Restricted accessResearch articleFirst published online 2017-11
Periradicular infiltration of the lumbar spine: testing the robustness of an interventional ultra-low-dose protocol at different body mass index levels
Computed tomography (CT)-guided periradicular infiltration remains a frequent interventional procedure for treatment of low back pain.
Purpose
To present an interventional ultra-low-dose protocol for CT-guided periradicular infiltration therapy and assess its application at different body mass index (BMI) levels.
Material and Methods
Over a period of 14 months, 79 patients underwent 183 CT-guided interventions for single-site lumbar periradicular therapy using an ultra-low-dose protocol with a basic setup of 100 kV and 5 mAs. Procedures were performed via intermittent fluoroscopy. A retrospective review was performed to analyze the parameters tube current and tube voltage, dose-length product, and BMI.
Results
The interventional ultra-low-dose protocol allowed safe treatment of 91.1% of the patients without a need for adapting the protocol. In seven patients with a higher BMI (range, 31–38 kg/m2; mean, 34 kg/m2), the tube current had to be increased to retain sufficient image quality. Only patients with a BMI of 30 and higher showed a significant correlation between BMI and dose-length product (P value = 0.02), resulting in a slightly increased dose (P value = 0.002).
Conclusion
The protocol presented for the interventional part of CT-guided periradicular infiltration allows to safely treat patients with a median calculated effective dose of 0.045 mSv (converted from a dose-length-product of 2.26 mGy*cm). Patients with a BMI of 30 and higher required a higher calculated effective dose with just one patient slightly exceeding 0.1 mSv.
AiraksinenOBroxJICedraschiCet al.Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J2006; 15: S192–300. Suppl. 2.
2.
ManchikantiLSinghVFalcoFJet al.Epidemiology of low back pain in adults. Neuromodulation2014; 17: 3–10. Suppl. 2.
3.
MartinBIDeyoRAMirzaSKet al.Expenditures and health status among adults with back and neck problems. JAMA2008; 299: 656–664.
LeeKSLinCLHwangSLet al.Transforaminal periradicular infiltration guided by CT for unilateral sciatica–an outcome study. Clin Imaging2005; 29: 211–214.
6.
VadVBBhatALLutzGEet al.Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine (Phila Pa 1976)2002; 27: 11–16.
7.
AndreisekGJenniMKlinglerDet al.Access routes and reported decision criteria for lumbar epidural drug injections: a systematic literature review. Skeletal Radiol2013; 42: 1683–1692.
8.
WagnerAL. CT fluoroscopy-guided epidural injections: technique and results. Am J Neuroradiol2004; 25: 1821–1823.
9.
StreitparthFDe BucourtMHartwigTet al.Real-time MR-guided lumbosacral periradicular injection therapy using an open 1.0-T MRI system: an outcome study. Invest Radiol2013; 48: 471–476.
10.
KramerJBlettnerMHammerGP. Image-guided injection therapy in the lumbar spine. Dtsch Arztebl Int2008; 105: 596–598.
11.
MaurerMHSchreiterNde BucourtMet al.Cost comparison of nerve root infiltration of the lumbar spine under MRI and CT guidance. Eur Radiol2013; 23: 1487–1494.
12.
DalyBTempletonPA. Real-time CT fluoroscopy: evolution of an interventional tool. Radiology1999; 211: 309–315.
13.
BrennerDJHallEJ. Computed tomography–an increasing source of radiation exposure. N Engl J Med2007; 357: 2277–2284.
14.
RogitsBJungnickelKLowenthalDet al.Prospective evaluation of the radiologist’s hand dose in CT-guided interventions. Rofo2013; 185: 1081–1088.
15.
SealsKFLeeEWCagnonCHet al.Radiation-induced cataractogenesis: a critical literature review for the interventional radiologist. Cardiovasc Intervent Radiol2016; 39: 151–160.
16.
WagnerLKEifelPJGeiseRA. Potential biological effects following high X-ray dose interventional procedures. J Vasc Interv Radiol1994; 5: 71–84.
17.
MaSKongBLiuBet al.Biological effects of low-dose radiation from computed tomography scanning. Int J Radiat Biol2013; 89: 326–333.
18.
GeiselDZimmermannERiefMet al.DNA double-strand breaks as potential indicators for the biological effects of ionising radiation exposure from cardiac CT and conventional coronary angiography: a randomised, controlled study. Eur Radiol2012; 22: 1641–1650.
19.
ArtnerJCakirBWeckbachSet al.Radiation dose reduction in CT-guided periradicular injections in lumbar spine: Feasibility of a new institutional protocol for improved patient safety. Patient Saf Surg2012; 6: 19–19.
20.
HoangJKYoshizumiTTTonchevaGet al.Radiation dose exposure for lumbar spine epidural steroid injections: a comparison of conventional fluoroscopy data and CT fluoroscopy techniques. Am J Roentgenol2011; 197: 778–782.
21.
LutzeMStendelRVesperJet al.Periradicular therapy in lumbar radicular syndromes: methodology and results. Acta Neurochir (Wien)1997; 139: 719–724.
22.
MalikVSWillettWCHuFB. Global obesity: trends, risk factors and policy implications. Nat Rev Endocrinol2013; 9: 13–27.
23.
ShrimptonPCJansenJTHarrisonJD. Updated estimates of typical effective doses for common CT examinations in the UK following the 2011 national review. Br J Radiol2016; 89: 20150346–20150346.
24.
CohenJ. Statistical power analysis forthe behavorial sciences, 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates, 1988.
25.
World Health Organization. Obesity: Preventing and Managing the Global Epidemic, Geneva: WHO, 2000.
26.
AlshamariMGeijerMNorrmanEet al.Low-dose computed tomography of the lumbar spine: a phantom study on imaging parameters and image quality. Acta Radiol2014; 55: 824–832.
27.
AlshamariMGeijerMNorrmanEet al.Low dose CT of the lumbar spine compared with radiography: a study on image quality with implications for clinical practice. Acta Radiol2016; 57: 602–611.
28.
YangCHWuTHChiouYYet al.Imaging quality and diagnostic reliability of low-dose computed tomography lumbar spine for evaluating patients with spinal disorders. Spine J2014; 14: 2682–2690.
29.
AmrheinTJSchaubergerJSKranzPGet al.Reducing Patient Radiation Exposure From CT Fluoroscopy-Guided Lumbar Spine Pain Injections by Targeting the Planning CT. Am J Roentgenol2016; 206: 390–394.
SchmidGSchmitzABorchardtDet al.Effective dose of CT- and fluoroscopy-guided perineural/epidural injections of the lumbar spine: a comparative study. Cardiovasc Intervent Radiol2006; 29: 84–91.
32.
ProkopM. [Radiation dose in computed tomography. Risks and challenges]. Radiologe2008; 48: 229–242.
33.
PaikNC. Radiation Dose reduction in CT fluoroscopy-guided cervical transforaminal epidural steroid injection by modifying scout and planning steps. Cardiovasc Intervent Radiol2016; 39: 591–599.
34.
SchinderaSTOdedraDRazaSAet al.Iterative reconstruction algorithm for CT: can radiation dose be decreased while low-contrast detectability is preserved?Radiology2013; 269: 511–518.
35.
GervaiseAOsemontBLecocqSet al.CT image quality improvement using adaptive iterative dose reduction with wide-volume acquisition on 320-detector CT. Eur Radiol2012; 22: 295–301.
36.
GervaiseAOsemontBLouisMet al.Standard dose versus low-dose abdominal and pelvic CT: comparison between filtered back projection versus adaptive iterative dose reduction 3D. Diagn Interv Imaging2014; 95: 47–53.
37.
Irwan R, Nakanishi S and Blum A. AIDR 3D – reduces dose and simultaneously improves image quality. Toshiba Medical Systems Europe White Paper. The Netherlands: Zoetermeer, 2011.
38.
American Association of Physicists in Medicine. Size Specific Dose Estimates (SSDE) in pediatric and adult body CT examinations. Report of the AAPM Task Group 204, College Park, MD, 2011.
