Fluoroscopy

• Novel Barium-Enhanced 3-Dimensional-Printed Spine Model for Pedicle Screw Training: A Cost-Effective Solution and Educational Validation
• Accuracy and Safety Assessment of Subaxial Cervical Pedicle Screw Instrumentation: A Systematic Review
• Revisiting Härtel's technique for percutaneous transoval glycerol injection
• Combined use of SpineJack and microwave ablation with CT and C-arm in the treatment of vertebral fractures in oncologic patients: a case- based technical note
• Accuracy and Safety Between Robot-Assisted and Conventional Freehand Fluoroscope-Assisted Placement of Pedicle Screws in Thoracolumbar Spine: Meta-Analysis
• Effect of Cold Saline Pre-Washing on Cement Leakage in Vertebroplasty: A Novel Approach
• Radiation Exposure and Dose Estimates of Robot-Guided Versus Fluoroscopy-Guided Spinal Fusion: A Meta-Analysis of Randomized Controlled Trials
• Evolution of Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Pre-, Partial-, and Full-navigation in a 15-year Cohort

Imaging technique that uses X rays to obtain real-time moving images of the internal structures of a patient through the use of a fluoroscope. In its simplest form, a fluoroscope consists of an X-ray source and fluorescent screen between which a patient is placed. However, modern fluoroscopes couple the screen to an X-ray image intensifier and CCD video camera allowing the images to be recorded and played on a monitor.

The use of X-rays, a form of ionizing radiation, requires the potential risks from a procedure to be carefully balanced with the benefits of the procedure to the patient. While physicians always try to use low dose rates during fluoroscopic procedures, the length of a typical procedure often results in a relatively high absorbed dose to the patient. Recent advances include the digitization of the images captured and flat panel detector systems; modern advances allow further reduction of the radiation dose to the patient.

In challenging-to-access anatomic regions, fluoroscopy and intraoperative neurophysiology can be employed to augment targeting of neuromodulation electrodes to the site of seizure onset zone or specific neurophysiological biomarkers of clinical interest while minimizing brain retraction ¹⁾.

C Arm

Digital subtraction angiography.

Fluoroscopy radiation exposure.

The aim of the present study was the verification of the accuracy of 2D fluoroscopy-based navigated pedicle screw placements at the thoracic and lumbar spine in a case series of traumatised patients. Within 36 months 111 pedicle screws were instrumented using C-arm based navigation in 29 patients, 60 at the thoracic and 51 at the lumbar spine. All screw positions were evaluated postoperatively by a routine thin-slice CT scan using multiplanar reconstruction. The position of a screw in relation of its pedicle was classified as: a) screw completely intraosseous, b) screw perforated less than thread level and c) screw perforated over thread level. In 34 thoracic (56.7%) and 32 lumbar (62.7%) screws complete intraosseous placement was observed, 14 thoracic screws (23.3%) and 14 lumbar screws (27.5%) perforated less than thread level. Perforations over thread level were found in 12 thoracic (20%) and 5 lumbar (9.8%) screws. Only medial and lateral perforations of the pedicle were documented (without neurological signs), cranial or caudal perforations did not occur. Segmentation of the C-arm navigation into two comparable treatment periods showed a learning curve with a reduction of perforations in the second sequence (after 57 pedicle instrumentations) of about 15%, this was not found to be statistically significant. The fluoroscopic navigation of pedicle screws is a safe procedure at the lumbar spine with equal accuracy compared to the non-navigated conventional instrumentation. Application of C-arm navigation at the thoracic spine showed more inaccuracies, so that 3D-based navigation seems to be more advantageous in this region ²⁾.

Quiñones-Hinojosa A, Robert Kolen E, Jun P, Rosenberg WS, Weinstein PR. Accuracy over space and time of computer-assisted fluoroscopic navigation in the lumbar spine in vivo. J Spinal Disord Tech. 2006 Apr;19(2):109-13. PubMed PMID: 16760784.

Fluoroscopy-guided lumbar puncture

Fluoroscopy is a real-time imaging technique that uses X-rays to visualize moving anatomical structures, medical devices, or contrast-enhanced areas of the body. Its indications span multiple medical specialties, including interventional radiology, orthopedics, cardiology, and gastroenterology. Below are the main indications categorized by specialty:

### 1. Musculoskeletal System

1. Fracture Reduction: Fluoroscopy helps guide orthopedic surgeons in reducing complex fractures.
2. Joint Injections and Aspirations: Used for intra-articular injections (e.g., corticosteroids, viscosupplementation) and joint aspirations.
3. Spinal Interventions:
   1. Epidural steroid injections
   2. Facet joint injections
   3. Radiofrequency ablation for chronic pain
   4. Vertebroplasty/Kyphoplasty for vertebral compression fractures
4. Orthopedic Hardware Placement: Ensures proper positioning of plates, screws, rods, and prostheses.

### 2. Cardiovascular System

1. Cardiac Catheterization: Fluoroscopy is essential for angiography, percutaneous coronary interventions (PCI), and electrophysiology studies.
2. Pacemaker and ICD Implantation: Guides lead placement within the heart.
3. Endovascular Aneurysm Repair (EVAR): Used for deploying stent grafts in aortic aneurysms.
4. Peripheral Angiography and Interventions: Guides balloon angioplasty and stent placements in peripheral arteries.

### 3. Gastrointestinal System

1. Barium Swallow/Esophagram: Evaluates swallowing disorders, gastroesophageal reflux, and structural abnormalities like strictures or diverticula.
2. Upper Gastrointestinal (GI) Series: Assesses gastric and duodenal pathology (e.g., ulcers, obstruction).
3. Small Bowel Follow-Through (SBFT): Detects Crohn’s disease, malabsorption syndromes, and small bowel obstruction.
4. Barium Enema: Diagnoses colorectal abnormalities, including strictures, masses, or Hirschsprung’s disease.
5. Percutaneous Gastrostomy Tube (PEG) Placement: Guides insertion of feeding tubes.

### 4. Genitourinary System

1. Voiding Cystourethrography (VCUG): Evaluates vesicoureteral reflux and urethral abnormalities.
2. Retrograde Urethrogram (RUG): Detects urethral strictures or trauma.
3. Ureteral Stent Placement and Removal: Helps position ureteral stents in obstructive uropathy.
4. Hysterosalpingography (HSG): Assesses uterine and fallopian tube patency in infertility workups.

### 5. Pulmonary System

1. Bronchoscopy with Fluoroscopy: Assists in transbronchial lung biopsies and stent placement.
2. Percutaneous Tracheostomy: Guides tracheal cannulation in critically ill patients.

### 6. Neurosurgery and Pain Management

1. Myelography: Used to assess spinal cord pathology when MRI is contraindicated.
2. Cervical, Thoracic, and Lumbar Spine Injections: Epidural steroid injections and selective nerve root blocks.
3. Intrathecal Pump and Spinal Cord Stimulator Placement: Ensures proper device positioning.

### 7. Interventional Radiology

1. Guided Biopsies (Lung, Liver, Kidney, Bone): Minimally invasive biopsy procedures.
2. Percutaneous Drainage of Abscesses: Includes placement of percutaneous nephrostomy or biliary drains.
3. Transjugular Intrahepatic Portosystemic Shunt (TIPS): Fluoroscopy is crucial for creating a shunt in portal hypertension.

### 8. Miscellaneous Indications

1. Foreign Body Removal: In the gastrointestinal, respiratory, or genitourinary tract.
2. Swallowing Studies in Stroke Patients: To assess aspiration risk.
3. Tumor Embolization: For liver, renal, or bone tumors prior to surgery or treatment.