Fluoroscopy

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Fluoroscopy is a technique that employs x-rays to generate real-time still images or video of a patient’s body. The x-rays pass through the body and create an image on a detector, which is then transmitted to a monitor for viewing by the physician. Thus, a part of the body that is radio-opaque or made so by the use of a dye or a contrast agent can be visualized. Similarly, an instrument or device or movement of internal body parts can be displayed. ^{[1, 2, 3]}

It is a commonly used medical technique that helps physicians with a wide variety of diagnostic and interventional procedures. Although low doses are used, in prolonged procedures, the cumulative exposure may result in a relatively high absorbed dose to the patient. Therefore, all necessary precautions should be used, and the benefits should outweigh the potential risks in a given clinical situation. ^{[4, 5, 6, 7, 8]}

Because fluoroscopy involves the use of ionizing radiation, it is relatively contraindicated in pregnant women because of potentially harmful effects on a developing fetus.

This review focuses on the use of fluoroscopy in orthopedic procedures.

Fluoroscopy is used in many types of examinations and procedures. Some examples include the following:

Orthopedic procedures, such as manipulation of broken bones in fracture reduction or insertion of implants and checking appropriate positioning or alignment.

Gastrointestinal investigations using contrast agents, such as barium in the intestine to study its outline and movement.

Cardiovascular and interventional radiology procedures, such as catheter insertion and monitoring of its progress (eg, to undo a blockage or insert a stent).

A fluoroscope in its simplest form (although rarely, if ever, used now) is an x-ray source at one end and a fluorescent screen at the other end. The part of the body that is to be imaged is placed between these ends. Low-dose radiation is used, and modern fluoroscopes couple the screen to an x-ray image intensifier to brighten the image sufficiently so as to be displayed as still images or video on a monitor. Recent advances allowing digitalization of the images and the use of flat panel detector systems have helped to further decrease the dose of radiation used.

Current equipment and safety measures help reduce the risks associated with fluoroscopy, including the following:

Display of the duration, rate, and cumulative amount of radiation exposure patients receive. ^[1]

Increased x-ray filtration to reduce the possibility of radiation injuries during long procedures.

Tighter controls on the size of the x-ray field to reduce the amount of radiation that falls outside the image target area.

A last-image-hold feature that allows the physician to view images without continually exposing patients to radiation.

Use of a laser localization attachment to the C-arm helps position the x-ray source precisely over the area under scrutiny and minimizes repeat exposures due to imprecise positioning

Fluoroscopy involves the use of ionizing radiation and, therefore, carries the same types of risk as other x-ray procedures. The radiation dose a patient receives depends on a variety of factors, including the body part examined and the duration of the procedure. ^{[9, 10, 11]} The exposure and dose required in an obese patient is greater than in a lean patient, and abdominal fluoroscopy results in a greater exposure than fluoroscopy of the hand or wrist because of the increased thickness and tissue density of the abdomen. ^[4]

Two types of risks are associated with fluoroscopy (and other ionizing radiation exposures):

Deterministic risks: The risk is nonexistent below a certain threshold of radiation dose, but it is nearly 100% at dose levels significantly greater than this threshold (eg, radiation burns to the skin and radiation-induced cataracts).

Stochastic risks: The risk is directly proportional to the radiation dose, with no minimum dose below which the risk is zero (eg, radiation-induced cancer).

In practice, a risk of radiation burns exists only when fluoroscopy is conducted over prolonged periods of time and with the use of higher doses of radiation. Regarding stochastic risks, the “as low as reasonably achievable” (ALARA) principle applies in that the radiation dose should be made as small as reasonably achievable to reduce these risks to an absolute minimum. When a medical need exists, however, the benefit of fluoroscopy usually far exceeds the small but real cancer risk associated with the procedure. Therefore, fluoroscopy is used with the lowest possible exposure for the shortest possible time.

Fomekong E, Safi SE, Raftopoulos C. Spine Navigation Based on 3-Dimensional Robotic Fluoroscopy for Accurate Percutaneous Pedicle Screw Placement: A Prospective Study of 66 Consecutive Cases. World Neurosurg. 2017 Dec. 108:76-83. [Medline].

Panchbhavi VK, Mays MM, Trevino S. Accuracy of intraoperative fluoroscopy with and without laser guidance in foot and ankle surgery. Foot Ankle Int. 2012 May. 33(5):415-9. [Medline].

Chen X, Wang L, Fallavollita P, Navab N. Precise X-ray and video overlay for augmented reality fluoroscopy. Int J Comput Assist Radiol Surg. 2013 Jan. 8 (1):29-38. [Medline].

Curtin BM, Armstrong LC, Bucker BT, Odum SM, Jiranek WA. Patient Radiation Exposure During Fluoro-Assisted Direct Anterior Approach Total Hip Arthroplasty. J Arthroplasty. 2016 Jun. 31 (6):1218-21. [Medline].

Braun E, Sack AM, Sayed D, Manion S, Hamm B, Brimacombe M, et al. Reducing Radiation Exposure in Lumbar Transforaminal Epidural Steroid Injections with Pulsed Fluoroscopy: A Randomized, Double-blind, Controlled Clinical Trial. Pain Physician. 2018 Jan. 21 (1):53-60. [Medline].

Tharmviboonsri T, Riansuwan K, Nitising A, Mahaisavariya B. Radiation exposure during 3D fluoroscopy of the knee: an experimental study. Eur J Trauma Emerg Surg. 2012 Jun. 38 (3):307-11. [Medline].

Lee K, Lee KM, Park MS, Lee B, Kwon DG, Chung CY. Measurements of surgeons’ exposure to ionizing radiation dose during intraoperative use of C-arm fluoroscopy. Spine (Phila Pa 1976). 2012 Jun 15. 37 (14):1240-4. [Medline].

Giordano BD, Baumhauer JF, Morgan TL, Rechtine GR 2nd. Cervical spine imaging using mini–C-arm fluoroscopy: patient and surgeon exposure to direct and scatter radiation. J Spinal Disord Tech. 2009 Aug. 22 (6):399-403. [Medline].

Rockville, MD. Food and Drug Administration. Public Health Advisory: Avoidance of Serious X-Ray-Induced Skin Injuries to Patients During Fluoroscopically-Guided Procedures. Center for Devices and Radiological Health, FDA. 1994.

Wagner LK, Eifel PJ, Geise RA. Potential biological effects following high X-ray dose interventional procedures. J Vasc Interv Radiol. 1994 Jan-Feb. 5(1):71-84. [Medline].

Huda W, Peters KR. Radiation-induced temporary epilation after a neuroradiologically guided embolization procedure. Radiology. 1994 Dec. 193(3):642-4. [Medline].

Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Mahan Mathur, MD Assistant Professor of Radiology and Biomedical Imaging, Yale University School of Medicine; Director, Medical Student Education, Associate Director, Diagnostic Radiology Residency Program, Yale-New Haven Hospital

Mahan Mathur, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Gowthaman Gunabushanam, MD, FRCR Assistant Professor, Department of Diagnostic Radiology, Yale University School of Medicine

Gowthaman Gunabushanam, MD, FRCR is a member of the following medical societies: American Roentgen Ray Society, Connecticut State Medical Society

Disclosure: Nothing to disclose.

Acknowledgments

The author acknowledges Ms. Suzanne Simpson for literary edits and Mr. Randal P. Morris for the illustration.

Fluoroscopy

Research & References of Fluoroscopy|A&C Accounting And Tax Services
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