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Fluoroscopy Radiation Safety for Spine interventional Pain Procedures in University Teaching Hospitals

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Fluoroscopic guidance is frequently utilized in performing various types of interventional techniques. The major purpose of fluoroscopy is accurate needle placement to ensure target specificity and accurate delivery of the injected drug. However, radiation exposure may be associated with risks to physician, patient, and personnel. Multiple studies have evaluated the risk of radiation exposure and techniques to reduce the risk in private practice settings. However, the literature is scant in evaluating the risk of radiation exposure in teaching hospitals in university settings. To evaluate safety and duration of radiation exposure for fluoroscopy guided interventional pain procedures in university pain clinics. Retrospective, case study. The data was reviewed from the fluoroscopy machines from March 2004 to April 2004 at two university pain clinics. Mean fluoroscopy time (FT), mean radiation dose per procedure, and utilization of pulsed fluoroscopy were analyzed. Data of a total of 165 cases of spine injection procedures were collected. The mean fluoroscopy time for lumbar epidural steroid injection, facet joint block, sympathetic nerve block, sacroiliac joint injection, and discography were 46.6 +/- 4.2; 81.5 +/- 12.8; 64.4 +/- 11; 50.6 +/- 41.9 and 146.8 + 25.1 seconds respectively. There were significant differences in fluoroscopy exposure times and radiation dosage for epidural steroid injection among different teaching physicians. Pulsed fluoroscopy was used in less than 10% of cases. The results of this study show that the fluoroscopy exposure time for various interventional procedures performed in the university settings are significantly higher than the radiation exposure periods in private practice settings. This study also showed significant differences among physicians in the same university setting.
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Pain Physician Vol. 8, No. 1, 2005
Pain Physician
Pain Physician
. 2005;8:49-53, ISSN 1533-3159
. 2005;8:49-53, ISSN 1533-3159
An Original Contribution
Fluoroscopy Radiation Safety for Spine interventional Pain
Procedures in University Teaching Hospitals
YiLi Zhou MD, PhD, Natasha Singh, MD, PhD, Salahadin Abdi, MD, PhD, JiuHua Wu, MD, Jennifer Crawford, RN,
and Fred A. Furgang, MD
A
ventional pain procedures are performed
annually in the United States, with at least
50% of them being performed under flu-
oroscopy (1-10). The major purpose of
fluoroscopy is to ensure correct needle
placement for accurate delivery of injec-
tate and solutions to increase clinical ef-
ficacy, decrease possible side effects, and
enhance patient safety. However, fluo-
roscopy does result in radiation expo-
sure with risks posed to patients, physi-
cians, and other personnel. It has been re-
ported that physicians performing the ra-
diographic or fluoroscopic procedures in
the first half of the 20
th
century had high-
er rates of cancer-related deaths than any
Background
: Fluoroscopic guidance
is frequently utilized in performing various
types of interventional techniques. The ma-
jor purpose of uoroscopy is accurate nee-
dle placement to ensure target speci city
and accurate delivery of the injected drug.
However, radiation exposure may be associ-
ated with risks to physician, patient, and per-
sonnel. Multiple studies have evaluated the
risk of radiation exposure and techniques to
reduce the risk in private practice settings.
However, the literature is scant in evaluat-
ing the risk of radiation exposure in teaching
hospitals in university settings.
Objective:
To evaluate safety and du-
ration of radiation exposure for uoroscopy
guided interventional pain procedures in uni-
versity pain clinics.
Study Design
: Retrospective, case
study.
Methods:
The data was reviewed from
the uoroscopy machines from March 2004
to April 2004 at two university pain clinics.
Mean uoroscopy time (FT), mean radiation
dose per procedure, and utilization of pulsed
uoroscopy were analyzed.
Results:
Data of a total of 165 cases of
spine injection procedures were collected.
The mean uoroscopy time for lumbar epidu-
ral steroid injection, facet joint block, sympa-
thetic nerve block, sacroiliac joint injection,
and discography were 46.6
+
4.2; 81.5
+
12.8;
64.4
+
11; 50.6
+
41.9 and 146.8+ 25.1 seconds
respectively.
There were signi cant differences in
uoroscopy exposure times and radiation
dosage for epidural steroid injection among
different teaching physicians. Pulsed uo-
roscopy was used in less than 10% of cases.
Conclusion
: The results of this study
show that the uoroscopy exposure time for
various interventional procedures performed
in the university settings are signi cantly
higher than the radiation exposure periods
in private practice settings. This study also
showed signi cant differences among physi-
cians in the same university setting.
Keywords
: uoroscopy, radiation safe-
ty, epidural steroid injection, facet joint
block, sympathetic nerve block, sacroiliac
joint injection, discography
From Jackson Memorial Hospital Pain Clinic, Univer-
sity Of Miami School of Medicine, Miami, Florida.
Address Correspondence: YiLi Zhou, MD, PhD, 1611
NW 12
th
Avenue, Miami, FL 33136
Disclaimer:
There was no external funding in prepa-
ration of this manuscript.
Con ict of Interest: None
Acknowledgement:
Manuscript received on 10/10/2004
Revision submitted on 12/15/2004
Accepted for publication on 12/20/2004
other physicians (2). Injuries to skin, mus-
cle, and eye lens due to the radiation from
fluoroscopic procedures have been widely
documented (11-18).
There are two major biological ef-
fects of radiation exposure: stochastic
and non-stochastic. A stochastic effect
is one in which the probability of the ef-
fect, rather than its severity, increases with
the dose of radiation. Cancer and genetic
changes due to radiation exposure are ex-
amples of the stochastic effect. Non-sto-
chastic, or deterministic, effect is the one
in which the probability of causing a cer-
tain type of harm will be zero at small
radiation doses. Above some threshold,
damage will become apparent. Cataracts,
erythema, epilation and even death are
examples of nonstochastic effects. If a pa-
tient is exposed to medical radiation once
or a few times in a low dose, nonstochastic
effects will not be apparent. Intervention-
al pain physicians and other OR person-
nel are chronically exposed to low dose ra-
diation. The stochastic effect of radiation
could impose a major threat to this group
of people due to the cumulative effect.
Botwin et al (8-10) and Manchikanti
et al (4-6) have prospectively evaluated
the radiation exposure to physicians per-
forming fluoroscopy guided intervention-
al procedures in private practice. These
studies found low radiation exposure
leading the authors to conclude that inter-
ventional procedures could be performed
safely under optimal conditions with ap-
propriate safety precautions.
Manchikanti et al (4-6) evaluated a
large number of patients in a private prac-
tice setting. In the first study (6), evalu-
ating 1,000 consecutive patients undergo-
ing interventional procedures with chron-
ic pain by a single physician, they showed
a per procedure radiation exposure of 7.7
+
0.21 seconds with a range of 1 to 69 sec-
onds, whereas, it was per patient 13.2
+
0.33 with a range of 1 to 97 seconds. They
reported radiation exposure for cervical
facet joint nerve blocks as 5.9
+
0.07 sec-
onds, for lumbar facet joint nerve blocks
as 5.7
+
0.09 seconds, whereas for caudal/
interlaminar epidurals, they reported it as
3.75
+
0.13 seconds. In a second study by
the same authors (4), they evaluated 1,156
patients undergoing 1,819 procedures,
however, they divided the physicians into
50
Pain Physician Vol. 8, No. 1, 2005
Zhou et al
Radiation Safety in University Pain Clinics
three groups based on their experience. In
this study, they showed that radiation ex-
posure with the most experienced physi-
cian was 7.5
+
0.27 seconds per procedure,
with 9.0
+
0.37 seconds for the physician
with mid level experience and 12.0
+
0.49
for the least experienced physician. For
the experienced physicians, the radiation
exposure was similar to the first study and
it was somewhat higher for the other phy-
sicians. In the third study (5), 500 consec-
utive patients were evaluated with mea-
sures to reduce radiation exposure. This
study showed further reduction of radia-
tion exposure with 8.9
+
0.4 seconds per
patient, whereas, it was 4.9 + 0.11 seconds
per procedure. In this study, the radiation
exposure for facet joint nerve blocks re-
duced to 4.5
+
0.07 seconds, and for cau-
dal or interlaminar epidurals, it was 2.7
+
0.27 seconds. For transforaminal epidur-
als in their studies (4-6), radiation expo-
sure ranged from 4.9
+
0.11 seconds to
13.2
+
0.33 seconds to 7.7
+
0.21 per pro-
cedure. They also demonstrated that by
utilizing enhanced protective measures,
radiation exposure was significantly re-
duced.
Botwin et al (8-10) also evaluated ra-
diation exposure to a physician perform-
ing fluoroscopically guided caudal epi-
dural steroid injections, lumbar transfo-
raminal epidural steroid injections, and
lumbar discography. The results showed
that total fluoroscopy time was 15.16 sec-
onds on average for transforaminal epi-
dural steroid injections (8), 12.55 sec-
onds for caudal epidural steroid injec-
tions (10), and 57.24 seconds for lumbar
discography. The differences between the
two groups of reports appear to be that
Manchikanti et al (4-6) used pulsed mode
in all the studies, whereas Botwin et al
used regular mode without pulse. Paul-
son et al (7) also reported radiation doses
to radiologists with CT fluoroscopy-guid-
ed interventional procedures, showing
that fluoroscopic time varied from 11 sec-
onds on average for sacroiliac joint injec-
tion, 18.4 seconds for cervical injections,
and 17.6 seconds for lumbar injections.
Consequently, all three groups of studies
have shown significantly less radiation ex-
posure than unpublished results in a uni-
versity setting.
Literature is scant regarding the issue
of radiation exposure during pain man-
agement procedures in university teach-
ing hospitals, even though some teach-
ing hospitals have an existing program for
fluoroscopic credentialing and safety (19).
Unlike private practices, the physicians in
the teaching hospitals allow training resi-
dents and fellows to perform procedures
under close supervision. This requires
longer fluoroscopy times, which in turn
increases the radiation exposure to the
patients and physicians performing the
procedures. To date, the literature is lim-
ited in evaluating the risk of radiation ex-
posure in teaching hospitals versus private
practice settings.
In this study, we retrospectively re-
viewed the data from fluoroscopy ma-
chines in two university pain clinics to
evaluate the mean fluoroscopy time and
total radiation exposure for various pain
management procedures. The aim of this
study is to evaluate the appropriateness
of fluoroscopy use in university teaching
hospitals for the purpose of designing a
better system for training of future inter-
ventional pain physicians.
METHODS
We reviewed the fluoroscopy ma-
chine records of a consecutive series of
165 patients who underwent spinal in-
terventional pain procedures in two uni-
versity teaching hospitals in Miami, FL.
The procedures were performed from
March 2004 to April 2004 by seven at-
tending physicians with the assistance of
a fellow or resident physician. The fluo-
roscopic time (FT), radiation dose gener-
ated by the fluoroscopic machine (mRem)
for each procedure, and the frequency of
pulsed fluoroscopy usage were analyzed.
Average fluoroscopic time is presented as
mean (
±
SE) for five common procedures
including epidural steroid injection, facet
joint block, sacroiliac joint injection, sym-
pathetic block and discography.
Statistical Analysis
Data was analyzed for various pro-
cedures and also for various physicians.
The fluoroscopic time and the mean ra-
diation dose generated by the fluoroscopy
machine were assessed by analysis of vari-
ance (ANOVA). Student t-test was used
for specific comparison between proce-
dures or physicians.
RESULTS
The data on a total of 165 consecu-
tive spinal injection procedures was col-
lected. This cohort included 99 cases of
epidural steroid injection (cervical, lum-
bar, interlaminar or transforaminal); 19
cases of facet joint blocks (including cer-
vical and lumbar medial branch block and
intra-articular injection); 10 cases of sym-
pathetic blocks (cervical and lumbar); 18
cases of sacroiliac (SI) joint injections; 8
cases of lumbar discography, and 11 oth-
er procedures including, vertebroplasty,
Gasserian Ganglion radiofrequency, and
percutaneous adhesiolysis.
Radiation exposures for ESI, facet
joint block, sympathetic nerve blocks, SI
joint injection, and lumbar discography
were 46.6
+
4.2, 81.5
+
12.8, 64.4
+
11,
50.6
+
41.9 and 146.8+ 25.1 seconds, re-
spectively (Fig 1).
Fig 1.
Mean  uoroscopic time for common pain procedures
ESI: epidural steroid injection; FB: facet joint block; SB: sympathetic nerve block;
ESI: epidural steroid injection; FB: facet joint block; SB: sympathetic nerve block;
SI: sacroiliac joint injection; DG: discography.
Zhou et al
Radiation Safety in University Pain Clinics
51
Pain Physician Vol. 8, No. 1, 2005
An Analysis of Variance found a
significant statistical difference on FT
among different teaching physicians for
ESI (F(6,92) = 6.87; p<0.0001) (Fig 2).
Among the physician group, one physi-
cian had the longest mean FT of 92
+
21
seconds for ESI. The shortest mean phy-
sician FT for ESI was 21.9
+
8.1 seconds.
The difference of mean fluoroscopic time
between the two physicians was signifi-
cant (
P
< 0.01). The mean radiation dose
P < 0.01). The mean radiation dose P
generated by fluoroscopy machine for ESI
is also significantly different among at-
tendings (F(6,92)=3.493; p=0.0037) (Fig
3) with the lowest radiation dose of 158
mRem by one attending and the highest
radiation dose of 1096.0 mRem by the
other (p=0.029).
Pulse Mode
Pulse mode was used by one of the
seven physicians in 16 of the 165 cases
(9.6%). The low dose button of the flu-
oroscopy machine was frequently turned
on during procedures. However, the fre-
quency of utility of this function cannot
be estimated because the OEC machine
does not automatically record the use of
this function. Neither the physicians nor
the patients reported any adverse reac-
tions to the radiation exposure during
this period.
DISCUSSION
This evaluation of radiation expo-
sure for spinal interventional procedures
in university teaching hospitals showed
significantly higher exposure rates com-
pared to the private practice. Our results
showed that for epidural steroid injection,
facet joint block, sympathetic nerve block,
sacroiliac joint injection, and lumbar dis-
cography, radiation exposure times were
46.6
+
4.2, 81.5
+
12.8, 64.4
+
11, 50.6
+
41.9 and 146.8
+
25.1 seconds radiation
exposure respectively. These results are
substantially different from the results re-
ported in private practices (4-10).
In the private practice setting,
Manchikanti et al (4-6), based on the ex-
perience of the physician and the protec-
tive measures undertaken, reported radi-
ation exposure of 2.7
+
0.27 seconds to
11.7
+
1.41 seconds, in contrast to our
results showing an average exposure of
46.6
+
4.2 seconds. This results in a fluo-
roscopic exposure of 4 to 17 times in uni-
versity settings. However, in our study, we
have not separated transforaminal epidu-
rals from caudal or interlaminar epidur-
als. Manchikanti et al (4-6) reported radi-
ation exposure times based on physician
experience and the protective measures
undertaken to range from 8.4
+
0.5 sec-
onds to 14.0
+
1.77 seconds. Even then,
Fig 2.
Mean  uoroscopic time for epidural steroid injection by physicians
Signi cant difference on the FT for ESI among the physicians (F(6,92)=6.87; p=0.0001)
Letter A to G represent 7 attendings unrelated to their  rst or last name.
Letter A to G represent 7 attendings unrelated to their  rst or last name.
Fig 3.
Mean radiation dose for ESI by physicians
Signi cant difference on the radiation dose for ESI among the physicians (F(6,92)=3.493; p=0.0037)
Letter A to G represent 7 attendings unrelated to their  rst or last name.
52
Pain Physician Vol. 8, No. 1, 2005
Zhou et al
Radiation Safety in University Pain Clinics
results in our study show radiation expo-
sure times three times greater than in pri-
vate practice. Similarly, Botwin et al (10)
showed the average fluoroscopic time for
caudal epidural as 12.55 seconds, again
our results showing 3 to 4 times high-
er exposure time. Botwin et al (8) also
showed for lumbar transforaminal epidu-
ral steroid injections, the average fluoro-
scopic time per procedure was 15.16 sec-
onds, again showing much higher expo-
sure rate in university settings compared
to private practice settings. For facet joint
injections, our exposure times were 81.5
+
12.8 seconds compared to 4.5
+
0.07 to
11.7
+
0.56 of Manchikanti et al (4-6) in-
dicating similar differences as interlam-
inar and caudal epidurals with private
practice compared to university setting.
Finally, for lumbar discography, radia-
tion exposure times in the present study
in university settings were 146.8 seconds
compared to the study by Botwin et al
(9) with mean fluoroscopy time for pro-
cedure of 57.24 seconds which again re-
veals that in university settings, for mean
fluoroscopy, it takes approximately two to
three times longer than in private prac-
tice settings. Manchikanti et al (4) also
showed differences among physicians
based on experience. While these differ-
ences in their study were significantly dif-
ferent, in the present study, the differenc-
es were not only significant but stagger-
ing. The results of this study show that in
university hospital settings, radiation ex-
posure is significantly higher than in pri-
vate practice settings.
Previous studies (4-10) have dem-
onstrated that fluoroscopy guided inter-
ventional pain procedures could be per-
formed under optimal conditions with
appropriate safety precautions. The year-
ly radiation exposure for the interven-
tionalists would still be within the lim-
it suggested by the National Council on
Radiation Protection and Measurement,
even when large volumes of procedures
are performed by the study physicians, as
long as FT and dose of radiation exposure
for each procedure are appropriately con-
trolled. However, because the long-term
adverse biological consequences of chron-
ic low dose radiation exposure remain un-
clear, and genetic and malignant change
is still a possibility (20, 21), the rule of
ALARA (as low as reasonably achievable)
has been advocated by the experts. The
rule of ALARA emphasizes the impor-
tance of short fluoroscopy, low radiation
dose, use of pulsed fluoroscopy and colli-
mation, increasing distance from the radi-
ation source, and appropriate utilization
of shields including aprons, leaded pro-
tective eyeglasses, thyroid shields, and X-
ray attenuating sterile surgical gloves (2).
The major reason for the differences
is the training in the university pain clin-
ics compared to the private practice set-
ting. Significant time is added due to the
training of residents and fellows in inter-
ventional techniques. However, it is un-
clear whether prolonged fluoroscopic ex-
posure in university pain practices will
lead to a more accurate needle place-
ment or better clinical result. There are
no studies evaluating this aspect. How-
ever, we believe that this may not be the
case. As shown by Manchikanti et al (4),
experience appears to be the major fac-
tor in fluoroscopic exposure time. Con-
sequently, it is possible that a prolonged
fluoroscopic exposure time, with accu-
mulation, could pose a threat to health-
care professionals in university settings.
Thus, it remains a challenge for univer-
sity pain practices to reduce the fluoro-
scopic time while maintaining the quali-
ty of education. One of the possible so-
lutions may be to prepare the trainees be-
fore they are allowed to perform a pro-
cedure in simulated situations. Further,
pre-procedure explanation, study about
the nature of the procedure and related
anatomy, review of the fluoroscopic imag-
ing and techniques for needle navigation
under fluoroscopy, routine implementa-
tion of the rules of radiation safety, as well
as practicing on cadavers may be imple-
mented as part of a training program. If
a trainee could be better prepared before
they start performing a procedure, in con-
junction with all other requirements, in-
cluding principles of ALARA, the fluoros-
copy time could conceivably be decreased.
However, confirmation of such a hypoth-
esis is required.
The results of the current study show
that the trainees are not the only factors
leading to a longer FT in the university
pain clinics. There is a significant differ-
ence for both mean FT and radiation dose
for ESI among attending physicians in the
two university pain clinics even when they
are facing the same group of residents and
fellows. The physician’s longest mean FT
for ESI was 92.0 seconds with a mean ra-
diation dose of 1096.0 mRem; the shortest
mean physician FT for ESI was 21.9 sec-
onds with a mean radiation dose of 158
mRem. This result suggests that there is
a significant difference in the pattern of
fluoroscopy usage among different teach-
ing physicians. The results of the current
study indicate the necessity of continuing
education programs regarding radiation
safety for practicing physicians.
Utilization of pulsed fluoroscopy is
another method to decrease the radia-
tion exposure. In pulsed mode, the X-ray
beam is emitted as a series of short puls-
es rather than continuously. At reduced
frame rates, pulsed fluoroscopy can pro-
vide 22% to 49% dose saving (22). Use
of the pulsed fluoroscopy could be essen-
tial in order to reduce the radiation expo-
sure, especially when prolonged fluoro-
scopic monitoring is required during the
procedures such as discography. In our
study, we found pulsed fluoroscopy was
used only by one of the seven physicians
in 16 of the 165 cases (9.6%). The results
of the current study suggest that aware-
ness of the appropriate use of pulsed fluo-
roscopy should also be emphasized.
The data of the current study is from
two university pain clinics in Miami, Flor-
ida. It is unclear whether prolonged flu-
oroscopy use is a common phenomenon
among the university pain practices. It is
worthy for university pain centers to re-
view their safety protocols for fluorosco-
py usage and reduce fluoroscopy time and
total radiation exposure for intervention-
al pain procedures while maintaining the
high quality of education.
CONCLUSION
This study evaluated radiation ex-
posure patterns in university pain cen-
ters. The results showed that there were
substantial differences among the physi-
cians, as well as procedures in radiation
exposure times compared to private prac-
tice settings. Thus, it remains a challenge
for university pain clinics to review their
radiation safety protocols, and reduce the
fluoroscopy time while maintaining the
quality of education. Further, there may
be various means to reduce radiation ex-
posure and improve quality of education
among the trainees.
Zhou et al
Radiation Safety in University Pain Clinics
53
Pain Physician Vol. 8, No. 1, 2005
YiLi Zhou, MD, PhD
Department of Anesthesiology,
Perioperative Medicine and Pain
Management
University of Miami School of
Medicine
1611 NW 12
th
Av
Miami, FL 33136
E-mail: yilizhoumd@yahoo.com
Natasha Singh, MD, PhD
Department of Anesthesiology,
Perioperative Medicine and Pain
Management
University of Miami School of
Medicine
1611 NW 12
th
Av
Miami, FL 33136
E-mail: Nsingh@med.miami.edu
Salahadin Abdi, MD, PhD.
Department of Anesthesiology
Perioperative Medicine and Pain
Management
University of Miami School of
Medicine
1611 NW 12
th
Av
Miami, FL 33136
E-mail Sabdi@med.miami.edu
JiuHua Wu, MD
Sylvester Cancer Center
University of Miami School of
Medicine
1611 NW 12
th
Av
Miami, FL 33136
E-mail: Jwu@med.miami.edu
J
ennifer Crawford, RN
Department of Anesthesiology,
Perioperative Medicine and Pain
Management
University of Miami School of
Medicine
1611 NW 12
th
Av
Miami, FL 33136
E-mail: Jcrwawford@UM-JMH.org
Fred A. Furgang, MD
Department of Anesthesiology,
Perioperative Medicine and Pain
Management
University of Miami School of
Medicine
1611 NW 12
th
Av
Miami, FL 33136
E-mail: FFurgang@med.miami.edu
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AUTHOR AFFILIATION
54
Pain Physician Vol. 8, No. 1, 2005
Zhou et al
Radiation Safety in University Pain Clinics
... It was first in 1992 that the Food and Drug Administration (FDA, USA) received some unverifiable reports linking the use of fluoroscopy to possible radiation injuries [36]. Since then, the issue of radiation exposure has been extensively addressed during different types of diagnostic procedures and surgeries, such as in lumbar discography [37][38][39][40], in vertebroplasty [39,40], in kyphoplasty [41], in minimally invasive transforaminal lumbar interbody fusion [42], and in pedicle screw insertion in the lumbar spine [43][44][45]. In pain practice, the radiation levels were explored during lumbar epidural steroid injections [38,[46][47][48][49][50][51][52], in medial branch blocks and facet joint injections [38,[50][51][52][53][54], in intercostal blocks [51], in stellate ganglion blocks [55], and in percutaneous adhesiolysis [51]. ...
... Since then, the issue of radiation exposure has been extensively addressed during different types of diagnostic procedures and surgeries, such as in lumbar discography [37][38][39][40], in vertebroplasty [39,40], in kyphoplasty [41], in minimally invasive transforaminal lumbar interbody fusion [42], and in pedicle screw insertion in the lumbar spine [43][44][45]. In pain practice, the radiation levels were explored during lumbar epidural steroid injections [38,[46][47][48][49][50][51][52], in medial branch blocks and facet joint injections [38,[50][51][52][53][54], in intercostal blocks [51], in stellate ganglion blocks [55], and in percutaneous adhesiolysis [51]. Potential biological effects following interventional procedures are manifested in the skin [36,[56][57][58], in the eyes [58][59][60], in glands (thyroid, parotid) [58], and in several other tissues (breast, lung, bone, blood) [58,[61][62][63]. ...
... Since then, the issue of radiation exposure has been extensively addressed during different types of diagnostic procedures and surgeries, such as in lumbar discography [37][38][39][40], in vertebroplasty [39,40], in kyphoplasty [41], in minimally invasive transforaminal lumbar interbody fusion [42], and in pedicle screw insertion in the lumbar spine [43][44][45]. In pain practice, the radiation levels were explored during lumbar epidural steroid injections [38,[46][47][48][49][50][51][52], in medial branch blocks and facet joint injections [38,[50][51][52][53][54], in intercostal blocks [51], in stellate ganglion blocks [55], and in percutaneous adhesiolysis [51]. Potential biological effects following interventional procedures are manifested in the skin [36,[56][57][58], in the eyes [58][59][60], in glands (thyroid, parotid) [58], and in several other tissues (breast, lung, bone, blood) [58,[61][62][63]. ...
... Higher radiation dose and longer fluoroscopy time were observed during lumbar procedures compared with cervical procedures, consistent with prior published literature (20,22,25). The mean fluoroscopy time of procedures in the present study was 50.1 seconds and 44.6 seconds (OEC 9800 cs 9900), which is marginally higher than prior estimations in a university setting (6,20,26). Wide ranges of fluoroscopy times and doses are reported in the literature, depending on setting (private vs. university) and even amongst individual providers within the same institution (12,26), suggesting a significant difference in fluoroscopy utilization patterns. Zhou et al noted average radiation doses as low as 158.0 mRem (1.58mSv) for some operators and as high as 1096.0 mRem (10.96mSv) for other operators when performing a variety of different lumbosacral pain procedures (26). ...
... The mean fluoroscopy time of procedures in the present study was 50.1 seconds and 44.6 seconds (OEC 9800 cs 9900), which is marginally higher than prior estimations in a university setting (6,20,26). Wide ranges of fluoroscopy times and doses are reported in the literature, depending on setting (private vs. university) and even amongst individual providers within the same institution (12,26), suggesting a significant difference in fluoroscopy utilization patterns. Zhou et al noted average radiation doses as low as 158.0 mRem (1.58mSv) for some operators and as high as 1096.0 mRem (10.96mSv) for other operators when performing a variety of different lumbosacral pain procedures (26). ...
... Wide ranges of fluoroscopy times and doses are reported in the literature, depending on setting (private vs. university) and even amongst individual providers within the same institution (12,26), suggesting a significant difference in fluoroscopy utilization patterns. Zhou et al noted average radiation doses as low as 158.0 mRem (1.58mSv) for some operators and as high as 1096.0 mRem (10.96mSv) for other operators when performing a variety of different lumbosacral pain procedures (26). ...
Article
Full-text available
Objectives Determine if an updated model compared to an older model of a common fluoroscope reduces radiation dose during interventional spine procedures. Methods Retrospective cohort study containing patients who underwent fluoroscopically-guided spine procedures between April 2016-December 2016. Multivariate regression analysis performed to examine the mean radiation dose during various interventional spine procedures using a GE OEC 9800 and GE OEC 9900 machine. Age, sex, BMI, spinal level, trainee presence, and fluoroscopy time was used as covariates in order to control for possible confounding variations in patient demographics and procedure characteristics before and after implementation of the new fluoroscope. Results Total of 271 injection encounters (male=43.9%, age=58.6 [13.4] years, BMI=29.0 [6.8] kg/m2) were analyzed. There was no significant difference in radiation dose per procedure between the machines (2779 [3158] mGycm2vs.2626 [3147] mGycm2, p=0.689). The mean fluoroscopy dose per procedure was significantly higher for lumbar compared to cervical injections (3778 [3736] mGycm2vs.1267 [968] mGycm2, p<0.001). These results did not change after adjusting for covariates (p>0.05). Higher BMI and longer fluoroscopy time were significantly associated with greater radiation dose (p<0.001). Conclusions Radiation dose exposure during fluoroscopically-guided interventional spine/pain procedures was not significantly different when comparing an older-and newer-generation fluoroscope; this remained true after controlling for possible confounding variables.
... We checked fluoroscopy approximately ten times in the pain clinic to confirm the proper location of the epidural catheter. The interlaminar epidural block took 46.6 ± 4.2 sec by mean to administer and radiation exposure was approximately 5 mSv per administration [6]. Therefore, her total radiation exposure was less than 25 mSv, far below the teratogenic dose. ...
... A physician should follow the principles of prescribing a low opiate dose as reasonably achievable or ALARA (as low as reasonably achievable) similar to radiation exposure guidelines to provide therapeutic effect without major side effects (390)(391)(392)(393)(394)(395)(396)(397)(398)(399)(400)(401)(402). ...
Article
Results: Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer. 1. A) Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. (Evidence: good) B) Despite limited evidence for reliability and accuracy, screening for opioid use is recommended, as it will identify opioid abusers and reduce opioid abuse. (Evidence: limited) C) Prescription monitoring programs must be implemented, as they provide data on patterns of prescription usage, reduce prescription drug abuse or doctor shopping. (Evidence: good to fair) D) Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. (Evidence: good) 2. A) Establish appropriate physical diagnosis and psychological diagnosis if available prior to initiating opioid therapy. (Evidence: good) B) Caution must be exercised in ordering various imaging and other evaluations, interpretation and communication with the patient; to avoid increased fear, activity restriction, requests for increased opioids, and maladaptive behaviors. (Evidence: good) C) Stratify patients into one of the 3 risk categories – low, medium, or high risk. D) A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy is utilized. (Evidence: fair) 3. Essential to establish medical necessity prior to initiation or maintenance of opioid therapy. (Evidence: good) 4. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: good) 5. A) Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting or moderate doses of long-acting opioids, as there is no significant difference between long-acting and short-acting opioids for their effectiveness or adverse effects. (Evidence: fair) B) The relative and absolute contraindications to opioid use in chronic non-cancer pain must be evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. (Evidence: fair to limited) 6. A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion. (Evidence: fair) 7. A) Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects. (Evidence: fair for short-term effectiveness, limited for long-term effectiveness) B) Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose, and greater than 91 mg of morphine equivalence as high dose. (Evidence: fair) C) In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided. (Evidence: good) 8. A) Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific training in the risks and uses. (Evidence: limited) B) Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to initiation, at 30 days and yearly thereafter. (Evidence: fair) 9. In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs. (Evidence: fair) 10. Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. (Evidence: good) 11. Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse effects. (Evidence: fair) Disclaimer: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.” Key words: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversion
... Several studies have concluded that higher BMI increases FT, but data on fluoroscopy duration during ERCP are limited. [16,17] In [18] showed that the overweight group demonstrated a 30% increase in the mean FT during the spinal procedure for the following reason: when performing the same kind of procedure on obesity patients, the quality of images was not good to confirm the exact position of intervention, and thus, the procedure duration was long. In the present study, we found that FT tended to be longer in the group with higher BMI. ...
Article
Full-text available
This study aimed to analyze the dose of radiation to which the physician is exposed during endoscopic retrograde cholangiopancreatography (ERCP) and to identify predictive factors of radiation exposure during the procedure. Furthermore, we evaluated the patient characteristics and procedural factors associated with prolonged fluoroscopy time (FT).A cross-sectional retrospective analysis of 780 ERCPs performed at a tertiary academic hospital over a 2-year period was conducted. The primary outcome was radiation exposure during ERCP as determined by FT; additionally, the association between variables and radiation exposure was determined. Moreover, we evaluated their correlations with age, sex, body mass index (BMI), diagnosis, duration of procedure, procedure name, and procedure complexity.According to the analysis of the 780 ERCPs performed in 2 years, the mean FT was 5.07 minutes (95% confidence interval [CI], 4.87-5.26). The mean radiation durations were as follows: cholelithiasis, 5.76 minutes (95% CI, 4.75-6.80); malignant biliary obstruction, 6.13 minutes (95% CI, 5.91-6.35); pancreatic disease, 5.28 minutes (95% CI, 4.45-6.28); and benign biliary stricture, 5.32 minutes (95% CI, 5.02-5.94). Significant differences affecting fluoroscopy duration between the 2 endoscopists were not observed in the present study. Multivariate analysis revealed that prolonged fluoroscopy duration was related to specific characteristics, including higher BMI (BMI >27.5 kg/m) (+4.1 minutes; 95% CI, 2.56-5.63), mechanical lithotripsy (+4.85 minutes; 95% CI, 0.45-9.25), needle-knife use (+4.5 minutes; 95% CI, 2.15-6.86), and malignant biliary obstruction (+2.34 minutes; 95% CI, 0.15-4.53).ERCPs are associated with significantly higher radiation exposure of patients on the specific procedure. Endoscopists should be aware of the determining factors, including patients with obesity, who underwent mechanical lithotripsy, who had malignant biliary obstruction, and who underwent a procedure using a needle knife, that affect FT during ERCP.
... The importance of radiation safety training was evident because the educated group was more likely to use protective gear [34]. The use of gear in an educational environment is particularly important because radiation exposure time has been estimated to be 2-14 times higher than that in environments where only experienced physicians perform procedures [35]. ...
Article
Full-text available
Background: The aim of this study was to evaluate radiation exposure to the eye and thyroid in pain physicians during the fluoroscopy-guided cervical epidural block (CEB). Methods: Two pain physicians (a fellow and a professor) who regularly performed C-arm fluoroscopy-guided CEBs were included. Seven dosimeters were used to measure radiation exposure, five of which were placed on the physician (forehead, inside and outside of the thyroid protector, and inside and outside of the lead apron) and two were used as controls. Patient age, sex, height, and weight were noted, as were radiation exposure time, absorbed radiation dose, and distance from the X-ray field center to the physician. Results: One hundred CEB procedures using C-arm fluoroscopy were performed on comparable patients. Only the distance from the X-ray field center to the physician was significantly different between the two physicians (fellow: 37.5 ± 2.1 cm, professor: 41.2 ± 3.6 cm, P = 0.03). The use of lead-based protection effectively decreased the absorbed radiation dose by up to 35%. Conclusions: Although there was no difference in radiation exposure between the professor and the fellow, there was a difference in the distance from the X-ray field during the CEBs. Further, radiation exposure can be minimized if proper protection (thyroid protector, leaded apron, and eyewear) is used, even if the distance between the X-ray beam and the pain physician is small. Damage from frequent, low-dose radiation exposure is not yet fully understood. Therefore, safety measures, including lead-based protection, should always be enforced.
... C-arm fluoroscopy is a method that facilitates the accurate application of facet joint blockage and enhances the treatment success rate and clinical effect (11). However, there is the disadvantage that both the patient and practitioner are exposed to radiation, which has been well documented in the literature to enhance the risk of cancer and damage to the skin, muscles and the eye lens (12). The main advantage of ultrasonography over C-arm fluoroscopy is that it does not involve radiation. ...
Article
Full-text available
Background: Facet joint blockage is a type of regional anesthesia which is performed selectively on the medial branch of the ramus dorsalis of the spinal nerve and is a current approach for the treatment of pain originating from facet arthropathy. This current approach to chronic low back pain caused by facet joint pathology is usually performed with ultrasound guidance. Objectives: The accuracy of anatomical placement of the facet joint with ultrasonography guidance is determined by C-arm fluoroscopy image taken as reference. Patients and Methods: A total of 22 patients who were diagnosed with facet joint syndrome were involved in the study. After detecting the superolateral corner of the facet joint, which is the target point with ultrasound, the control was provided with C-arm fluoroscopy by giving radiopaque fluid. In order to verify the localization, a mixture of 40 mg triamcinolone and 1 cc 2% lidocaine was injected. Results: Nerve blockage was applied to 67 facet joints at L3 - L4, L4 - L5 and L5 - S1 level in a total of 22 patients (15 female and seven male) diagnosed with facet joint syndrome. The patients’ mean age was 63 (range, 48 - 80), the mean body mass index was 28.4 (range, 18.9 - 38.1) and the mean time to determine facet localization with ultrasonography (USG) was 240 seconds (range, 140 - 320). Patients’ mean visual analog scale (VAS) decreased from 7 (range, 6 - 9) to 2.5 (range, 1 - 6). In the C-arm fluoroscopy control after the injection of radio-opaque material, the needle was found to be located in the lamina in four segments and it was relocated. In addition to this, two facet joints were not localized in ultrasound. This study concluded that the location of the facet joint with USG guidance is possible with 91% sensitivity and 100% positive predictive value when C-arm fluoroscopy was regarded as a gold standard in determining facet joint localization. No complications were observed. Conclusion: The results showed that ultrasonography guided facet joint block can be considered as a minimally invasive procedure that could be easily applied without radiation exposure.
Article
The purpose of the study – to present an analysis of clinical trials to study the clinical efficacy and safety of the technique of percutaneous laser decompression of intervertebral discs based on a review of Russian and foreign studies. The review article presents modern literature data covering the issues of indications, contraindications, technique, efficacy and safety of percutaneous laser disc decompression in patients with degenerative disease of the lumbar intervertebral discs. The publication present modern data on the choice of the most rational tactics for surgical treatment of patients with this pathology. Relevant, unresolved issues are indicated, which dictates the need for large randomized placebo-controlled clinical trials, with the inclusion of the latter’s results in systematic reviews and meta-analyzes.
Article
Purpose Understanding all factors that may impact radiation dose and procedural time is crucial to safe and efficient image-guided interventions, such as fluoroscopically guided sacroiliac (SI) joint injections. The purpose of this study was to evaluate the effect of flow pattern (intra- vs. periarticular), patient age, and body mass index (BMI) on radiation dose and fluoroscopy time. Methods A total of 134 SI joint injections were reviewed. Injectate flow pattern, age, and BMI were analyzed in respect to fluoroscopy time (minutes), radiation dose (kerma area product (KAP); µGy m ² ), and estimated skin dose (mGy). Results BMI did not affect fluoroscopy time, but increased BMI resulted in significantly higher skin and fluoroscopy doses ( p < 0.001). There was no association between fluoroscopy time and flow pattern. Higher skin dose was associated with intraarticular flow ( p = 0.0086), and higher KAP was associated with periarticular flow ( p = 0.0128). However, the odds ratios were close to 1. There was no significant difference between fluoroscopy time or dose based on patient age. Conclusion Increased BMI had the largest impact on procedural radiation dose and skin dose. Flow pattern also showed a statistically significant association with radiation dose and skin dose, but the clinical difference was small. Proceduralists should be aware that BMI has the greatest impact on fluoroscopy dose and skin dose during SI joint injections compared to other factors.
Article
Objective Lumbar radicular Syndrome (LRS) is a common spinal pathology and is attributed to complex interplay of mechanical, inflammatory and immunological processes. Epidural injection of steroids has a significant therapeutic role in mitigating the inflammatory component of LRS. Trans-foraminal approach under image guidance enables a targeted drug delivery. The current narrative review discusses the various aspects related to lumbar trans-foraminal epidural injection of steroid (LTFIS). Methods An elaborate search on PubMed, Google and Medline databases was made using keywords “lumbar selective nerve root block”, “lumbar trans-foraminal epidural steroid injection”, “selective nerve root block in lumbar disc prolapse”, “trans-foraminal epidural steroid injection in lumbar prolapse”, “selective nerve root block in lumbar radiculopathy”, and “trans-foraminal epidural steroid injection in lumbar radiculopathy” The articles were selected based on specific inclusion criteria. Results Our search identified 539 articles. All articles discussing alternate procedures, LTFIS in other pathologies, diagnostic roles of LTFIS, not pertaining to concerned questions, in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials or level 1 studies were given preference. Overall, 108 articles were included. Being a focussed narrative review, further screening [Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) or Methodological Index for non-randomized studies (MINORS) criteria] was not performed to select articles. Based on the evidence, LTFIS is an effective and useful treatment modality. It is offered to patients with lumbar disc herniation (LDH) presenting with persistent, unilateral, radiculopathy after a course of conservative measures for around 6 weeks’ duration. It has been reported to yield better results than caudal or inter-laminar epidural injections. The anti-inflammatory and nociceptive signal stabilization actions of steroids, as well as mechanical effects of washout of inflammatory mediators and neural lysis contribute to its efficacy. The three different approaches include sub-pedicular, retro-neural and retro-discal. The procedure is performed under image guidance using a water-soluble contrast under fluoroscopy. The four described radiculogram patterns include “arm”, “arrow”, “linear” and “splash”. Computerised tomography, ultrasonography and magnetic resonance imaging are other modalities, which may be helpful in performing LTFIS. The use of particulate versus non-particulate steroids is controversial. Conclusion The overall success rate of SNRB is reported to be 76–88%. The majority of benefits are observed during immediate and early post-injection period. Clinical factors including duration and severity of symptoms, and radiological factors like presence of osteophytes, location, size and type of disc prolapse influence outcomes. The radiculogram “splash” pattern is associated with poor outcomes.
Article
Full-text available
Cardiac angiography produces one of the highest radiation exposures of any commonly used diagnostic x ray procedure. Recently, serious radiation induced skin injuries have been reported after repeated therapeutic interventional procedures using prolonged fluoroscopic imaging. Two male patients, aged 62 and 71 years, in whom chronic radiodermatitis developed one to two years after two consecutive cardiac catheterisation procedures are reported. Both patients had undergone lengthy procedures using prolonged fluoroscopic guidance in a limited number of projections. The resulting skin lesions were preceded, in one case, by an acute erythema and took the form of a delayed pigmented telangiectatic, indurated, or ulcerated plaque in the upper back or below the axilla whose site corresponded to the location of the x ray tube during cardiac catheterisation. Cutaneous side effects of radiation exposure result from direct damage to the irradiated tissue and have known thresholds. The diagnosis of radiation induced skin injury relies essentially on clinical and histopathological findings, location of skin lesions, and careful medical history. Interventional cardiologists should be aware of this complication, because chronic radiodermatitis may result in painful and resistant ulceration and eventually in squamous cell carcinoma.
Article
Teaching patients how to care for irradiated skin during and after a course of radiation therapy is a major concern of oncology nurses. Part I of this two-part article (ONF 19(5):801-807) focused on the mechanisms of skin injury. Many topical preparations are available for skin care. When these substances are applied, both the active ingredient and the vehicle must be appropriate for the condition being treated. Preparations may be applied to the skin as liquids (e.g., lotions, solutions, tinctures used in wet dressings, soaks, baths) or solids (e.g., powders, creams, ointments). As skin reaction progresses during a course of radiation therapy, recommendations for skin care will change. Healing of injury occurs in three stages: inflammation, proliferation, and maturation. Wound healing proceeds more rapidly in a moist environment, and a variety of occlusive dressings can be used with moist desquamation.
Article
Some interventional procedures can result in very high x-ray doses. Potential biological effects of high x-ray doses are reviewed. Deterministic and stochastic effects in skin, bone, parotid glands, and lung are discussed. Threshold doses for the effects and relevant dosimetric principles are addressed. General principles for minimizing the potential for these effects are presented. Knowledge about these effects and the means to minimize radiation dose can assist the physician in the care of patients undergoing lengthy invasive radiologic procedures.
Article
A 58-year-old man underwent percutaneous transluminal coronary angioplasties in June 1992 and May 1993. Approximately 3 weeks after the last procedure, a cutaneous lesion developed into an ulcer over the right scapular region. The ulcer failed to heal with conservative treatment; therefore, surgical excision was performed. The localization and the course of the development indicated injury caused by radiation, and this was confirmed by the histologic examination. To avoid such injury in interventional procedures with long fluoroscopic time, several precautions should be taken. These include continuous surveillance of the X-ray dosage, the use of different projections to avoid exposure to one skin area throughout the whole procedure, keeping the irradiated area as small as possible, and good planning of the procedure.
Article
Since 1992, the U.S. Food and Drug Administration (FDA) has received reports of radiation-induced injuries to the skin in patients who had undergone fluoroscopically guided interventional procedures. The reports were investigated to determine the procedure- or equipment-related factors that may have contributed to the injury. The injuries ranged in severity from erythema to moist desquamation to tissue necrosis that required skin grafting. They occurred after a variety of interventional procedures that required extended periods of fluoroscopy compared with those of typical diagnostic procedures. Medical facilities and physicians should be aware of the magnitude of radiation doses to the skin that can result from the long exposure times required by complex interventional procedures. The FDA recommends several steps for reducing these injuries, including establishing protocols for each procedure, determining radiation dose rates for specific fluoroscopy systems and operating modes, and monitoring cumulative absorbed doses to areas of the skin.
Article
Transjugular intrahepatic portosystemic shunt (TIPS) is a recently introduced angiographic technique for achieving portal decompression. New invasive radiographic procedures such as TIPS can result in radiation exposure equal to that received by patients during radiation therapy. With these high doses of radiation, patients are at increased risk for radiodermatitis and long-term sequelae, such as scarring and carcinoma. Ours is the first reported case of radiodermatitis after TIPS.
Article
Several cases of ophthalmologically confirmed lens injuries, caused by occupational radiation exposure, have occurred in two X-ray rooms devoted to vascular and visceral interventional radiology procedures. Both laboratories were equipped with overcouch X-ray systems not designed for interventional radiology and without specific tools for radiation protection of the eyes. Typical workloads ranged from between two and five procedures per day. For the two radiologists affected, estimates for the dose to eye lens ranged from 450 to 900 mSv per year, over several years. Once the incidents had been detected, the X-ray systems in both rooms were removed and new equipment specifically designed for interventional radiology was installed, including suspended shielding screens. Since these lens injuries were only detected accidentally, measures to avoid similar occurrences in the future are discussed.
Article
To determine the radiation dose to radiologists who perform computed tomographic (CT) fluoroscopic interventional procedures by using a quick-check method and a low-milliampere technique. Two hundred twenty CT fluoroscopy--guided interventional procedures were performed in 189 patients. Procedures included 57 spinal injections, 17 spinal biopsies, 24 chest biopsies, 20 abdominal aspirations, 44 abdominal biopsies, and 58 abdominal drainages. Procedure details were prospectively recorded and included site, depth, target diameter, milliampere value, kilovolt peak, fluoroscopic time, and CT technique (continuous CT fluoroscopy, quick-check method, or a combination of these techniques). An individual collar and finger radiation detector were worn by each radiologist during each procedure to determine the dose per procedure. The quick-check technique was performed in 191 (87%) of 220 procedures. Four procedures were performed with continuous CT fluoroscopy, and a combination technique was used for 25 (11%) procedures. The overall mean CT fluoroscopic time was 17.9 seconds (range, 1.2--101.5 seconds). The mean milliampere value was 13.2 mA (range, 10--50 mA). The overall mean radiologist radiation dose per procedure was 2.5 mrem (0.025 mSv) (whole body). Individual procedure doses ranged from 0.66 to 4.75 mrem (0.007--0.048 mSv). The finger radiation dose was negligible. By using a low-milliampere technique and the quick-check method, CT fluoroscopic time and radiation exposure can be minimized.