Browse > Article
http://dx.doi.org/10.3348/kjr.2016.17.3.405

Factors Affecting Radiation Exposure during Lumbar Epidural Steroid Injection: A Prospective Study in 759 Patients  

Kim, Suyoung (Department of Radiology, Seoul National University Bundang Hospital)
Shin, Joon-Ho (Department of Rehabilitation, National Rehabilitation Center)
Lee, Joon Woo (Department of Radiology, Seoul National University Bundang Hospital)
Kang, Heung Sik (Department of Radiology, Seoul National University Bundang Hospital)
Lee, Guen Young (Department of Radiology, Seoul National University Bundang Hospital)
Ahn, Joong Mo (Department of Radiology, Seoul National University Bundang Hospital)
Publication Information
Korean Journal of Radiology / v.17, no.3, 2016 , pp. 405-412 More about this Journal
Abstract
Objective: To estimate and compare radiation exposure and intervention time during lumbar epidural steroid injection (ESI) 1) under different practitioners and methods with continuous fluoroscopic monitoring, and 2) under one practitioner with different methods and monitoring. Materials and Methods: We consecutively recruited 804 patients who underwent lumbar ESI and 759 patients who underwent 922 interventions were included for analysis in this investigation. Three different practitioners (a senior faculty member, junior faculty member, trainee) performed lumbar ESI using different methods (caudal, interlaminar, transforaminal). The senior faculty member performed lumbar ESI under two different methods of fluoroscopic monitoring (continuous [CM] and intermittent monitoring [IM]). The dose area product (DAP) fluoroscopy time, and intervention time during lumbar ESI were compared for 1) ESI methods and practitioners under CM, and 2) ESI methods and monitoring. Results: With CM, interaction between the effects of the practitioner and the intervention on DAP was significant (p < 0.001), but not fluoroscopy time (p = 0.672) or intervention time (p = 0.852). The significant main effects included the practitioner and intervention on DAP, fluoroscopy time, and intervention time with CM (p < 0.001). DAPs and fluoroscopy time for caudal, interlaminar, and transforaminal ESI were higher with CM than with IM (p < 0.001). Intervention time did not differ between CM and IM. Conclusion: Radiation exposure is dependent on the practitioners and methods and within the established safety limits during lumbar ESIs under CM. With an experienced practitioner, IM leads to less radiation exposure than CM.
Keywords
Low back pain; Epidural steroid injection; Fluoroscopy; Radiation dosage;
Citations & Related Records
연도 인용수 순위
  • Reference
1 White AH, Derby R, Wynne G. Epidural injections for the diagnosis and treatment of low-back pain. Spine (Phila Pa 1976) 1980;5:78-86   DOI
2 Bartynski WS, Grahovac SZ, Rothfus WE. Incorrect needle position during lumbar epidural steroid administration: inaccuracy of loss of air pressure resistance and requirement of fluoroscopy and epidurography during needle insertion. AJNR Am J Neuroradiol 2005;26:502-505
3 Liu SS, Melmed AP, Klos JW, Innis CA. Prospective experience with a 20-gauge Tuohy needle for lumbar epidural steroid injections: is confirmation with fluoroscopy necessary? Reg Anesth Pain Med 2001;26:143-146
4 Weil L, Frauwirth NH, Amirdelfan K, Grant D, Rosenberg JA. Fluoroscopic analysis of lumbar epidural contrast spread after lumbar interlaminar injection. Arch Phys Med Rehabil 2008;89:413-416   DOI
5 Botwin KP, Natalicchio J, Hanna A. Fluoroscopic guided lumbar interlaminar epidural injections: a prospective evaluation of epidurography contrast patterns and anatomical review of the epidural space. Pain Physician 2004;7:77-80
6 Stitz MY, Sommer HM. Accuracy of blind versus fluoroscopically guided caudal epidural injection. Spine (Phila Pa 1976) 1999;24:1371-1376   DOI
7 Trentman TL, Rosenfeld DM, Seamans DP, Hentz JG, Stanek JP. Vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections. Pain Pract 2009;9:59-64   DOI
8 Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med 2009;10:1389-1394   DOI
9 Bogduk N, Dreyfuss P, Baker R, Yin W, Landers M, Hammer M, et al. Complications of spinal diagnostic and treatment procedures. Pain Med 2008;9:S11-S34   DOI
10 Fitzgibbon DR, Posner KL, Domino KB, Caplan RA, Lee LA, Cheney FW; American Society of Anesthesiologists. Chronic pain management: American Society of Anesthesiologists Closed Claims Project. Anesthesiology 2004;100:98-105   DOI
11 Manchikanti L, Cash KA, Moss TL, Pampati V. Radiation exposure to the physician in interventional pain management. Pain Physician 2002;5:385-393
12 Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine (Phila Pa 1976) 2007;32:1754-1760   DOI
13 Aufrichtig R, Xue P, Thomas CW, Gilmore GC, Wilson DL. Perceptual comparison of pulsed and continuous fluoroscopy. Med Phys 1994;21:245-256   DOI
14 Manchikanti L, Cash KA, Moss TL, Rivera J, Pampati V. Risk of whole body radiation exposure and protective measures in fluoroscopically guided interventional techniques: a prospective evaluation. BMC Anesthesiol 2003;3:2   DOI
15 Rosenthal LS, Mahesh M, Beck TJ, Saul JP, Miller JM, Kay N, et al. Predictors of fluoroscopy time and estimated radiation exposure during radiofrequency catheter ablation procedures. Am J Cardiol 1998;82:451-458   DOI
16 Mahesh M. Fluoroscopy: patient radiation exposure issues. Radiographics 2001;21:1033-1045   DOI
17 Pfirrmann CW, Oberholzer PA, Zanetti M, Boos N, Trudell DJ, Resnick D, et al. Selective nerve root blocks for the treatment of sciatica: evaluation of injection site and effectiveness--a study with patients and cadavers. Radiology 2001;221:704-711   DOI
18 Lee JW, Kim SH. Epidural steroid injection. Neurointervention 2008;3:20-27
19 The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP 2007;37:1-332
20 1990 Recommendations of the International Commission on Radiological Protection. Ann ICRP 1991;21:1-201   DOI
21 Reitman CA, Watters W 3rd. Subdural hematoma after cervical epidural steroid injection. Spine (Phila Pa 1976) 2002;27:E174-E176   DOI
22 Shope TB. Radiation-induced skin injuries from fluoroscopy. Radiographics 1996;16:1195-1199   DOI
23 Turner JE. Atoms, radiation, and radiation protection. Weinheim: Wiley-VCH, 2007
24 Parr AT, Diwan S, Abdi S. Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician 2009;12:163-188
25 Rozin L, Rozin R, Koehler SA, Shakir A, Ladham S, Barmada M, et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol 2003;24:351-355   DOI
26 Goodman BS, Posecion LW, Mallempati S, Bayazitoglu M. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008;1:212-222   DOI
27 Karambatsakidou A, Tornvall P, Saleh N, Chouliaras T, Lofberg PO, Fransson A. Skin dose alarm levels in cardiac angiography procedures: is a single DAP value sufficient? Br J Radiol 2005;78:803-809   DOI
28 Bogaert E, Bacher K, Thierens H. A large-scale multicentre study in Belgium of dose area product values and effective doses in interventional cardiology using contemporary X-ray equipment. Radiat Prot Dosimetry 2008;128:312-323
29 Wagner LK, Eifel PJ, Geise RA. Potential biological effects following high X-ray dose interventional procedures. J Vasc Interv Radiol 1994;5:71-84   DOI
30 Shim DM, Kim YM, Oh SK, Lim CM, Kown BT. Radiation induced hand necrosis of an orthopaedic surgeon who had treated a patient with fluoroscopy-guided spine injection. J Korean Orthop Assoc 2014;49:250-254   DOI
31 Botwin KP, Freeman ED, Gruber RD, Torres-Rames FM, Bouchtas CG, Sanelli JT, et al. Radiation exposure to the physician performing fluoroscopically guided caudal epidural steroid injections. Pain Physician 2001;4:343-348
32 Manchikanti L, Cash KA, Moss TL, Pampati V. Effectiveness of protective measures in reducing risk of radiation exposure in interventional pain management: a prospective evaluation. Pain Physician 2003;6:301-305
33 Botwin KP, Thomas S, Gruber RD, Torres FM, Bouchlas CC, Rittenberg JJ, et al. Radiation exposure of the spinal interventionalist performing fluoroscopically guided lumbar transforaminal epidural steroid injections. Arch Phys Med Rehabil 2002;83:697-701   DOI