 0.191 mGy·m2 for lumbar interlaminar epidural injection. The shortest procedure time was determined in transforaminal (37.3 seconds) injections, and the longest was in lumbar interlaminar (46.7 seconds) injections. Caudal epidural injection also had the highest radiation dose per BMI which was 0.00749, and cervical interlaminar epidural injection had the lowest radiation dose per BMI, which was 0.00214.

LIMITATIONS: Firstly, injections were performed by first- or second-year fellows in pain medicine. Moreover, patient-related factors (previous surgery, scoliosis, etc.) affecting radiation exposure were ignored.

CONCLUSIONS: Radiation dose levels and procedure times of 4 approaches of epidural injections were obtained from 3,711 procedures performed in a university hospital pain medicine clinic. BMI of patients was taken into account with the dose levels of injections given per BMI. Multicenter research with standardized techniques will assure more reliable reference levels, which will guide pain physicians to self-assess their own levels of radiation exposure.

KEY WORDS: Spine, epidural injections, radiation, radiation exposure, fluoroscopy, prevention, device safety