Radiation in Spine Care: A Comprehensive Review of Radiation Sources, Emerging Technology, Cancer Risk, and Radiation Stewardship.
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Radiation from medical imaging is increasingly recognized as a modifiable carcinogenic exposure. The precise population-level cancer burden remains debated, but the oncologic cost is real, unevenly distributed by patient age and sex and largely controllable at the point of clinical decision-making. Spine care occupies a central position in this discussion because many patients are exposed to ionizing radiation repeatedly over the course of their care. This includes patients within a wide age range undergoing surgery, fluoroscopic- or computerized tomography (CT)-guided percutaneous interventions, and serial imaging. In younger patients, the attributable cancer risk per unit dose is greater and the latency period for radiation-induced malignancy is longer; in patients requiring repeated interventions, cumulative lifetime radiation exposure may also become substantial. These concerns are increasingly relevant as navigation, robotics, and augmented reality platforms have expanded the use of preoperative and intraoperative CT. In this context, we sought to synthesize the current evidence across radiation physics, carcinogenesis risk modeling, perioperative radiation sources, patient-level risk heterogeneity, surgeon and operating room personnel exposure, and technology-specific evidence. Particular attention is paid to patient-level heterogeneity as cancer risk per unit dose varies by nearly an order of magnitude across age and sex strata such that oncologic implications of an otherwise identical imaging protocol may differ substantially depending on the patient receiving it. Building on the evidence, we introduce a radiation budgeting framework that treats the full perioperative episode as the unit of radiation accountability and propose radiation stewardship in spine care as a structural analog to antibiotic stewardship in infectious disease.