Reducing Radiation Exposure in Lumbar Transforaminal Epidural Steroid Injections with Pulsed Fluoroscopy: A Randomized, Double-blind, Controlled Clinical Trial.

Background: Fluoroscopy-guided lumbar transforaminal epidural steroid injections (L-TFESI) result in radiation exposure that carries risks to patients, physicians, and procedural staff.

Objective: We aim to evaluate the feasibility of using pulsed fluoroscopy to safely reduce radiation exposure during L-TFESI.

Study Design: This is a prospective, double-blind, randomized controlled trial.

Setting: This study took place in a single-center, academic, outpatient interventional pain management clinic.

Methods: Patients undergoing L-TFESI were randomly assigned to either continuous mode fluoroscopy (high-dose), pulsed fluoroscopy with 8 pulses per second (medium-dose), or pulsed fluoroscopy with one pulse per second (low-dose). Data on radiation doses and other clinical and demographic factors were also collected.

Results: In total, 231 cases were analyzed in the high-dose group (n = 81), medium-dose group (n = 72), and low-dose group (n = 78). Mean radiation effective dose (µSv) was 121 in the high-dose group, 57.9 in the medium-dose group, and 34.8 in the low-dose group (P < 0.001). The incidence of inadequate image quality in the pulsed groups was 6% (9/150). The body mass index (BMI, mean ± SD) was significantly higher in patients with inadequate image quality (37.3 ± 7.2) than with adequate quality (30.5 ± 7.2, P = 0.005).

Limitations: Radiation doses were measured using the meter on C-arm fluoroscopes rather than by direct measurement.

Conclusions: The use of pulsed fluoroscopy during L-TFESI resulted in radiation dose reduction of up to 72.1% without causing any significant adverse events. Pulsed fluoroscopy should be considered as an initial fluoroscopic setting for L-TFESI to reduce radiation exposure.

Key Words: Radiation, epidural, fluoroscopy, injection, exposure, pulse.