Roccatagliata L, Presilla S, Pravatà E, Cianfoni A. Radiation dose to the operator during fluoroscopically guided spine procedures. Neuroradiology. 2017 Sep;59(9):885-892.

Fluoroscopy is widely used to guide diagnostic and therapeutic spine procedures. The purpose of this study was to quantify radiation incident on the operator (operator Air Kerma) during a wide range of fluoroscopy-guided spine procedures and its correlation with the amount of radiation incident on the patient (Kerma Area Product-KAP).

Pavlicek W, Sensakovic WF, Zhou Y, et al. Sample Content Of Kinesthetic Educational Training: Reducing Scattered X‐Ray Exposures To Interventional Physician Operators Of Fluoroscopy. J Appl Clin Med Phys. 2020 Jul;21(7):196-208.

Here, we share one example of a kinesthetic (live, hands‐on simulation) educational program in use at our facility for some time (~10 years). In this example, the format and content specifically target methods of reducing physician operator exposures from scattered x rays. A kinesthetic format identifies and promotes the adoption of exposure‐reducing behaviors. Key kinesthetic elements of this type of training include: physician hands‐on measurements of radiation levels at locations specific to their standing positions (e.g., primary arterial access points) in the room using handheld exposure rate meters, measurement of exposure rate reduction to physicians provided by using personal protective equipment, that is, wearable aprons, hanging lead drapes, and pull‐down shields. Physician choice of procedure‐specific tableside selectable controls affecting exposure rate from optional fluoroscopy, Cine or digital subtraction angiography (DSA), along with comparative measured contribution to physician exposure is demonstrated. The inverse square exposure rate reduction to physicians when stepping back from the table during DSA is a key observation.

Morris PP, Geer CP, Singh J, et al. Radiation dose reduction during neuroendovascular procedures. J Neurointerv Surg. 2018 May;10(5):481-486.

To describe the impact of steps towards reduction of procedural doses of radiation during neuroendovascular procedures. Phantom exposures under controlled circumstances were performed using a Rando-Alderson adult-sized head phantom. Customized imaging protocols were devised for pediatric and adult imaging and implemented in clinical use. Outcome data for estimated skin doses (ESD) and dose-area product (DAP) following pediatric and adult diagnostic and interventional procedures over 4.5 years were analyzed retrospectively.

Miller TR, Jindal G, Krejza J, Gandhi D. Impact Of Endovascular Technique On Fluoroscopy Usage: Stent-Assisted Coiling Versus Flow Diversion For Paraclinoid Internal Carotid Artery Aneurysms. Neuroradiol J. 2014 Dec;27(6):725-731.

The purpose of this study was to evaluate the impact of endovascular technique–flow diversion versus stent-assisted coiling (SAC) on fluoroscopy time in patients treated for wide-neck paraclinoid ICA aneurysms. Flow diversion was associated with a significant reduction in fluoroscopy time (52.0 minutes versus 77.4 minutes), and demonstrated a strong trend towards shorter total procedure time (172 minutes versus 202 minutes). Average patient radiation exposure as measured by DAP was lower in the flow diversion group, 13225 mGy(x)cm(2) versus 15124 mGy(x)cm(2), although this finding was not statistically significant. There was no significant difference in contrast usage between the two groups, 152 ml and 159 (flow diversion and SAC respectively). The rate of complete aneurysm occlusion was higher in the flow diversion group (80% versus 60%).


Active personal dosimeters (APD) supply real-time data on radiation dose rates and equivalent doses, enabling reduction of operator exposure to radiation in diagnostic and surgical procedures. Data from the use of the Raysafe i2 APD system in an angiography room are reported. Preliminary characterisation of the APD system was first carried out in terms of angular dependence and of Hp(10) response during the simulation of five typical surgical protocols. Reference measurements, simultaneously obtained from TLDs, were used to obtain a correction factor. APD data for patients and for primary and secondary operators were then recorded over 52 surgical procedures. The correlation between kerma air product (KAP) and reference point air kerma (Kar) and operator dose as a function of position with respect to the source of radiation is reported. The data indicate that the APD system could help operators to optimise behaviours and use of room protection to effectively minimise radiation dose.

Maino P, Presilla S, Colli Franzone PA, et al. Radiation Dose Exposure for Lumbar Transforaminal Epidural Steroid Injections and Facet Joint Blocks Under CT vs. Fluoroscopic Guidance. Pain Pract. 2018 Jul;18(6):798-804.

Transforaminal epidural steroid injections (TFESIs) and facet joint blocks can be performed under fluoroscopy or computed tomography (CT) guidance. The purpose of this retrospective cohort study was to compare patient radiation dose for lumbar TFESIs and facet joint blocks under CT guidance vs. fluoroscopic guidance.

Lee YS, Lee HK, Cho JH, Kim HG. Analysis of radiation risk to patients from intra-operative use of the mobile X-ray system (C-arm). J Res Med Sci. 2015 Jan;20(1):7-12.

The aim of this study was to investigate clinical applications of mobile C-arms and consequent radiation risk, to increase medical attention on radiation protection, and to provide basic data for safe radiation use in the operating room. Orthopedic surgery was the most frequent with 165 cases (44.1%). The highest DAP value and effective dose were found in liver transplant among surgical specialty fields. The highest DAP value and effective dose were observed in intra-operative mesenteric portography among types of surgery.

Konieczny MR, Krauspe R. Navigation Versus Fluoroscopy in Multilevel MIS Pedicle Screw Insertion: Separate Analysis of Exposure to Radiation of the Surgeon and of the Patients. Clin Spine Surg. 2019 Jun;32(5):E258-E265.

To analyze exposure to radiation of the surgeon and-separately-of patients in minimally invasive surgery (MIS) of multilevel posterior stabilization by percutaneous pedicle screw insertion guided by navigation (PIN) versus percutaneous pedicle screw insertion guided by fluoroscopy (PIF).

Klepanec A, Salat D, Harsany J, et al. Neurointerventionalist and Patient Radiation Doses in Endovascular Treatment of Acute Ischemic Stroke. Cardiovasc Intervent Radiol. 2020 Apr;43(4):604-612.

From October 2017 to January 2019, we prospectively collected patient radiation data and neurointerventionalist data from real-time dosimetry from all consecutive thrombectomies. Multivariate analysis was performed to analyze patient total dose area product (DAP) and neurointerventionalist dose variability in terms of clinical characteristics and the technical parameters of thrombectomies. Local dose reference levels (RL) were derived as the 75th percentile of the patient dose distributions.