manowar rules

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I am admittedly careless at times with my hands in the path of the x-ray during fluoroscopic procedures. I am otherwise careful with radiation safety, wearing lead glasses, taking a step back during laterals, generally avoiding live fluoro, etc. I was led to believe that incidental exposure to the hands for the procedures we do was generally benign. But I've come across some articles that are leading me to believe otherwise.

Radiation Induced Hand Necrosis of an Orthopaedic Surgeon Who Had Treated a Patient with Fluoroscopy-Guided Spine Injection
Primary cutaneous carcinosarcoma developing after chronic C-arm radiation exposure
https://www.researchgate.net/public...on_Induced_by_Occupational_Radiation_Exposure

Hand_Necrosis.jpg
The guy above got radiation necrosis of his bilateral thumb and forefingers requiring skin grafting. He was an orthopedic surgeon who did spine injections under fluoroscopy for 17 years. Another high volume proceduralist who apparently did a lot of vertebral augmentation developed squamous cell carcinoma of the hands after 11 years. The third guy was an orthopedic surgeon who with significant fluoroscopy exposure (unsure if through injections or other ortho procedures) who developed "primary cutaneous carcinosarcoma" after a 20-year career. Interestingly, all of these cases are out of South Korea.

I have no idea how these guys practiced. Maybe they just held the fluoro pedal down continuously with their hands in the beam. But I do about 50 procedures/week, and these cases do make me a little paranoid and I'm going to be a lot more careful to keep my hands out of the x-ray.

I also don't know how common this radiation damage is outside of these case reports. Do you guys know of any proceduralists that have had issues with their hands after years of fluoro exposure?

What techniques do you use to avoid exposure to you hands?
I know there are leaded gloves, but I heard most avoid these since they affect the fluoro unit's automatic brightness control to increase x-ray output, negating their benefit. Some people use forceps to manipulate the needle. I find this kind of awkward and only use this technique during kyphos and Vertiflex, not basic injections.

For now I think I'm just going to try to be more mindful to keep my hand out of the beam, and wear one of those ring dosimeters for awhile to track my exposure.
 

paindoc007

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I know there are leaded gloves, but I heard most avoid these since they affect the fluoro unit's automatic brightness control to increase x-ray output, negating their benefit.

That’s correct only if your hands are actually IN the picture. Which should frankly never be the case. If you’re using a lot of live fluoro (only time I do this is threading an scs lead and injecting cement), feel free to use lead gloves with impunity
 

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That’s correct only if your hands are actually IN the picture. Which should frankly never be the case. If you’re using a lot of live fluoro (only time I do this is threading an scs lead and injecting cement), feel free to use lead gloves with impunity
Wearing lead gloves is a terrible idea if they are going to be on screen. Increase radiation and increase scatter. Don’t do it.
 
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paindoc007

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Wearing lead gloves is a terrible idea if they are going to be on screen. Increase radiation and increase scatter. Don’t do it.

Right. Maybe I wrote that poorly, but we’re saying the same thing. No reason to worry about using lead gloves since they should never be in the picture anyway if you do use them.

oh also, if you’re worried about fluoro, really spend time educating your X-ray techs about collimating. It’s amazing to me how lazy people are about that.
 
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i always do brief live for TFESI especially cervical to look for vascular uptake.. am i the only one?
 

paindoc007

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i always do brief live for TFESI especially cervical to look for vascular uptake.. am i the only one?

Yea you’re right. live fluoro for epidurals. It’s so brief that I didn’t even think of it when I wrote above though.

But more importantly, you’re still doing cervical tfesi? Eek. Maybe wanna rethink the risk of that one...
 
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manowar rules

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Yeah, certainly there are safeguards for us to take.

I am just surprised that, in modern times with modern equipment, there are proceduralists that have x-rayed their hands to the point of necrosis.
 

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I try to do a in out thing with my hands when taking images.. pull them back to my waist. I always get on to the X-ray tech for any hand-o-grams
 
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Ligament

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Some of you new docs may never have witnessed how some dinosaurs used flouro. Talking live fluoro almost full time, hands in screen most of the time, terrible technique, full dose settings on fluoro. You might not be able to believe your eyes.
 
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Ferrismonk

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I also think it's also telling these cases aren't fellowship trained pain docs, these are surgeons playing at being an interventional pain doc. They tend to care much less about flouro exposure in my experience.
 
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pastafan

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I also think it's also telling these cases aren't fellowship trained pain docs, these are surgeons playing at being an interventional pain doc. They tend to care much less about flouro exposure in my experience.
Over more than 20 yrs in the OR I never once saw an orthopod collimate on any procedure. Clueless....
 
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TIVAndy

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Yea you’re right. live fluoro for epidurals. It’s so brief that I didn’t even think of it when I wrote above though.

But more importantly, you’re still doing cervical tfesi? Eek. Maybe wanna rethink the risk of that one...

I'm working with a lot of surgeons who request specific levels for TFESI at cervical. I think the complication data comes from era where people were injecting particulate to cervical TFESI - but correct me if i am wrong please.
 
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I'm working with a lot of surgeons who request specific levels for TFESI at cervical. I think the complication data comes from era where people were injecting particulate to cervical TFESI - but correct me if i am wrong please.
The needle and the damage done.
VA doesn’t always follow Netter.
 
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I'm working with a lot of surgeons who request specific levels for TFESI at cervical. I think the complication data comes from era where people were injecting particulate to cervical TFESI - but correct me if i am wrong please.
Answer to the surgeon is no.
 
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I'm working with a lot of surgeons who request specific levels for TFESI at cervical. I think the complication data comes from era where people were injecting particulate to cervical TFESI - but correct me if i am wrong please.
I still worry about vertebral artery injury from the needle. I think the worst risk is from particulate but direct injury or arterial injection is still possible. I’ve done a few but I think it’s very important to educate the patient (and usually the surgeon) that a negative result means surgery probably won’t help but a positive result does not guarantee a good result from surgery.
 
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Baron Samedi

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Surgeons have so many other tools available to them to determine a pain source that C-TFESI shouldn't be necessary. There are countless surgeons who are able to make decisions without this needless dangerous procedure.
 
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gaseous_clay

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I'm working with a lot of surgeons who request specific levels for TFESI at cervical. I think the complication data comes from era where people were injecting particulate to cervical TFESI - but correct me if i am wrong please.
Vertebral artery vasospasm can happen with just the needle placement. Also, one has to worry about potentially injecting micro bubbles intra-arterial.
 
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MD87

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Vertebral artery vasospasm can happen with just the needle placement. Also, one has to worry about potentially injecting micro bubbles intra-arterial.
Theoretical, or are there confirmed cases of this? Are there any cases of catastrophic events in TFESI when only dex and no local is used? Thanks.
 

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I don't do cervical TFESI and there is a large article written in Anesthesia about this several years ago.

Nationwide, the number of those being done are plummeting.

There is no difference in answering your surgeon's clinical question by doing a cervical TFESI at right C4-5 or ILESI at either C7-T1 or C6-7.

There is no selectivity with TFESI, especially if it is done correctly, and especially in the cervical spine which is composed of anatomy that is much closer geographically than in the lumbar spine.

If I do a C6-7 ILESI with 3cc of injectate I'm pushing medicine a long way up there, and your one level unilateral cervical TFESI is spreading up down multiple levels so the selectivity is completely gone.

Your surgeon only says that bc he learned that in residency and fellowship bc his attendings were all older and the literature wasn't there yet.

At Emory, we pretty much only did cervical TFESI and so when I went out to Stanford for fellowship, I mentioned that and asked why we didn't do TFESI and they recoiled in horror.
 
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MD87

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I don’t do cervical TFESI either.

Obviously, ILESI is not without risk, and an epidural hematoma could be devastating in the cervical spine. I do between 0 and 5 of them per week, and while not technically challenging, I do have a healthy amount of anxiety during the procedures.

I work at an orthopedic practice, and the doc in my region who does cervical TFESI is likely leaving in the next 6 months. I’m sure there will be requests for me to do them. The surgeons I work with are nice enough, and I don’t think it will be a big issue if I say “no.”

For my own education, can someone please direct me to an article/case of a bad outcome when dex is used? I looked online and couldn’t find any when dex is used.

Also, this article is interesting, and is in opposition to what a number of other articles say about spread in the ventral epidural space after ILESI. Wondering what everyone’s thoughts are (aside from the fact that is nuts that they injected so damn high...)


Thanks for your thoughts
 

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I regards to fluoro, I do something Im not aware of anyone else doing. I have lead drapes I have the tech lay on top of the patient, above and below the field. My hand is always behind that drape. It also reduces scatter to me and everyone else in the room. I do >90 procedures per week and my badge levels are undetectable.
 
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I regards to fluoro, I do something Im not aware of anyone else doing. I have lead drapes I have the tech lay on top of the patient, above and below the field. My hand is always behind that drape. It also reduces scatter to me and everyone else in the room. I do >90 procedures per week and my badge levels are undetectable.
Can you sketch a diagram or take a pic? Not quite sure what you mean but I’m always interested in techniques to lower exposure.
 

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Any of that lead getting in the imaging field will drastically increase radiation exposure to everyone in the room. Even just instrumentation increases scatter.
 

manowar rules

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I am aware and work to keep it out of the beam. My badge levels indicate minimal (undetectable) exposure.
And this is the badge you wear on the outside of your lead? That is impressive, mine definitely ain’t undetectable
 

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I don't do cervical TFESI and there is a large article written in Anesthesia about this several years ago.

Nationwide, the number of those being done are plummeting.

There is no difference in answering your surgeon's clinical question by doing a cervical TFESI at right C4-5 or ILESI at either C7-T1 or C6-7.

There is no selectivity with TFESI, especially if it is done correctly, and especially in the cervical spine which is composed of anatomy that is much closer geographically than in the lumbar spine.

If I do a C6-7 ILESI with 3cc of injectate I'm pushing medicine a long way up there, and your one level unilateral cervical TFESI is spreading up down multiple levels so the selectivity is completely gone.

Your surgeon only says that bc he learned that in residency and fellowship bc his attendings were all older and the literature wasn't there yet.

At Emory, we pretty much only did cervical TFESI and so when I went out to Stanford for fellowship, I mentioned that and asked why we didn't do TFESI and they recoiled in horror.
What about performing a cervical selective nerve root block with lidocaine to answer the surgeon's clinical question? Isn't that more selective than the cervical TFESI and the ILESI?
 
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bedrock

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I am aware and work to keep it out of the beam. My badge levels indicate minimal (undetectable) exposure.

Really like this idea. Did you get just long lead squares from somewhere?

With COVID, does your staff wipe down these lead squares between each case?
 

mid|ine

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Really like this idea. Did you get just long lead squares from somewhere?

With COVID, does your staff wipe down these lead squares between each case?

We wipe down after every patient

I have 2 different pieces, a smaller rectangle, I usually place above the field (don't use on cervicals), and a larger square a place below the field. These are 1mm equivalent. Make sure they are large enough to drape over the sides of most patients so they don't fall off.

You can order them from where ever you get your lead gowns.
 

painfree23

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We wipe down after every patient

I have 2 different pieces, a smaller rectangle, I usually place above the field (don't use on cervicals), and a larger square a place below the field. These are 1mm equivalent. Make sure they are large enough to drape over the sides of most patients so they don't fall off.

You can order them from where ever you get your lead gowns.
do u have a link/picture of what you are talking about?
 
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This is talking about shielding to protecting patients, which doesn’t work well because it’s the radiation scattered inside the body as the beam passes through that creates the most exposure. Midline is talking about using it to block radiation scattered out of the patient and onto other people in the room, as well as reflected off the underside of the table and patient, which has a more sound rationale.
 

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This is talking about shielding to protecting patients, which doesn’t work well because it’s the radiation scattered inside the body as the beam passes through that creates the most exposure. Midline is talking about using it to block radiation scattered out of the patient and onto other people in the room, as well as reflected off the underside of the table and patient, which has a more sound rationale.
I agree with hanging the extra lead as a side curtain, but not laying it over the patient.
 

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The lead “fringed” skirt around the table is good.
 

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Those are shocking images; thank you for sharing. Sadly, radiation safety is an afterthought for many fluoro using physicians. Any dose of medical radiation is unhealthy. (even one base pair mutation is too much). Cosmic rays are already bombarding your DNA as we speak, why add more insult?

I step away for every image and use live sparingly. I'm working on reducing my exposure during difficult SCS lead floating.
 
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Those are shocking images; thank you for sharing. Sadly, radiation safety is an afterthought for many fluoro using physicians. Any dose of medical radiation is unhealthy. (even one base pair mutation is too much). Cosmic rays are already bombarding your DNA as we speak, why add more insult?

I step away for every image and use live sparingly. I'm working on reducing my exposure during difficult SCS lead floating.
Do you already do low dose and pulsed with a low pulse rate?
 
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myrandom2003

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I don't do cervical TFESI and there is a large article written in Anesthesia about this several years ago.

Nationwide, the number of those being done are plummeting.

There is no difference in answering your surgeon's clinical question by doing a cervical TFESI at right C4-5 or ILESI at either C7-T1 or C6-7.

There is no selectivity with TFESI, especially if it is done correctly, and especially in the cervical spine which is composed of anatomy that is much closer geographically than in the lumbar spine.

If I do a C6-7 ILESI with 3cc of injectate I'm pushing medicine a long way up there, and your one level unilateral cervical TFESI is spreading up down multiple levels so the selectivity is completely gone.

Your surgeon only says that bc he learned that in residency and fellowship bc his attendings were all older and the literature wasn't there yet.

At Emory, we pretty much only did cervical TFESI and so when I went out to Stanford for fellowship, I mentioned that and asked why we didn't do TFESI and they recoiled in horror.

Just to show an example of what you said... this was posted by someone on the ‘gram IMG_6392.JPG . How selective is that??
 
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SommeRiver

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Pt better for 30 days, comes back to see surgeon who now performs C4-7 ACDF given the information he got from the epidural.

I would do an ILESI with particulate and see what happens first.
 
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