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Enhancing occupational safety in the X-ray laboratory

Bansal, Priyaa,b; Luna, Michaelc,d; Dutton, Margaretd; Maini, Aneele; Banerjee, Subhashc,f; Brilakis, Emmanouil S.g; Maini, Brijeshwara,b; Khalili, Houmana,b

Author Information
doi: 10.1097/MCA.0000000000001091
  • Open

Abstract

Introduction

Working in an X-ray laboratory carries several occupational health hazards. The risks associated with radiation exposure are well-defined and several strategies have been developed to minimize patient and operator radiation dose [1–8]. The cumulative burden of bearing the weight of protective leaded aprons in the X-ray laboratory has been associated with a significant risk of orthopedic illnesses [5,9,10]. Several surveys by the Society for Cardiovascular Angiography and Interventions (SCAI) have demonstrated nearly 50% incidence of occupational-induced orthopedic injuries over the duration of a career [9–11]. Cervical and lumbar spinal injuries were most frequently reported, followed by hip, knee, and ankle joint injuries. Age over 50 years and working in the cardiac catheterization laboratory for more than 15 years were associated with higher injury risk [12]. The high risk of spine injury led to the development of the term ‘interventionalist’s disc disease’ [13].

The authors created and dispersed a survey via email, text message, and social media; a total of 70 interventional cardiology recipients responded. Of the total number of responses, 84% reported one or more orthopedic injuries that may be attributed to work: 25% in the cervical spine; 61.6% in the lumbar or sacral spine; 38.5% in the shoulder; 25% knee or hip; 21.2% sciatica or other nerve impingements (Fig. 1). Despite 82.1% utilizing different methods to manage the injuries (physical therapy, strength training, stretching, and pain medication), up to 80% still reported possible lingering pain. As a result, 22.9% have considered early retirement (Table 1).

Table 1 - Orthopedic injury or musculoskeletal pain in the X-ray laboratory survey results
Characteristics Mean ± SD
BMI (kg/m2) 25.9 ± 3.7
Percent (n)
Age
 20–40 28.6% (20)
 41–60 58.6% (41)
 >60 12.8% (9)
Sex
 Male 84.3% (59)
 Female 15.7% (11)
Years in X-ray laboratory
 <5 21.2% (14)
 5–15 30.3% (24)
 16–25 27.3% (18)
 >25 21.2% (14)
Hours per week in X-ray laboratory
 1–20 45.7% (32)
 21–40 31.4% (22)
 41–50 22.9% (16)
Prior orthopedic injury or chronic musculoskeletal pain 74.3% (52)
Work-related
 Yes 42.0% (21)
 Maybe 42.0% (21)
 No 16.0% (8)
Methods to manage injury/pain
 None 17.9% (12)
 Physical therapy 31.3% (21)
 Strength training 19.4% (13)
 Stretching 17.9% (12)
 Pain medicine 13.5% (9)
NSAIDS or other pain medication doses per week
 0 47.0% (23)
 1–10 48.9% (24)
 >10 4.1 % (2)
Lingering pain as a result of the injury
 Yes 56.0% (28)
 Maybe 24.0% (16)
 No 20.0% (10)
Shoes worn in the X-ray laboratory
 Clogs 29.0% (20)
 Sneakers 63.8% (44)
 Formal/dress shoes 7.2 % (5)
Early retirement planned due to injuries
 Yes 8.6% (6)
 Maybe 14.3% (10)
 No 77.1% (54)
Assumed risk of orthopedic injury compared to colleagues who do not practice in the X-ray laboratory (1 = no increased risk; 5 = far greater risk)
 1 5.7% (4)
 2–3 25.7% (18)
 4–5 68.6% (48)

F1
Fig. 1:
Survey results: types of orthopedic injuries in the X-ray laboratory.

Limited progress has been achieved in reducing orthopedic injuries in the X-ray laboratory. SCAI published a joint position statement calling for innovation to reduce these risks [14]. With the increasing volume and complexity of transcatheter procedures, it is essential to further study the incidence and pathogenesis of these orthopedic injuries and develops and implements strategies to prevent and treat them.

Shielding

There are three modes of shielding: personal protective devices (PPEs), architectural, and equipment-mounted. Considerable efforts have been made to optimize PPE design without undermining radiation protection. The most commonly used PPE, lead garments, have been the standard mode of radiation protection used by personnel during fluoroscopy. Conventional 0.5 mm lead aprons are heavy (approximately 7 kg); however, newer aprons are 20–40% lighter and are made of barium, tungsten, antimony, and tin. Improper lead weight and fitting can influence the likelihood of musculoskeletal injury and pain. Garments that are too large can allow scatter to pass through armholes and thereby increase radiation exposure, particularly increased risk for female operators. Therefore, all personal protective aprons should be properly fitted. As compared with one-piece wraparound aprons, two-piece aprons have been found to decrease loading pressures on the cervical and thoracic spines due to the distribution of weight to the hips instead of the back. Importantly, the vest of the two-piece apron should be lifted from the shoulders while securely fastening at the waist to reduce stress on the shoulders. Recent innovations have also sought to further decrease the weight burden with non-lead alternatives such as bismuth [15].

Ceiling-suspended shields, such as Zero-Gravity (Fig. 2) and Newton Medical System (Newton Inc., Quebec, Canada), are walk-in suits that eliminate the axial weight of lead aprons placed on the body of the interventionalist. The gantry allows for movement along the X, Y, and Z axes. These shields are typically made of transparent leaded plastic that is adjustable during the procedure. This system has been available for several years; however, its adoption has remained slow primarily due to cost and slight limitation to the operator’s freedom of movement.

F2
Fig. 2:
Zero-Gravity ceiling-suspended shielding.

Newer shielding technologies have been developed to attempt to reduce interference in procedural performance. Radiaction (InnovaHealth Partners, Tel Aviv, Israel) shields the fluoroscopic system itself instead of the personnel. The system operates by deploying a shield from the C-arm unit that encapsulates the radiation source at any angle, thereby significantly reducing scatter radiation. Protego (Image Diagnostics, Fitchburg, Massachusetts, USA) features a compact radiation barrier system comprised of a suspension support arm holding a beveled upper shield made of a soft leaded apron that accommodates all C-arm angles without manipulation, a central orifice that allows for patient and vascular access, and a lower table shield with an interconnected patient drape.

Robotic systems

The Percutaneous Robotically Enhanced Coronary Intervention and Complex Robotically Assisted Percutaneous Coronary Intervention (PCI) studies have demonstrated the safety and efficacy of uncomplicated PCI with remote manipulation using robotic technology [16,17]. Although vascular access, diagnostic coronary angiography, and placement of coronary guide catheter must be done manually, the operator’s ‘load bearing’ time can be significantly reduced with a hybrid robotic approach. The operator has a remote control with a joystick and touch-screen interface to guide a robotic arm mounted to the laboratory table while sitting in a lead-lined interventional cockpit (Fig. 3). The guide catheter is connected to a disposable sterile cassette which is attached to the robotic arm, through which intravascular tools can be exchanged. The robotic arm is maneuverable for both radial and femoral access. Limitations at this time include over-the-wire equipment, complex lesions including heavily calcified lesions that may require atherectomy, bifurcation lesions, and tortuous vessels. There is, additionally, a loss of tactile feedback with telestenting, which can be critical in the outcome of complex PCI. However, this is an evolving technology that may have the potential to overcome these limitations in the future while significantly reducing radiation exposure and orthopedic strain for the interventionalist.

F3
Fig. 3:
Optimal interventional suite design with robotically-assisted percutaneous coronary intervention. Reprinted with permission from Carrozza JP. Robotic-assisted PCI – a new approach to the transcatheter treatment of coronary artery disease. Cath Lab Digest. 2012;10(20. Copyright HMP Global.

Interventional suite design

Procedure rooms should be designed to foster optimal positioning of the equipment to reduce repetitive stress and posture-related injuries (Fig. 3). The monitors should be placed in the operator’s direct field of view to prevent unnatural orientation of the head, neck, and shoulders. The C-arm and other imaging equipment should be optimally positioned to allow the operator to stand without the need to hunch. Expansion monitors can be utilized in instances when the C-arm lies between the physician and the ceiling-mounted monitors.

Table height is ergonomically important as well. Operating surface height should be adjusted to maintain a comfortable posture without the need to elevate the arm. In one study, the optimal height of the operating table was at the level of the surgeon’s upper thigh during laparoscopic surgery. Further, the hands were positioned at the level of the elbow with the forearm in a horizontal position. This allowed the operator’s elbow joint to remain in a predominantly neutral position, which decreased the strain on the upper arms and shoulders. In this study, there was a reduction in the back, shoulder, as well as wrist discomfort during surgery [18].

The use of floor mats compared to hard surfaces has also been evaluated. Increasing bilateral gluteal medius co-activation has been identified as a key factor in developing lower back pain due to prolonged standing [19]. In contrast, phasic muscle activity helps to promote venous return. Standing on cushioned surfaces has been suggested to create subtle muscular movement, reducing musculoskeletal strain, improving blood flow, and decreasing discomfort and fatigue [20]. Mats made up of various materials ranging from vinyl to viscoelastic have been shown to affect operator perception of discomfort compared to concrete; however, very little evidence was found in support of specific material properties as factors when choosing the optimum type of surface. Minimal mat compressibility (ranging from 2.2 to 8.9%) was important in the comfort ratings [21].

Footwear

Like floor mats, shoe insoles have also been shown, with varying degrees, to improve discomfort with prolonged standing. In fact, King demonstrated the combination of shoe insoles with these mats resulted in the most reduction of discomfort [20].

Several studies have investigated the wearing of support stockings or hosiery during standing at work using subjective as well as biomechanical or physiological measures. Most of the studies reviewed support the use of compression stockings in the reduction of subjective complaints of leg fatigue, pain, and swelling in work requiring prolonged standing. The findings with the physiological and biomechanical measures are less convincing, although some positive findings in reduction of leg swelling and leg fluid volume have been reported [21–24].

Radial approach

Transradial approach has gained traction with less risk of bleeding, reduced vascular complications, and faster discharge [25,26]. There is a learning curve to the transradial approach which may, at least initially, increase the procedural time. However, with practice, fluoroscopy time and radiation dose are comparable to the transfemoral approach once the operator has performed greater than 60% of procedures with transradial approach over 5 years [27]. Similarly, in a substudy of the RadIal Versus femorAL access for coronary angiography and intervention trial in patients with acute coronary syndromes, only lower-volume centers had longer fluoroscopic times and higher radiation doses [28].

Radiation dose may still be higher in some patients using transradial access. Tortuosity at the level of the right innominate and aortic system may require breathing maneuvers or an exchange of wires that can add additional fluoroscopic imaging. In contrast, left radial access (LRA) has been shown to reduce radiation exposure to both the patient and operator compared with right radial access using a proper laboratory setup [29]. LRA does require preparation to pronate the patient’s hand to prevent operators from leaning across the table to manipulate catheters. This can be accomplished by using a wedge to angle the patient 30 degrees towards the right as well as an arm sling. There have also been arm boards (ex. Cobra Board by TZ Medical) designed to elevate and adduct the left arm to prevent drifting during the procedure. Alternatively, the use of distal left radial arterial access (i.e. snuffbox) does not require pronation and provides an additional level of comfort for the patient. In addition to reduced radiation exposure and fluoroscopic timing, LRA is favored in patients with prior coronary artery bypass graft surgery due to easier cannulation of the left subclavian artery.

PCI can theoretically be performed in a seated position, particularly in complex procedures of long anticipated duration. A configuration with the patient’s left arm angled at 90 degrees relative to the catheterization table will have the added benefit to LRA by seating the operator further from the C-arm, thereby potentially reducing radiation exposure.

Exercise

Intermittently resting one foot on a 6-inch block in addition to walking and stretching the back during a long case can decrease musculoskeletal strain. Postprocedurally, a 5-min stretching routine targeted to elongate overworked muscles can be beneficial (Fig. 4). For example, cervical stabilization and isometric exercises will strengthen the deep flexors to improve posture and decrease strain on the spine. These can easily be performed in the control room, sitting on a chair, or standing in a doorway. Maintenance of fitness outside of work, with emphasis on core body strength, is equally important. In our survey, only 19% regularly perform core workouts (Fig. 5). Simple exercises utilizing an elastic band can target the upper back, developing posterior chain strength and endurance (Fig. 6). Weight management should also be considered, as evidence suggests that obesity can hasten orthopedic injuries [30].

F4
Fig. 4:
Five-minute postprocedural stretching routine.
F5
Fig. 5:
Survey results: exercises interventional cardiologists perform regularly.
F6
Fig. 6:
At-home posterior chain strengthening routine.

Conclusion

Leaded aprons and prolonged standing during fluoroscopic procedures carry significant risk for orthopedic injuries. Strategies that prevent or minimize the use of leaded garments (such as the Zero-Gravity system and robotic PCI) and maintenance of proper ergonomic and exercise regimens will allow for a long, healthy, and productive career. Hospitals should invest in adopting platforms that have the potential to mitigate these occupational risks.

Acknowledgements

Conflicts of interest

E.B.: Consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Ebix, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; research support from Regeneron and Siemens. Shareholder: MHI Ventures. H.K.: Abbott Vascular Speaker Bureau. For the remaining authors, there are no conflicts of interest.

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Keywords:

interventionalist; musculoskeletal strain; orthopedic; X-ray laboratory

Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.