Surgeon, Staff, and Patient Radiation Exposure in MIS TLIF: Impact of 3D CT-Based Navigation in Comparison to Conventional Fluoroscopy Aided Technique.

Presented at SMISS Annual Forum 2018
By Arvind Kulkarni MS(ORTH) Dip(ORTH) FCPS Dip(SICOT)
With Sang-Ha Shin , Sang-Ho Lee , Han-Joong Keum Wooridul Spine Hospital, Seoul, Republic of Korea ,

Disclosures: Arvind Kulkarni MS(ORTH) Dip(ORTH) FCPS Dip(SICOT) None Sang-Ha Shin B; Joimax GmbH., Sang-Ho Lee B; Joimax GmbH. , Han-Joong Keum Wooridul Spine Hospital, Seoul, Republic of Korea B; Joimax.,


MIS-TLIF is increasingly used but has been found to generate increased radiation exposure. 3D C-arm devices are capable of providing 3D image sets for intraoperative navigation.


This study was designed to compare the radiation exposure between 2D & 3D intraoperative imaging techniques in MIS TLIF and discuss the wide utility of intraoperative 3D navigation in minimal invasive spine surgery techniques.


263 patients that underwent single level MIS-TLIF (2011-18) were allocated to one of two groups with respect to the applied intra-operative imaging technique: conventional fluoroscopy (Fluoro group) and 3D Cone-beam CT based navigation (3D NAV group). 232 patients were in Fluoro group and 33 in the 3D NAV group. Radiation exposure was measured from the time of positioning of the patient to the end of the procedure both for navigated and non-navigated freehand instrumentations; end-point being radiation exposure to surgeon-staff measured by numerical exposure readings (seconds) directly from the Arcadis-Orbic 3D/ 2D c-arm.


The accumulated radiation exposure for the surgeon was significantly higher in the non-navigated group, average 2.18 times (p<0.001). The radiation exposure to the patient was higher with the 3D NAV technique 109.66 sec versus 57.57 sec (Fluoro) reaching a statistically significant level. Surgeon-Staff received only 24% of the total radiation generated in the OR. Use of 3D NAV resulted in 54.27% reduction in exposure to the surgeon-staff compared to the Fluoro group. Learning curve is attained by the 22nd case with decrease in surgical time and dependence upon C-arm imaging during various stages of MIS TLIF. Variation in radiation exposure is seen with different etiologies and implant systems in use.


Intraoperative 3D-CT navigation for MIS-TLIF is technically feasible and reliable with reasonable set up time. It helps the surgeon-staff to escape the harmful radiation to a significant level with added advantage of increased accuracy aided-by multi-planar reconstruction. Total navigation can be implemented with ease utilizing integrated templates of manufacturer specific implants &burr. 3D Navigation also helps in minimizing adjacent level degeneration by avoiding proximal facet violation and extended applications like tumor resection and motion preservation by selective decompressions.