| BackgroundLumbar disc herniation is one of most common diseases of spine surgery.The treatment methods for lumbar disc herniation can be conservative or surgical treatment.Surgical treatment for lumbar disc herniation can be broadly classified into 2 categories:open and minimally invasive surgery.With the advancement in surgical technique and technology,minimally invasive surgical procedures have become more and more popular.Transforaminal percutaneous endoscopic lumbar discectomy(transforaminal PELD)is considered as a minimally invasive,safe and effective treatment method for radiculopathy caused by soft disc herniation.However,it is necessary to use fluoroscopy to indirectly visualize pertinent anatomy to achieve an optimal result on radiographs.So during the procedures of transforaminal PELD,the surgeons always rely heavily on the use of ionizing radiation.Therefore,radiation exposure to the surgeon and patient during PELD is inevitable.It is known that increased radiation exposure may be associated with potential and deterministic adverse events,such as cataract formation,leukemia,thyroid cancer,and other malignancies.Therefore,it is meaningful to reduce the radiation dose of practitioners and patients to reduce the risk of potential radiation-induced complications.At present,there is no way to take the place of fluoroscopy completely,although some preventive strategies have been suggested to reduce radiation dose.Since the introduction of spinal ultrasound,ultrasonography has been widely used in the diagnosis of spinal diseases,guidance of facet joint injection,and selective nerve root block.So ultrasonography maybe plays the role of reducing the most of the radiation time and dose of transforaminal PELD.This study was designed to evaluate the safety of ultrasound-assisted PELD and the radiation dose to surgeons during ultrasound-assisted PELD,and to investigate whether the usage of ultrasonography could reduce the radiation exposure to the surgeon and patient.Objective1.To evaluate the effect and safety of ultrasound-assisted PELD using the anatomy of ultrasonography of lumbar spine.2.To evaluate the safety of ultrasound-assisted PELD and the radiation dose to surgeons during ultrasound-assisted PELD,and to investigate whether the usage of ultrasonography could reduce the radiation exposure to the surgeon by comparing with other studies.3.To evaluate the safety of ultrasound-assisted PELD and the radiation dose to surgeons and patients during ultrasound-assisted PELD,and to investigate whether the usage of ultrasonography could reduce the radiation exposure to the surgeon and patient by a randomized controlled study.Material and methods:1.Step-by-step assessment of the lumbar spine in 20 volunteers by the following views:longitudinal median view through the spinal processes,transverse view through the spinal processes,longitudinal paramedian oblique view,longitudinal view through the facet joints,longitudinal view through the transverse processes.Then determine the patient's conditions that can get the clear ultrasonic view.Observing 20 fluoroscopy-guided PELD by ultrasonography to know the relationship between the view of fluoroscopy and the view of ultrasonography.2.Recording the radiation exposure dose of the surgeons' chest above and below the shielding and the fluoroscopy time in 25 transforaminal PELDs(25 levels).The age and BMI of patients,fluoroscopy time,radiation exposure dose of this study were compared with that of other study by t test using SPSS 20.0.The effective dose and number of possible levels per year within the yearly occupational exposure limit(OEL)were calculated.3.Recording the radiation exposure dose of the surgeons' chest above and below the shielding,the radiation exposure dose of patients and the fluoroscopy time in 60 transforaminal PELDs(60 levels),which were divided into two groups randomly,fluoroscopy-assisted PELD and ultrasound-assisted PELD.The age and BMI of patients,fluoroscopy time,radiation dose of surgeons and patients were compared between the two groups by t test using SPSS 20.0.The age and BMI of patients,fluoroscopy time,radiation exposure dose of surgeons and patients of subgroups of ultrasound-assisted PELD were compared between the four subgroups by x test using SPSS 20.0.The effective dose and number of possible levels per year within the yearly occupational exposure limit(OEL)were calculated.Results1.Ultrasonography of the lumbar spine:to get the deep location of the anatomic structures of interest,use of a low-frequency transducer is necessary.Longitudinal median view through the spinal processes can show the spinal process,and determine the midline and the levels.Transverse view through the spinal processes can show the spinal process,lamina,facet joint and transverse process.Longitudinal view through the facet joints can show the facet joints and the capsule,can also show the tip of the needle when it reaches the facet joints and evaluate the position of the tip.Longitudinal view through the transverse processes can show erector spinae muscles,transverse process,intertransverse ligament and psoas,and also can evaluate the position of the needle tip.Longitudinal view along the needle can show spinal process,lamina,facet joint and transverse process,erector spinae muscles,can show the deepness and direction of the needle.According to the evaluation of 20 volunteers,clear ultrasonography can been get,when the BMI of the volunteer no more than 24.0 kg/m2.According the observation of 20 fluoroscopy-guided PELD by ultrasonography,longitudinal view through the facet joints and longitudinal view along the needle are most important during the ultrasound-assisted PELD.2.There are 25 cases including in the study of the application of ultrasound-assisted PELD,age 48.2±14.2 years.The mean operation time was 67.6±14.6 minutes(range from 49 to 109 minutes).The mean fluoroscopy time was 2.9±0.7 seconds(range from 1.9 to 4.5 seconds).The radiation doses per disc level at chest below lead apron was 1.4±0.6 ?Sv and above lead apron was 25.8±12.0?Sv,and effective radiation doses per disc level was 1.3±0.6 ?Sv,respectively.Ultrasound-assisted PELD had significantly less radiation exposure dose per level at the chest below and above apron,effective dose per level,and fluoroscopy time than those of fluoroscopy-assisted PELD comparing to the Ahn's study.According to the findings of this case series study,1938 levels of ultrasound-assisted transforaminal PELD could be performed per year without using lead apron and 38,462 levels of PELD per year wearing a lead apron without exceeding the OEL for whole-body radiation(50 mSv).3.There are 60 cases including in the randomized controlled study of the application of ultrasound-assisted PELD.All the cases have single level ultrasound-assisted PELD,and have the radiation pain relief.There was a case suffering intervertebral disc infection,and no other complication such as nerve injuries was observed in any of the cases.For the fluoroscopy-assisted PELD group,the radiation doses per disc level at chest below lead apron was 11.7±3.7?Sv and above lead apron was 126.7±29.3 ?Sv,and effective radiation doses per disc level was 9.0±2.5 ?Sv,radiation doses per disc level of patients was 127.4±27.1 ?Sv respectively.For ultrasound-assisted PELD group,the radiation doses per disc level at chest below lead apron was 2.1±0.6 ?Sv and above lead apron was 26.5±5.7 ?Sv,and effective radiation doses per disc level was 1.7±0.4?Sv,radiation doses per disc level of patients was 25.2±4.9 ?Sv respectively.Ultrasound-assisted PELD had significantly less surgeon radiation dose per level,radiation of patients,dose per level,the mean operation time and fluoroscopy time than those of fluoroscopy-assisted PELD.According to the findings of this case series study,395 levels of fluoroscopy-assisted transforaminal PELD could be performed per year without using lead apron,and 5556 levels of fluoroscopy-assisted PELD per year wearing a lead apron without exceeding the OEL for whole-body radiation.1887 levels of ultrasound-assisted transforaminal PELD could be performed per year without using lead apron,and 29412 levels of ultrasound-assisted transforaminal PELD per year wearing a lead apron without exceeding the OEL for whole-body radiation.Conclusion1.The findings of this study suggest that ultrasound-assisted PELD is safe and effectiveness,and ultrasound-assisted needle insertion and foraminal plasty during transforaminal PELD is a feasible way to reduce radiation exposure time and doses to surgeons and patients.2.Ultrasound-assisted PELD can reduce radiation exposure time and doses to surgeons and patients.However,ultrasound may not completely take the place of fluoroscopy at present. |
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