SYSTEMATIC INTERVENTION TO REDUCE RADIATION DOSE FROM FLUOROSCOPIC GUIDED PROCEDURES IN THE RADIOLOGY DEPARTMENT

Abstract

Background: Radiation effects are one of the pillars that determines how radiologists, radiology technologists and radiology trainees practice radiology and take decisions related to patient care and management. Although the risk of cancer increases with the ionizing radiation dose, the severity of the stochastic effects does not; the patients will either develop cancer or will not. Hence, the principle “as low as reasonably achievable” (ALARA) of radioprotection became fundamental to the principles of radiation protection. Fluoroscopic guided lumbar puncture to retrieve CSF is an example of a radiological procedure that may potentially result in a significant radiation dose. We developed a 3-point systematic approach with checklist for fluoroscopic guided lumbar puncture, with the aim to decrease the radiation dose/fluoroscopy time of the procedure. Objectives: In this study we aim to check if our developed 3-point systematic approach with checklist for the fluoroscopic guided lumbar puncture will reduce the fluoroscopic time of the procedure with similar or improved complications and failure rates compared to the standard technique. Methods: We did a retrospective review of patients that underwent fluoroscopic guided lumbar puncture (LP) in the department of Radiology, at the University of Iowa Hospitals and Clinic, Iowa City, IA, USA between 2019 and 2021. 145 cases performed using the developed 3-point systematic approach with checklist and 226 cases performed using the standard technique were included in our study. We collected data on relevant patient demographics, date of procedure, type of procedure, fluoroscopy time, immediate complications, CSF color, physician performing the procedure and procedure technical success rate. The chi-squared test was used to compare categorical variables and the independent t-test was used to compare continuous variables between the two age groups. Univariate and multivariate linear regression models were conducted to investigate the effect of different patient and procedural factors on fluoroscopy time. Statistical analyses were carried out with the use of IBM SPSS software package version 28.0, level of significance of p < 0.05. Results: There is significant reduction in radiation dose and fluoroscopy time in the group where the 3-point systematic approach with checklist was used (2.03 sec) compared to the group where only the standard technique was used (25.62 sec). This significant dose reduction remained statistically significant when adjusting for several potential confounders: type of the procedure (lumbar puncture with or without myelogram), age, BMI, date of the study (first vs second half of the academic year), gender and staff performing the procedure. Furthermore, there is statistically significantly higher success rate of the fluoroscopic guided lumbar puncture in the group where the 3-point systematic approach with checklist was used (99.3%) compared to the group where only the standard technique was used (95.6%). There was no statistically significant difference in the complication rate and traumatic tap rate between the group where the 3-point systematic approach with checklist was used and the group where only the standard technique was used. In our linear regression model, doing a myelogram, increased patient age and doing the procedure in the first half of the year are factors contributing to a statistically significant increase in fluoroscopy time. Conclusion: The 3-point systematic approach with checklist was associated with 1162% decrease in fluoroscopy time/radiation dose of fluoroscopic guided lumbar punctures and statistically significantly increase in success rate reaching more than 99% compared to the standard technique. No difference in traumatic tap rates and complication rates was noted between the two groups. We believe that our study will provide a cornerstone for future research on effective interventions and approach for dose reduction in fluoroscopy guided procedures.