脊柱微创手术的辐射危害及其防护进展

医学影像学是现代医学最重要的诊断工具之一,术中X线透视检查因可实时获得患者的骨骼结构信息和可移动便利性而被广泛使用于脊柱手术中[1]。脊柱微创手术近年来因其创伤小、出血少、创口美观、感染几率小、术后恢复快、疗效相当而得到迅速的发展并在全世界各地得到广泛推广[2～4],现已明确可应用于脊柱退行性疾病[5]、脊柱畸形[6]、外伤[7]和肿瘤[8]等。然而,由于脊柱微创手术经常需要在X射线透视下进行定位和复位检查,所以脊柱外科医生的辐射危害是临床上不容忽视的问题[9]。高剂量辐射可以诱发肿瘤、白内障、心血管疾病等,低剂量辐射暴露与肿瘤、白内障、心血管疾病等联系也是当下研究的热点[10～13]。增强对辐射危害的基本认识,提高辐射的防范意识,掌握减少辐射暴露的原则与方法是每一位脊柱外科医生的职业健康的必修课[3、14]。笔者就脊柱微创手术的辐射危害及其防护进展综述如下。     

介入诊疗工作人员的综合防护评价

目的评价综合防护方法在介入诊疗中对工作人员的防护效果及其应用价值。方法在174例介入诊疗中分别采用床下铅橡胶帘,床边悬挂可活动式铅玻璃防护屏,医用铅防护服,铅防护围脖,铅防护眼镜及距离等对工作人员进行X射线辐射综合防护,利用RAD-60S个人报警剂量仪监测防护前后的X射线辐射剂量,并进行统计学分析。结果综合防护方法可明显减少X射线辐射剂量,有显著性防护意义。结论综合防护方法在介入诊疗中可有效减少X射线辐射剂量,保护工作人员的身体健康。     

手外科手术中应用OEC Elite MiniView C型臂X线机应注意的射线防护问题

目的 探讨手外科手术中应用C型臂X线机时应注意的射线防护问题.方法 分析OEC EliteMiniView C型臂X线机投入使用前期及使用过程中射线防护及管理状况,对手外科医生给予日常防护相关问题的指导.结果 通过合理进行射线防护及管理,使参与手术人员及患者得到有效的防护.结论 C型臂X线机在手外科手术中使用频次高,合...     

磁力导航结合CT三维成像系统在胸腰椎经皮椎弓根螺钉置入术中的临床应用

正传统的体表定位穿刺结合术中透视经皮置入椎弓根螺钉技术是脊柱外科基础操作技术之一,操作者需具备一定的解剖学知识储备及开放手术经验基础。便捷、有效但存在较为陡峭的学习曲线是它的技术特征。术中需要不断的透视以取得合理的进针点,避免穿入椎管或椎间孔造成神经损伤的风险,术者需接受超额的射线暴露,或需佩戴沉重的防护装备。同时,该术式对于透视技师的要求极高,需根据每位患者的生理曲度和椎体旋转情况个性化调整合适的透视机位,十分繁琐。同时,我国基层医院大型相关辅助手术定位设备及辐射暴露保护装置均尚未得到普遍     

医用射线防护毯用于腹部介入治疗

<正>介入治疗技术近年发展迅速^[1],应用范围不断拓展,但操作过程中医患所受辐射剂量远大于普通X线检查^[2],放射安全相关问题逐渐增多[3]。如何降低辐射剂量对于保障医患身体健康具有重要意义。目前通过增加防护设备减少术中环境辐射剂量的研究较少,且缺乏临床数据支持。本研究在介入治疗过程中将新型医用射线防护毯(以下简称“防护毯”)直接覆盖于患者体表射线主要照射部位,观察其减少环境辐射剂量的效果及对成像质量的影响。     

机器人辅助脊柱手术的应用现状与发展前景

传统脊柱外科手术常面临手术视野差、风险高等问题, 机器人辅助脊柱手术发展迅速, 特别是在螺钉置入方面, 可通过提供三维成像和精确定位来优化手术流程、提高手术精准性、缩短手术时间、减少辐射暴露并改善患者预后。机器人辅助系统还具有较强的影像识别和分析能力, 减少操作的不稳定性, 减轻术者疲劳感, 并允许远程操作。尽管机器人辅助脊柱手术在螺钉置入准确性和降低辐射暴露方面显示出优势, 但其对手术时间的影响则仍有争议, 且高成本也是推广中的一大障碍。长远来看, 机器人辅助脊柱手术需要更广泛的临床验证, 以及对长期效果的观察。技术方面, 未来发展重点包括手术导航与成像技术改善、人工智能集成、远程手术能力提升、机器人功能拓展, 以及伴随着技术发展的政策引导和临床指南的建立。随着技术的进步和逐渐普及, 机器人辅助系统有望在脊柱手术领域扮演更为重要的角色。     

脊柱手术的安全防护

近年来我国骨科脊柱手术的开展越来越普及，与先进国家的差距进一步缩小，特别是在脊柱内固定手术方面，传统的脊柱内固定术不断地改进和发展，各种新型的脊柱内固定器械系统不断涌现并逐渐应用于临床，使得日益复杂的脊柱疾病的治疗手段不断增加。如：SOCON内固定装置、Compact及USS技术和RF技术等。随着这些技术的持续发展，也对手术室护士的专业配合工作提出了更高的要求。现就脊柱手术配合中安全防护的体会介绍如下：     

机器人辅助与常规徒手置入腰骶椎椎弓根螺钉精确度的前瞻性比较研究

近年来,图像引导技术在脊柱外科领域的应用日趋广泛,该技术能够提高脊柱手术中镙钉置入位置的精确度,同时在手术中有效减少患者和医生射线暴露的累积时间。但更高的置钉精确度是否能够真正增进患者的临床效益,目前尚未得到证实。     

重视脊柱内镜技术快速发展中的并发症问题

随着微创外科技术的普遍应用,脊柱外科已进入微创及个体化的阶段。脊柱内镜技术作为脊柱微创技术的重要手段,具有切口小、出血少、术后疼痛程度低、住院时间短、康复快等诸多优点,已广泛应用于脊柱相关疾病的治疗中[1-6]。手术并发症与外科技术发展如影相随,如何有效提高手术安全性和降低手术并发症是外科领域永恒的话题。随着手术设备和技术的不断改进和发展,脊柱内镜技术在国内外得到广泛推广与应用,治疗范畴也不断扩大,开展这项技术的同时,更应正确理性的看待这项技术,合理掌握其适应证,重视并发症的有效防治,有效提高手术的安全性。     

腰椎微创手术术前定位器的设计及临床应用

 脊柱微创手术的优势是切口小, 而准确的术前体表定位对于脊柱微创手术十分重要, 如果定位不准确, 就势必造成切口延长, 从而增加损伤。而既往的各种体表标志定位、金属标记定位等方法定位不够准确、需要多次透视;既增加手术时间, 又使医护人员及患者多次暴露在 X线辐射下。为使脊柱微创手术的定位更加准确, 减少医护人员的辐射, 缩短手术时间, 我们设计了专门用于腰椎微创手术术前定位的微创定位器并应用于临床, 取得较好的效果。     

Does Less Invasive Spine Surgery Result in Increased Radiation Exposure? A Systematic Review

Background

Radiation exposure to patients and spine surgeons during spine surgery is expected. The risks of radiation exposure include thyroid cancer, cataracts, and lymphoma. Although imaging techniques facilitate less invasive approaches and improve intraoperative accuracy, they may increase radiation exposure.

Questions/purposes

We performed a systematic review to determine whether (1) radiation exposure differs in open spine procedures compared with less invasive spine procedures; (2) radiation exposure differs in where the surgeon is positioned in relation to the C-arm; and (3) if radiation exposure differs using standard C-arm fluoroscopy or fluoroscopy with computer-assisted navigation.

Methods

A PubMed search was performed from January 1980 to July 2013 for English language articles relating to radiation exposure in spine surgery. Twenty-two relevant articles met inclusion criteria. Level of evidence was assigned on clinical studies. Traditional study quality evaluation of nonclinical studies was not applicable.

Results

There are important risks of radiation exposure in spine surgery to both the surgeon and patient. There is increased radiation exposure in less invasive spine procedures, but the use of protective barriers decreases radiation exposure. Where the surgeon stands in relation to the image source is important. Increasing the distance between the location of the C-arm radiation source and the surgeon, and standing contralateral from the C-arm radiation source, decreases radiation exposure. The use of advanced imaging modalities such as CT or three-dimensional computer-assisted navigation can potentially decrease radiation exposure.

Conclusions

There is increased radiation exposure during less invasive spine surgery, which affects the surgeon, patient, and operating room personnel. Being cognizant of radiation exposure risks, the spine surgeon can potentially minimize radiation risks by optimizing variables such as the use of barriers, knowledge of position, distance from the radiation source, and use of advanced image guidance navigation-assisted technology to minimize radiation exposure. Continued research is important to study the long-term risk of radiation exposure and its relationship to cancer, which remains a major concern and needs further study as the popularity of less invasive spine surgery increases.     

Effective in vivo radiation dose with image reconstruction controlled pedicle instrumentation vs. CT-based navigation

There is a rapid increase of computer-assisted surgery (CAS) in the spine for insertion of pedicle screws. In contrast to the traditional technique using fluoroscopy, CT is the primary source for surgical navigation systems. PURPOSE OF THE STUDY: To compare organ and effective doses of fluoroscopy-controlled versus computer-assisted pedicle screw insertion under the aspect of risk reduction and number needed to treat. MATERIALS AND METHODS: In 20 consecutive cases of traditional pedicle screw instrumentation under fluoroscopic control the effective doses were recorded in vivo and the organ doses then calculated. Simulating a spiral CT necessary for the 3-D-model for navigation we defined a spiral CT protocol for the instrumented levels and calculated organ and effective doses from Monte Carlo Results from CT examinations. RESULTS: Organ doses were clearly higher for the CT model than in any of the fluoroscopic procedures in vivo. The mean effective dose for the CT model was fifteen times higher than the fluoroscopic dose: 7.27 mSv versus 0.48 mSv. CONCLUSIONS: In experienced hands open pedicle screw insertion in the thoracic and lumbar spine using fluoroscopy-control requires a fifteen times lower radiation dose than do CT scans necessary for computer-assisted surgery. Regarding the published small percentage of neurological complications in traditional screw insertion technique the use of computer-assisted surgery in pedicle screw insertion using CT scan should be limited to carefully chosen indications. The development of navigation systems based on other data sources than CT should be encouraged.     

计算机辅助脊柱手术

计算机辅助手术应用于脊柱手术是近年来的一个热点。脊柱手术是一类高风险手术,精确而方便的手术方法是每一位脊柱外科医生的梦想。计算机辅助技术在脊柱手术中的应用让我们拥有了实现梦想的可能。计算机辅助技术在脊柱手术中的应用包括胸腰椎椎弓根螺钉置入和经关节螺钉固定C1,2(寰枢椎)。本文主要侧重介绍椎弓根螺钉的置入,因为内固定正成为脊柱手术中越来越重要的一部分。     

Image guidance: fluoroscopic navigation

Computer-assisted orthopaedic surgery slowly is making its way into routine orthopaedic practice. Orthopaedic trauma has long been identified as a potential impact area of this new technology. Early experience with three-dimensional (3D) image-guided surgery was promising, but this particular technique was limited by the inability to update the 3D computer model in the operating room after fracture reduction maneuvers or implant placement. Virtual fluoroscopy, or fluoroscopic navigation, became available in 1999 and has proven to be a more versatile technology for fracture treatment. Fluoroscopic navigation systems allow the surgeon to store multiple intraoperative fluoroscopic images on a computer workstation; the position of special optically-tracked surgical instruments or implants then may be virtually overlaid onto the stored images in multiple planes during implant placement. The ability to update images after fracture manipulation now has expanded the application of computer-assisted surgery to any procedures that traditionally have relied on intraoperative C-arm use. In selected applications, this technology has been shown to decrease operative time and intraoperative radiation exposure. The advantages of the new technique of fluoroscopic navigation and its current use in trauma applications will be discussed.     

Image-guided spine surgery: state of the art and future directions

Navigation technology is a widely available tool in spine surgery and has become a part of clinical routine in many centers. The issue of where and when navigation technology should be used is still an issue of debate. It is the aim of this study to give an overview on the current knowledge concerning the technical capabilities of image-guided approaches and to discuss possible future directions of research and implementation of this technique. Based on a Medline search total of 1,462 publications published until October 2008 were retrieved. The abstracts were scanned manually for relevance to the topics of navigated spine surgery in the cervical spine, the thoracic spine, the lumbar spine, as well as ventral spine surgery, radiation exposure, tumor surgery and cost-effectivity in navigated spine surgery. Papers not contributing to these subjects were deleted resulting in 276 papers that were included in the analysis. Image-guided approaches have been investigated and partially implemented into clinical routine in virtually any field of spine surgery. However, the data available is mostly limited to small clinical series, case reports or retrospective studies. Only two RCTs and one metaanalysis have been retrieved. Concerning the most popular application of image-guided approaches, pedicle screw insertion, the evidence of clinical benefit in the most critical areas, e.g. the thoracic spine, is still lacking. In many other areas of spine surgery, e.g. ventral spine surgery or tumor surgery, image-guided approaches are still in an experimental stage. The technical development of image-guided techniques has reached a high level as the accuracies that can be achieved technically meet the anatomical demands. However, there is evidence that the interaction between the surgeon (‘human factor’) and the navigation system is a source of inaccuracy. It is concluded that more effort needs to be spend to understand this interaction.     

Improving accuracy and reducing errors in spinal surgery—a new technique for thoracolumbar-level localization using computer–assisted image guidance

BACKGROUND CONTEXT: The accurate identification of the correct vertebral level during surgery remains problematic and still accounts for a significant percentage of litigation. The ideal technique for spinal-level localization would have the following characteristics: easy availability in the operating theater, lowest-possible radiation exposure for the professional team and the patient, simple technique which is easily reproducible at any time during surgery, usable with all forms of spine surgery, permanently recordable, able to be used throughout the spine, able to be easily checked by nonspecialist members of the team, and accurate. PURPOSE: We describe a new technique for thoracolumbar-level localization, based on these principles, which uses computer-assisted image guidance. STUDY DESIGN: Surgery technique development in clinical practice. METHODS: The technique uses standard image intensifier radiology with FluoroNav Spine or FluoroNav MAST software on the StealthStation computer-assisted surgery system. (Medtronic Navigation, Louisville, ed) Adjacent, contiguous, images are taken in the desired plane from the reference area of the lumbosacral junction to the general area of operative interest. These images can then be displayed simultaneously on the computer screen. Use of the probe extension feature allows counting, external to the skin and drapes, from the reference level to the level of interest at any time without additional radiation exposure. Standard navigation can then be undertaken at the operative level. RESULTS: This technique has been used in 17 cases, all of which have been undertaken in the mid- or low-thoracic and lumbar regions where the operative level is not visible on the same image intensifier image as the lumbosacral junction. All cases have undergone postoperative radiology to check the surgery level and no cases of incorrect level of surgery have occurred. No accuracy errors have developed during surgery and no complications from the reference arc have occurred. CONCLUSIONS: This technique is indicated for level localization in the spine where the operative level cannot be visualized on the same fluoroscopy field of view as the reference level. It has a relative contraindication in the upper thoracic spine, in the very obese, and in the presence of osteoporosis where fluoroscopic imaging is difficult, although we postulate a technique using preoperative computed tomography (CT) to overcome these difficulties. This technique satisfies a number of criteria for the "ideal technique" and has advantages over current methods. A number of caveats are level localization and the use of this technique are presented.     

Comparison of Radiation Exposure in Lumbar Pedicle Screw Placement With Fluoroscopy Vs Computer-Assisted Image Guidance With Intraoperative Three-Dimensional Imaging

Background/objective: Little is known about the long-term effects of chronic exposure to ionizingradiation. Studies have shown that spine surgeons may be exposed to significantly more radiation than thatobserved in surgery on the appendicular skeleton. Computer-assisted image guidance systems have beenshown in preliminary studies to enable accurate instrumentation of the spine. Computer-assisted image guidance systems may havesignificant application to the surgical management of spinal trauma and deformity. The objective of this study was to compare C-arm fluoroscopy and computer-assisted imageguidance in terms of radiation exposure to the operative surgeon when placing pedicle screw-rod constructsin cadaver specimens.

Methods: Twelve single-level (2 contiguous vertebral bodies) lumbar pedicle screw-rod constructs (48screws) in 4 fresh cadavers were placed using standard C-arm fluoroscopy and computer-assisted imageguidance (Stealth Station with lso-C^3D ).Pedicle screw-rod constructs were placed at L1-L2, L3-L4, and L5-S1 in 4 fresh cadaver specimens. Imaging was alternated between C-arm fluoroscopy and computer-assistedimage guidance with Stealth Station lso-C^3D. Radiation exposure was measured using ringand badge dosimeters to monitor the thyroid, torso, and index finger. Postprocedure CT scans were obtained to judge accuracy of screw placement.

Results: Mean radiation exposure to the torso was 4.33 ± 2.66 mRemfor procedures performed with standard fluoroscopy and 0.33 ± 0.82 mRem for procedures performed with computer-assisted image guidance. This difference was statistically significant (P = 0.012). Radiation exposure to the index finger and thyroid was negligible for all procedures. The accuracy of screw placement was similar for both techniques.

Conclusions: Computer-assisted image guidance systems allow for the safe and accurate placement ofpedicle screw-rod constructs with a significant reduction in exposure to ionizing radiation to the torso of theoperating surgeon.     

Wirbelsäulenverletzungen und Unfallfolgezustände

The aim of computer-assisted navigation procedures is to increase the anatomical orientation intraoperatively, to improve the accuracy, to minimize the invasiveness and to reduce the emission of radiation. In the field of orthopedic surgery navigation has been used for over 15 years and these techniques are particularly widely used in spinal surgery. There are three major applications of navigation: CT-based (computed tomography) navigation which needs a preoperative CT scan, 2D navigation which is based on standard X-ray images of a C-arm during surgery and 3D navigation which requires an intraoperatively performed C-arm based 3D scan. Higher accuracy has been proven for instrumentation of the lumbar and cervical spine and reduced emission of radiation could be demonstrated. Higher accuracy for pedicle screw insertions of the thoracic spine is still not proven in prospective studies with sufficient numbers of pedicle screws. Navigation systems provide additional information for better anatomical orientation in spinal surgery and can reduce intraoperative fluoroscopy time. Intraoperative 3D scan technology with automatic registration is the perfect tool in spinal surgery today. Knowledge of the classical techniques remains crucial for the safety of patients.     

Radiation exposure and reduction in the operating room: Perspectives and future directions in spine surgery

Intraoperative imaging is vital for accurate placement of instrumentation in spine surgery. However, the use of biplanar fluoroscopy and other intraoperative imaging modalities is associated with the risk of significant radiation exposure in the patient, surgeon, and surgical staff. Radiation exposure in the form of ionizing radiation can lead to cellular damage via the induction of DNA lesions and the production of reactive oxygen species. These effects often result in cell death or genomic instability, leading to various radiation-associated pathologies including an increased risk of malignancy. In attempts to reduce radiation-associated health risks, radiation safety has become an important topic in the medical field. All practitioners, regardless of practice setting, can practice radiation safety techniques including shielding and distance to reduce radiation exposure. Additionally, optimization of fluoroscopic settings and techniques can be used as an effective method of radiation dose reduction. New imaging modalities and spinal navigation systems have also been developed in an effort to replace conventional fluoroscopy and reduce radiation doses. These modalities include Isocentric Three-Dimensional C-Arms, O-Arms, and intraoperative magnetic resonance imaging. While this influx of new technology has advanced radiation safety within the field of spine surgery, more work is still required to overcome specific limitations involving increased costs and inadequate training.     

Computer-Assisted Orthopaedic Surgery and Robotic Surgery in Total Hip Arthroplasty

Various systems of computer-assisted orthopaedic surgery (CAOS) in total hip arthroplasty (THA) were reviewed. The first clinically applied system was an active robotic system (ROBODOC), which performed femoral implant cavity preparation as programmed preoperatively. Several reports on cementless THA with ROBODOC showed better stem alignment and less variance in limb-length inequality on radiographic evaluation, less incidence of pulmonary embolic events on transesophageal cardioechogram, and less stress shielding on the dual energy X-ray absorptiometry analysis than conventional manual methods. On the other hand, some studies raise issues with active systems, including a steep learning curve, muscle and nerve damage, and technical complications, such as a procedure stop due to a bone motion during cutting, requiring re-registration and registration failure. Semi-active robotic systems, such as Acrobot and Rio, were developed for ease of surgeon acceptance. The drill bit at the tip of the robotic arm is moved by a surgeon''s hand, but it does not move outside of a milling path boundary, which is defined according to three-dimensional (3D) image-based preoperative planning. However, there are still few reports on THA with these semi-active systems. Thanks to the advancements in 3D sensor technology, navigation systems were developed. Navigation is a passive system, which does not perform any actions on patients. It only provides information and guidance to the surgeon who still uses conventional tools to perform the surgery. There are three types of navigation: computed tomography (CT)-based navigation, imageless navigation, and fluoro-navigation. CT-based navigation is the most accurate, but the preoperative planning on CT images takes time that increases cost and radiation exposure. Imageless navigation does not use CT images, but its accuracy depends on the technique of landmark pointing, and it does not take into account the individual uniqueness of the anatomy. Fluoroscopic navigation is good for trauma and spine surgeries, but its benefits are limited in the hip and knee reconstruction surgeries. Several studies have shown that the cup alignment with navigation is more precise than that of the conventional mechanical instruments, and that it is useful for optimizing limb length, range of motion, and stability. Recently, patient specific templates, based on CT images, have attracted attention and some early reports on cup placement, and resurfacing showed improved accuracy of the procedures. These various CAOS systems have pros and cons. Nonetheless, CAOS is a useful tool to help surgeons perform accurately what surgeons want to do in order to better achieve their clinical objectives. Thus, it is important that the surgeon fully understands what he or she should be trying to achieve in THA for each patient.