A new protective method to reduce radiation exposure

A new protective method to reduce radiation exposure

Hisashi Koga

Iwai FESS Clinics, Tokyo, Japan

Correspondence to: Hisashi KOGA, MD, PhD. Iwai FESS Clinics, 8-17-2 Minamikoiwa Edogawa-ku, Tokyo 133-0056, Japan. Email: hkoga0808@gmail.com.

Provenance and Peer Review: This article was commissioned by the Editorial Office, Journal of Spine Surgery. The article did not undergo external peer review.

Comment on: Ishii K, Iwai H, Oka H, et al. A protective method to reduce radiation exposure to the surgeon during endoscopic lumbar spine surgery. J Spine Surg 2019;5:529-34.

Submitted Nov 26, 2019. Accepted for publication Dec 24, 2019.

doi: 10.21037/jss.2019.12.03

Radiation protection depends on three fundamental factors: exposure time, distance, and shielding. Ishii et al. described a new method for radiation shielding, called Separation between Two Spaces (STS) (1). The basic principle of STS method is a separation of the space around operative table into two spaces using a lead protector: one space contains the patient, operation table, X-ray tube and image intensifier, and the other space is the rest of the operation room. The operators and operative staffs are doing own job in the latter space.

A systematic review published by Matityahu et al. summarized the radiation exposure to surgeons during several types of surgeries (spine, hip, femur, tibia, general orthopedic, and trauma surgeries) (2). According to their review, percutaneous vertebroplasty (PVP), balloon kyphoplasty (BKP), and pedicle screw placement result in high radiation exposure. Taher et al. reported that the radiation exposure time during lateral lumbar interbody fusion (LLIF) was 88.7 s and that the exposure doses were as follows: gluteal muscle, 0.0231 mSv; axilla, 0.042 mSv; thyroid gland, 0.0219 mSv; eye 0.0264 mSv, and hand, 1.90 mSv (3). Ahn et al. reported that the radiation exposure time during percutaneous endoscopic lumbar discectomy (PELD) was 2.5 min and that the doses per operated level were as follows: neck, 0.0785 mSv; chest, 0.1718 mSv; right upper arm, 0.0461 mSv; left ring finger, 0.7318 mSv; and right ring finger, 0.6694 mSv (4). As the International Commission on Radiological Protection recommends that the annual radiation dose of radiation workers should not excess 20 mSv, I believe that the aforementioned doses are sufficiently high for a single operation. Falavigna et al. surveyed the members of AOSpine Latin America and reported that thyroid lead protection, lead glasses, and lead gloves were used by 64.2%, 20.2%, and 7% of spine surgeons, respectively (5). This indicates that shielding, which is one of the fundamental factors for radiation protection, is not considered important by spine surgeons because of its cumbersomeness. Therefore, the demand for non-cumbersome shielding is high. As the STS method can be set-up before disinfecting the patient’s skin, the surgeons are not inconvenienced during the operation. STS diminished the average radiation exposure doses to the chest and abdomen to less than 1/10 compared to the doses without STS (0.8 and 0.7 µSv, respectively, with STS, and 10.8, and 10.2 µSv, respectively, without STS).

We have some knowledge regarding reduction in radiation exposure (6-8). The key to reduction in radiation dose is the use of pulsed and collimated X-ray beams (6). To increase the distance from the X-ray tube, Funao et al. strongly recommended holding the needle of the percutaneous pedicle screw with a long Kocher clamp during fluoroscopic shots, thus achieving lower effective doses to the surgeons (0.06, 0.06, and 0.07 mSv for one, two, and three fusion levels, respectively) during minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in combination with the “one-shot fluoroscopic technique” to reduce the radiation exposure time (38.7, 53.1, and 58.5 s for one, two, and three fusion levels, respectively) (9). Even when using a long Kocher clamp, widening of the distance between the X-ray tube and the surgeons is limited. Dissemination of the STS method is expected to further reduce the radiation exposure.

We can also avail technologies that may reduce radiation exposure, such as the operative navigation system, which is frequently used (10). The combination of robotics and telemedicine is a complete solution for radiation exposure to surgeons. As these technologies are expensive, STS can have high cost-effectiveness and convenience for use in all types of operations.

It should be recognized that radiation hazards are an issue for medical doctors and other healthcare professionals, such as operative nurses and radiological technicians. Minimally invasive spine surgeries (MISSs), such as PVP, BKP, LLIF, PELD, and MIS-TLIF, particularly require the use of fluoroscopy. The protection system described in Ishii’s article may contribute to further developments in the field of MISS.


Funding: None.


Conflicts of Interest: The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.


  1. Ishii K, Iwai H, Oka H, et al. A protective method to reduce radiation exposure to the surgeon during endoscopic lumbar spine surgery. J Spine Surg 2019;5:529-34. [Crossref] [PubMed]
  2. Matityahu A, Duffy RK, Goldhahn S, et al. The Great Unknown-A systematic literature review about risk associated with intraoperative imaging during orthopaedic surgeries. Injury 2017;48:1727-34. [Crossref] [PubMed]
  3. Taher F, Hughes AP, Sama AA, et al. 2013 Young Investigator Award winner: how safe is lateral lumbar interbody fusion for the surgeon? A prospective in vivo radiation exposure study. Spine (Phila Pa 1976) 2013;38:1386-92. [Crossref] [PubMed]
  4. Ahn Y, Kim CH, Lee JH, et al. Radiation exposure to the surgeon during percutaneous endoscopic lumbar discectomy: a prospective study. Spine (Phila Pa 1976) 2013;38:617-25. [Crossref] [PubMed]
  5. Falavigna A, Ramos MB, Iutaka AS, et al. Knowledge and Attitude Regarding Radiation Exposure Among Spine Surgeons in Latin America. World Neurosurg 2018;112:e823-9. [Crossref] [PubMed]
  6. Yamashita K, Higashino K, Hayashi H, et al. Pulsation and Collimation During Fluoroscopy to Decrease Radiation: A Cadaver Study. JB JS Open Access 2017;2:e0039.
  7. Yamashita K, Higashino K, Wada K, et al. Radiation Exposure to the Surgeon and Patient During a Fluoroscopic Procedure: How High Is the Exposure Dose? A Cadaveric Study. Spine (Phila Pa 1976) 2016;41:1254-60. [Crossref] [PubMed]
  8. Yamashita K, Ikuma H, Tokashiki T, et al. Radiation Exposure to the Hand of a Spinal Interventionalist during Fluoroscopically Guided Procedures. Asian Spine J 2017;11:75-81. [Crossref] [PubMed]
  9. Funao H, Ishii K, Momoshima S, et al. Surgeons' exposure to radiation in single- and multi-level minimally invasive transforaminal lumbar interbody fusion; a prospective study. PLoS One 2014;9:e95233. [Crossref] [PubMed]
  10. Staartjes VE, Molliqaj G, van Kampen PM, et al. The European Robotic Spinal Instrumentation (EUROSPIN) study: protocol for a multicentre prospective observational study of pedicle screw revision surgery after robot-guided, navigated and freehand thoracolumbar spinal fusion. BMJ Open 2019;9:e030389. [Crossref] [PubMed]
Cite this article as: Koga H. A new protective method to reduce radiation exposure. J Spine Surg 2020;6(1):1-2. doi: 10.21037/jss.2019.12.03