Abstract
BACKGROUND CONTEXT
Radiographs, fluoroscopy, and computed tomography (CT) are increasingly utilized in
the diagnosis and management of various spine pathologies. Such modalities utilize
ionizing radiation, a known cause of carcinogenesis. While the radiation doses such
studies confer has been investigated previously, it is less clear how such doses translate
to projected cancer risks, which may be a more interpretable metric.
PURPOSE
(1) Calculate the lifetime cancer risk and the relative contributions of preference-sensitive
selection of imaging modalities associated with the surgical management of a common
spine pathology, isthmic spondylolisthesis (IS); (2) Investigate whether the use of
intraoperative CT, which is being more pervasively adopted, increases the risk of
cancer.
STUDY DESIGN/SETTING
Retrospective cross-sectional study carried out within a large integrated health care
network.
PATIENT SAMPLE
Adult patients who underwent surgical treatment of IS via lumbar fusion from January
2016 through December 2021.
OUTCOME MEASURES
(1) Effective radiation dose and lifetime cancer risk associated with each exposure
to ionizing radiation; (2) Difference in effective radiation dose (and lifetime cancer
risk) among patients who received intraoperative CT compared to other intraoperative
imaging techniques.
METHODS
Baseline demographics and differences in surgical techniques were characterized. Radiation
exposure data were collected from the 2-year period centered on the operative date.
Projected risk of cancer from this radiation was calculated utilizing each patient's
effective radiation dose in combination with age and sex. Generalized linear modeling
was used to adjust for covariates when determining the comparative risk of intraoperative
CT as compared to alternative imaging modalities.
RESULTS
We included 151 patients in this cohort. The range in calculated cancer risk exclusively
from IS management was 1.3-13 cases of cancer per 1,000 patients. During the intraoperative
period, CT imaging was found to significantly increase radiation exposure as compared
to alternate imaging modalities (adjusted risk difference (ARD) 12.33mSv; IQR 10.04,
14.63mSv; p<.001). For a standardized 40 to 49-year-old female, this projects to an
additional 0.72 cases of cancer per 1,000. For the entire 2-year perioperative care
episode, intraoperative CT as compared to other intraoperative imaging techniques
was not found to increase total ionizing radiation exposure (ARD 9.49mSv; IQR -0.83,
19.81mSv; p=.072). The effect of intraoperative imaging choice was mitigated in part
due to preoperative (ARD 13.1mSv, p<.001) and postoperative CTs (ARD 22.7mSv, p<.001).
CONCLUSIONS
Preference-sensitive imaging decisions in the treatment of IS impart substantial cancer
risk. Important drivers of radiation exposure exist in each phase of care, including
intraoperative CT and/or CT scans during the perioperative period. Knowledge of these
data warrant re-evaluation of current imaging protocols and suggest a need for the
development of radiation-sensitive approaches to perioperative imaging.
Keywords
Abbreviations:
CT (Computed Tomography), IS (Isthmic Spondylolisthesis), ARD (Adjusted Risk Difference), IQR (Interquartile Range)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: February 01, 2023
Accepted:
January 24,
2023
Received in revised form:
January 15,
2023
Received:
October 11,
2022
Footnotes
FDA device/drug status: Not applicable.
Author disclosure: AMC: Nothing to disclose. BMS: Nothing to disclose. HML: Nothing to disclose. JSZ: Nothing to disclose. GXX: Nothing to disclose. AJS: Royalties: Wolters Kluwer (B, Paid directly to institution), Springer (A, Paid directly to institution). AKS: Nothing to disclose.
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