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Interv Pain Med
Interv Pain Med
Interventional Pain Medicine
2772-5944
Elsevier

S2772-5944(23)00122-X
10.1016/j.inpm.2023.100290
100290
Letters to the Editor
Comments on: “Radiation exposure in fluoroscopy guided spinal interventions: A prospective observational study of standard practice in a physiatry academic center”
Kennedy Austin
Abrahams Eldhose eldhose-abrahams@ouhsc.edu
∗
Department of Anesthesiology, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
∗ Corresponding author. Oklahoma University Health Sciences Center, Department of Anesthesiology, 920 SL Young Blvd #1140, Oklahoma City, OK, 73104, USA. eldhose-abrahams@ouhsc.edu
08 11 2023
12 2023
08 11 2023
2 4 10029014 10 2023
26 10 2023
© 2023 The Authors
2023
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmcDear Editor:

We applaud Drs. Nguyen, Piché, Mares, and Denis [1] for their work on quantifying radiation exposure to pain physicians who perform common fluoroscopic-guided spinal interventions in an academic setting. In addition to expressing our support of the study, we would like to make a couple suggestions for further investigation into this important topic.

First, this study obtained radiation exposure data over the three-month period (October to December), which traditionally corresponds to the second quarter of fellowship training. We propose to extend this study over the course of the entire academic year. We expect that decreases in fluoroscopy time and perceived radiation exposure may be noted throughout the progression of training. Yang et al. showed significant reduction in fluoroscopy time for lumbar punctures during the last quarter versus the first quarter of neuroradiology fellowship [2], and decreasing fluoroscopic time over the course of the academic year [3]. Similarly, interventional cardiology fellows performing catheterization procedures experienced higher radiation exposure at the beginning versus the end of fellowship [4]. These findings suggest that radiation exposure decreases as experience increases. Further investigation over the course of the full academic year for Interventional Pain may reveal a similar trend. With such data, program directors may better structure their curriculum and assignments to minimize perceived radiation exposure for trainees.

Second, the authors collected data from routine and relatively rapid spinal interventions: facet and sacro-iliac joint blocks, transforaminal and caudal epidural steroid injections, medial and lateral branch blocks, and radiofrequency ablations. However, this may not accurately reflect radiation exposure in practices that perform advanced procedures which may require longer fluoroscopy time and confer greater radiation exposure, such as neuromodulation with spinal cord stimulator implantation or dorsal route ganglion stimulation, spinal distraction with kyphoplasty or interspinous spacer insertion, basivertebral nerve ablations, and intrathecal pump implants. In this study, the three-month cumulative exposure on the operators’ finger ranged from 0.53 to 1.83 mSv for 87–196 procedures, making the calculated exposure on the finger less than 0.01 mSv per procedure. In comparison, radiation exposure from percutaneous vertebroplasty procedures performed by spine surgeons over a three-month period were five-to ten-fold higher than those in the current study: 6.7 (right) and 14.5 (left) mSv hand exposure over 32 procedures involving 136 levels [5], for an average of 0.05 and 0.11 mSv, respectively, per augmented level. Therefore, further research accounting for differing levels of procedure complexity may be useful to accurately quantify radiation exposure, particularly for novice practitioners.

The authors have successfully demonstrated the safety of a standard pain practice in an academic setting in their three-month study, and provided a reassuring theoretical, maximum exposure scenario. We believe our suggestions for additional investigations – to account for trainee experience over time and inclusion of advanced procedures – may yield more complete information which can improve safe practices to minimizes radiation exposure for trainees and early career interventional pain physicians.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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References

1 Nguyen D. Piché F. Mares C. Denis I. Radiation exposure in fluoroscopy guided spinal interventions: a prospective observational study of standard practice in a physiatry academic center Interven Pain Med 2 3 2023 10.1016/j.inpm.2023.100273
2 Yang H. Schaffer K. Liu L. Mahesh M. Yousem D.M. Benchmarking lumbar puncture fluoroscopy time during fellowship training AJNR. Am J Neuroradiol 38 3 2017 656 658 10.3174/ajnr.A5031 27908868
3 Nayate A. Schmitt J. Mohan S. Nasrallah I. Trends in fluoroscopy time in fluoroscopy-guided lumbar punctures performed by trainees over an academic Year Acad Radiol 24 3 2017 373 380 10.1016/j.acra.2016.11.004 28110798
4 Watson L. Riggs M. Bourland P. Radiation exposure during cardiology fellowship training Health Phys 73 4 1997 690 693 10.1097/00004032-199710000-00016 9314232
5 Harstall R. Heini P.F. Mini R.L. Orler R. Radiation exposure to the surgeon during fluoroscopically assisted percutaneous vertebroplasty: a prospective study Spine 30 16 2005 1893 1898 10.1097/01.brs.0000174121.48306.16 16103862
