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Computed Tomography of the Spine. Clin Neuroradiol 2022; 33:271-291. [DOI: 10.1007/s00062-022-01227-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/10/2022] [Indexed: 11/24/2022]
Abstract
AbstractThe introduction of the first whole-body CT scanner in 1974 marked the beginning of cross-sectional spine imaging. In the last decades, the technological advancement, increasing availability and clinical success of CT led to a rapidly growing number of CT examinations, also of the spine. After initially being primarily used for trauma evaluation, new indications continued to emerge, such as assessment of vertebral fractures or degenerative spine disease, preoperative and postoperative evaluation, or CT-guided interventions at the spine; however, improvements in patient management and clinical outcomes come along with higher radiation exposure, which increases the risk for secondary malignancies. Therefore, technical developments in CT acquisition and reconstruction must always include efforts to reduce the radiation dose. But how exactly can the dose be reduced? What amount of dose reduction can be achieved without compromising the clinical value of spinal CT examinations and what can be expected from the rising stars in CT technology: artificial intelligence and photon counting CT? In this article, we try to answer these questions by systematically reviewing dose reduction techniques with respect to the major clinical indications of spinal CT. Furthermore, we take a concise look on the dose reduction potential of future developments in CT hardware and software.
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Radiation dose of fluoroscopy-guided versus ultralow-dose CT-fluoroscopy-guided lumbar spine epidural steroid injections. Skeletal Radiol 2022; 51:1055-1062. [PMID: 34611727 DOI: 10.1007/s00256-021-03920-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Compare radiation dose of lumbar spine epidural steroid injections (ESIs) performed under fluoroscopy guidance and ultralow-dose CT-fluoroscopy guidance. MATERIALS AND METHODS Retrospective review of consecutive lumbar ESIs performed using fluoroscopy, between May 2017 and April 2019, and using ultralow-dose CT-fluoroscopy, between August 2019 and February 2021, was performed. Ultralow-dose CT-fluoroscopy technique omits a planning CT scan, utilizes CT-fluoroscopy, and minimizes radiation dose parameters. Patient characteristics (age, sex, height, weight, body mass index (BMI)), procedural characteristics (anatomic level, type of ESI, procedure time, pain reduction, complications, trainee participation), and radiation dose were compared. Chi-square tests and two-sample t-tests were performed for statistical analysis. RESULTS One hundred and forty-seven patients (mean age 55.8 ± 16.7; 85 women) underwent ESIs using fluoroscopy. Sixty-six patients (mean age 60.9 ± 16.7; 33 women) underwent ESIs using ultralow-dose CT-fluoroscopy. The effective dose for the fluoroscopy group was 0.30 mSv ± 0.34, compared to 0.15 mSV ± 0.11 for ultralow-dose CT-fluoroscopy (p < 0.001). The average age in the CT-fluoroscopy group was older (p = 0.04), and there was more trainee participation in the fluoroscopy group (p < 0.001); otherwise there was no statistically significant difference in patient or procedural characteristics between the conventional fluoroscopy group and the ultralow-dose CT-fluoroscopy group. There was no statistically significant difference in immediate post-procedure pain reduction between the groups (p = 0.16). Four intrathecal injections occurred only in the fluoroscopy group, though this difference was not significant (p = 0.18). CONCLUSION Ultralow-dose CT-fluoroscopy technique for image-guided lumbar spine ESIs can lower radiation dose compared to fluoroscopy-guided technique.
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Arif S, Brady Z, Enchev Y, Peev N, Encheva E. Minimising radiation exposure to the surgeon in minimally invasive spine surgeries: A systematic review of 15 studies. Orthop Traumatol Surg Res 2021; 107:102795. [PMID: 33333283 DOI: 10.1016/j.otsr.2020.102795] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 09/22/2020] [Accepted: 09/29/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intraoperative imaging in minimally invasive spinal surgeries is associated with significant radiation exposure to surgeons, which overtime can lead to serious health hazards including malignancy. In this study, the authors conducted a systematic review to evaluate the efficacy of navigation assisted fluoroscopy methods on radiation exposure to the surgeon in minimally invasive spine surgeries, percutaneous endoscopic lumbar discectomy/percutaneous endoscopic transforaminal discectomy versus minimally invasive spine transforaminal lumbar interbody fusion (PELD/PETD versus MIS-TLIF). METHODS A systematic literature search was conducted using PUBMED/MEDLINE on 20th July, 2020. Inclusion criteria were applied according to study design, surgical technique, spinal region, and language. Data extracted included lumbar segment, average operation time (min), fluoroscopic time (s), and radiation dose (μSV), efficacy of modified navigation versus conventional techniques; on reducing operation, fluoroscopy times and effective radiation dose. RESULTS Fifteen studies (ten prospectives, and five retrospectives) were included for quantitative analysis. PELD recorded a shorter operation time (by 126.3min, p<0.001) and fluoroscopic time (by 22.9s, p=0.3) than MIS-TLIF. The highest radiation dose/case (μSV) for both techniques were recorded at the surgeon's: finger, chest, neck and eye. The effective dose for MIS-TLIF was 30μSV higher than PELD. Modified navigation techniques recorded a shorter operation time (by 15.9min, p=0.3); fluoroscopy time (by 289.8s, p=0.3); effective radiation dose (by 169.5μSV, p=0.3) than conventional fluoroscopy methods. DISCUSSION This systematic literature review showed that although navigation assisted fluoroscopy techniques are superior to conventional methods in minimising radiation exposure, lack of statistical significance warrants future randomised controlled trials, to solidify their efficacy in reducing radiation related hazards.
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Affiliation(s)
- Shahswar Arif
- Medical university of Varna, ul. "Professor Marin Drinov" 55, 9002 Center Varna, Bulgaria
| | - Zarina Brady
- Medical university of Varna, ul. "Professor Marin Drinov" 55, 9002 Center Varna, Bulgaria.
| | - Yavor Enchev
- Medical university of Varna, ul. "Professor Marin Drinov" 55, 9002 Center Varna, Bulgaria; Department of neurosurgery, medical university of Varna, university hospital "St. Marina", Varna, Bulgaria
| | - Nikolay Peev
- Department of neurosurgery, Royal Victoria hospital, Belfast health and social care trust, Belfast, Northern Ireland, United Kingdom
| | - Elitsa Encheva
- Medical university of Varna, ul. "Professor Marin Drinov" 55, 9002 Center Varna, Bulgaria
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Jenkins NW, Parrish JM, Sheha ED, Singh K. Intraoperative risks of radiation exposure for the surgeon and patient. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:84. [PMID: 33553377 PMCID: PMC7859810 DOI: 10.21037/atm-20-1052] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intraoperative radiological imaging serves an essential role in many spine surgery procedures. It is critical that patients, staff and physicians have an adequate understanding of the risks and benefits associated with radiation exposure for all involved. In this review, we briefly introduce the current trends associated with intraoperative radiological imaging. With the increased utilization of minimally invasive spine surgery (MIS) techniques, the benefits of intraoperative imaging have become even more important. Less surgical exposure, however, often equates to an increased requirement for intraoperative imaging. Understanding the conventions for radiation measurement, radiological fundamental concepts, along with deterministic or stochastic effects gives a framework for conceptualizing how radiation exposure relates to the risk of various sequela. Additionally, we describe the various options surgeons have for intraoperative imaging modalities including those based on conventional fluoroscopy, computer tomography, and magnetic resonance imaging. We also describe different ways to prevent unnecessary radiation exposure including dose reduction, better education, and use of personal protective equipment (PPE). Finally, we conclude with a reflection on the progress that has been made to limit intraoperative radiation exposure and the promise of future technology and policy.
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Affiliation(s)
- Nathaniel W Jenkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - James M Parrish
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Evan D Sheha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Shah V, Hillen T, Jennings J. Comparison of low-dose CT with CT/CT fluoroscopy guidance in percutaneous sacral and supra-acetabular cementoplasty. ACTA ACUST UNITED AC 2020; 25:353-359. [PMID: 31358490 DOI: 10.5152/dir.2019.18362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Percutaneous cementoplasty is a minimally invasive treatment modality for painful osteoporotic and pathologic sacral and supra-acetabular iliac fractures. This study compares the use of low-dose CT guidance with CT/CT fluoroscopy in sacral and supra-acetabular cementoplasty. METHODS A retrospective review of patients who had undergone sacral or supra-acetabular cementoplasty was performed with patients grouped by use of CT/CT fluoroscopy or low-dose CT guidance during the procedure. Parameters evaluated included type of fracture, laterality of lesions, pain scores, pain medication use, imaging parameters, procedure time, dose-length product, effective dose, cement volume, and complications. RESULTS There were 17 patients identified who underwent cementoplasty utilizing dual CT/CT fluoroscopy, while 13 patients had their procedures performed with low-dose CT. There was a statistically significant decrease in radiation dose in the low-dose CT group (1481 mGy•cm) compared with the CT/CT fluoroscopy group (2809 mGy•cm) (P = 0.013). There was a significant decrease in procedure time with low-dose CT for bilateral lesions (P = 0.016). There was no significant difference between groups in complication rate (P = 0.999). Clinically nonsignificant cement extravasation occurred in two patients (10%) in the CT/CT fluoroscopy group and in one patient (8%) in the low-dose CT group (P = 0.999). There was a significant decrease in pain scores compared with baseline on the visual analogue scale in both groups at 1 week (low-dose CT P = 0.002, CT/CT fluoroscopy P = 0.008) and 1 month postprocedure (low-dose CT P = 0.014, CT/CT fluoroscopy P = 0.004), but no difference between groups at 1 day (P = 0.196), 1 week (P = 0.368), or 1 month (P = 0.514). CONCLUSION Sacral and supra-acetabular cementoplasties can be performed safely and precisely using low-dose multiple-acquisition CT guidance while providing significant radiation dose reduction with no difference in extravasation rates, postprocedural pain reduction, and complications compared with CT/CT fluoroscopy.
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Affiliation(s)
- Veer Shah
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Travis Hillen
- Division of Musculoskeletal Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jack Jennings
- Division of Musculoskeletal Radiology, Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Brady Z, Arif S, Enchev Y, Peev N, Encheva E. Reduction of radiation exposure in spinal surgery. J Neurosurg Sci 2020; 65:79-80. [PMID: 32043850 DOI: 10.23736/s0390-5616.20.04882-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | | | - Yavor Enchev
- Medical University of Varna, Varna, Bulgaria.,Department of Neurosurgery, Medical University of Varna, St. Marina University Hospital, Varna, Bulgaria
| | - Nikolay Peev
- Department of Neurosurgery, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
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Scout-guided needle placement-a technical approach for dose reduction in CT-guided periradicular infiltration. Neuroradiology 2019; 62:341-346. [PMID: 31838562 DOI: 10.1007/s00234-019-02339-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To develop and evaluate a technical approach for CT-guided periradicular infiltration using quantitative needle access and guidance parameters extracted from CT scout images. METHODS Five 3D-printed phantoms of the abdomen mimicking different patients were used to develop a technical approach for scout-guided periradicular infiltration. The needle access point, puncture depth, and needle angulation were calculated using measurements extracted from anterior-posterior and lateral CT scout images. Fifty needle placements were performed with the technique thus developed. Dose exposure and number of image acquisitions were compared with ten procedures performed using a conventional free-hand technique. Data were analyzed with the Mann-Whitney U test. RESULTS Parameters derived solely from scout images provided adequate guidance for successful and reliable needle placement. Needle guidance was performed with the same equipment as the standard periradicular infiltration. Two scout images and 3.5 ± 2.3 (mean ± SD) single-shot images for needle positioning were acquired. Mean DLP ± SD was 3.8 ± 2.5 mGy cm. The number of single-shot acquisitions was reduced by 68% and the overall dose was reduced by 84% in comparison with the conventional free-hand technique (p < 0.0001). CONCLUSION Scout-guided needle placement for periradicular infiltration is feasible and reduces radiation exposure significantly.
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Systematic Evaluation of Low-dose MDCT for Planning Purposes of Lumbosacral Periradicular Infiltrations. Clin Neuroradiol 2019; 30:749-759. [DOI: 10.1007/s00062-019-00844-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/04/2019] [Indexed: 12/16/2022]
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Narain AS, Hijji FY, Yom KH, Kudaravalli KT, Haws BE, Singh K. Radiation exposure and reduction in the operating room: Perspectives and future directions in spine surgery. World J Orthop 2017; 8:524-530. [PMID: 28808622 PMCID: PMC5534400 DOI: 10.5312/wjo.v8.i7.524] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/21/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
Intraoperative imaging is vital for accurate placement of instrumentation in spine surgery. However, the use of biplanar fluoroscopy and other intraoperative imaging modalities is associated with the risk of significant radiation exposure in the patient, surgeon, and surgical staff. Radiation exposure in the form of ionizing radiation can lead to cellular damage via the induction of DNA lesions and the production of reactive oxygen species. These effects often result in cell death or genomic instability, leading to various radiation-associated pathologies including an increased risk of malignancy. In attempts to reduce radiation-associated health risks, radiation safety has become an important topic in the medical field. All practitioners, regardless of practice setting, can practice radiation safety techniques including shielding and distance to reduce radiation exposure. Additionally, optimization of fluoroscopic settings and techniques can be used as an effective method of radiation dose reduction. New imaging modalities and spinal navigation systems have also been developed in an effort to replace conventional fluoroscopy and reduce radiation doses. These modalities include Isocentric Three-Dimensional C-Arms, O-Arms, and intraoperative magnetic resonance imaging. While this influx of new technology has advanced radiation safety within the field of spine surgery, more work is still required to overcome specific limitations involving increased costs and inadequate training.
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Aichmair A, Farshad M. Reply to the Letter to the Editor of M. Avellanal concerning: "Cost-effectiveness of conservative versus surgical treatment strategies of lumbar spinal stenosis in the Swiss setting: analysis of the prospective multicenter Lumbar Stenosis Outcome Study (LSOS)" by A. Aichmair et al. (Eur Spine J; 2016. doi:10.1007/s00586-016-4937-y). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:1318-1319. [PMID: 28190205 DOI: 10.1007/s00586-017-4998-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 02/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Alexander Aichmair
- Spine Division, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Mazda Farshad
- Spine Division, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Hazards of Ionizing Radiation and its Impact on Spine Surgery. World Neurosurg 2016; 92:353-359. [DOI: 10.1016/j.wneu.2016.05.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 12/28/2022]
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Reducing Patient Radiation Exposure From CT Fluoroscopy-Guided Lumbar Spine Pain Injections by Targeting the Planning CT. AJR Am J Roentgenol 2016; 206:390-4. [PMID: 26797369 DOI: 10.2214/ajr.15.14436] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE CT fluoroscopy-guided lumbar spine pain injections typically include a preprocedural planning CT that contributes considerably to patient dose. The purpose of this study was to quantify the degree of radiation exposure reduction achieved by modifying only the planning CT component of the examination. MATERIALS AND METHODS A retrospective review was performed of 80 CT fluoroscopy-guided lumbar spine injections. Forty patients were scanned with a standard protocol using automatic tube current modulation (method A). Another 40 patients were scanned using a new technique that fixed the tube current of the planning CT to either 50 or 100 mA on the basis of the patient's anteroposterior diameter and that reduced the z-axis coverage (method B). Dose-length products (DLPs) were compared for the two methods. RESULTS The mean maximal tube current for the planning CT was 435.0 mA for method A and 67.5 mA for method B. The mean z-axis was shorter for method B at 6.5 cm than for method A at 9.6 cm (p < 0.0001). The mean DLP for the planning CT was 11 times lower for method B than for method A: 27.9 versus 313.1 mGy × cm, respectively (p < 0.0001). When method B was used, the mean DLP for the total procedure (i.e., planning CT plus CT fluoroscopy components) was reduced by 78%. There was no significant difference between methods A and B in CT fluoroscopy time (p = 0.37). All procedures were technically successful. CONCLUSION A nearly fivefold reduction in radiation exposure can be achieved in CT fluoroscopy-guided lumbar spine pain injections through modifications to the planning CT alone.
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Paik NC. Radiation Dose Reduction in CT Fluoroscopy-Guided Lumbar Interlaminar Epidural Steroid Injection by Minimizing Preliminary Planning Imaging. Eur Radiol 2014; 24:2109-17. [DOI: 10.1007/s00330-014-3245-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 04/29/2014] [Accepted: 05/14/2014] [Indexed: 11/24/2022]
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Bui J, Bogduk N. A systematic review of the effectiveness of CT-guided, lumbar transforaminal injection of steroids. PAIN MEDICINE 2013; 14:1860-5. [PMID: 24330228 DOI: 10.1111/pme.12243] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the effectiveness and safety of computerized tomography (CT) guided, lumbar transforaminal injection of steroids in the treatment of radicular pain. DESIGN Systematic review of published literature. INTERVENTIONS Two reviewers independently assessed 19 publications on the effectiveness and safety of CT-guided, lumbar transforaminal injection of steroids. OUTCOME MEASURES For effectiveness, the primary outcome was the success rate for relief of pain. For safety, the radiation exposure involved and the nature of complications were determined. RESULTS Much of the literature fails to provide evidence. Two studies reported decreases in mean or median pain scores but no other data. Two studies reported success rates of between 34% and 62% for achieving 50% relief of pain at between 1 and 6 months after treatment. CT-guided injections may involve greater radiation exposure than does fluoroscopy-guided injections and do not avoid catastrophic spinal cord injury. CONCLUSION The evidence-base for CT-guided lumbar transforaminal injection of steroids is meagre. This intervention is not more effective than fluoroscopy-guided injections and is not demonstrably safer.
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Affiliation(s)
- John Bui
- Department of Medical Imaging, John Hunter Hospital, Newcastle, New South Wales, Australia
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MR Imaging-guided Lumbosacral Spinal Injection Procedures. Tech Orthop 2013. [DOI: 10.1097/bto.0b013e3182867817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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