SUPPLEMENT
Radiation Safety in Pediatric Orthopaedics Michelle S. Caird, MD
Abstract: Patients, surgeons, and staff are exposed to ionizing radiation in pediatric orthopaedic surgery from diagnostic studies and imaging associated with procedures. Estimating radiation dose to pediatric patients is based on complex algorithms and dose to surgeons and staff is based on dosimeter monitoring. Surgeons can decrease radiation exposure to patients with careful and thoughtful ordering of diagnostic studies and by minimizing exposure intraoperatively. Surgeon and staff radiation exposure can be minimized with educational programs, proper shielding and positioning intraoperatively, and prudent use of intraoperative imaging. Overall, better awareness among pediatric orthopaedic surgeons of our role in radiation exposure can lead to improvements in radiation safety.
composition in the plane of the beam, and the energy of the beam. In addition, estimating the dose to surgeons and staff working in the presence of ionizing radiation medical imaging modalities is based on monitoring from dosimeter badges and rings worn by the staff. There are annual recommended limits for radiation exposure for staff. Factors that influence the radiation dose include time of radiation exposure, distance between the source and person, and shielding (material and its thickness) between the radiation source and the person. Factors influencing an individual’s radiation risk have been estimated from exposures in Hiroshima and Nagasaki. These include genetic considerations, patient age, sex, and the estimated radiation exposure.
Key Words: radiation exposure, ionizing radiation, medical imaging, computed tomography, fluoroscopy (J Pediatr Orthop 2015;35:S34–S36)
BACKGROUND Ionizing radiation comes to us from many sources outside of medical practice, including cosmic rays, radon, and radionuclides that we encounter in foods such as potassium isotopes in salt substitutes. Medical sources of ionizing radiation include radionuclides used in nuclear medicine imaging such as technetium 99, and other imaging modalities such as computed tomography (CT) scans, plain radiography, and fluoroscopy.1 Radiation effects on humans are divided into deterministic effects, including hair loss, skin burns, nausea, and cataract formation,2,3 and stochastic effects, which cause carcinogenesis and teratogenesis. Sensitive tissues are the gonads, breasts, thyroid, gastrointestinal tract, and bone marrow.4 Radiation exposure to pediatric patients is especially concerning because children have greater radiosensitivity than adults and they have longer life expectancy following radiation exposure.1 Estimating the radiation dose to a patient is complex. Algorithms for estimations are based on patient size, thickness of the body in the plane of the beam, body From the Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI. The author declares no conflicts of interest. Reprints: Michelle S. Caird, MD, Department of Orthopaedic Surgery, University of Michigan, 1540 E Hospital Dr, Ann Arbor, MI 481094241. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
S34 | www.pedorthopaedics.com
PATIENT RADIATION EXPOSURE In pediatric orthopaedics, our patients are exposed to radiation through diagnostic studies and imaging associated with surgical procedures. Plain radiographs are used commonly for fracture treatment, for monitoring growth disturbances and limb-length and alignment problems, and for scoliosis monitoring. Much of the literature on patient exposure to radiation in orthopaedics comes to us from studies on scoliosis monitoring.5–11 Posteroanterior (PA) scoliosis films offer lower radiation dose to thyroid and breast tissue than anteroposterior films. Digital plain radiography has the potential for lower radiation if care is taken by the technician. We should give careful consideration to the monitoring protocols for growing scoliosis patients, especially those with early-onset scoliosis.12 CT scans account for one of the fastest growing areas of radiation exposure for patients in the United States, and CT scans in children are on the rise as well. Some of this increase in childhood CT scans stems from important advances in care such as CT scans of the cervical spine for trauma evaluations. This imaging has become much more common in trauma centers for full evaluation of the pediatric cervical spine. Also in pediatric trauma situations, CT scans of the chest, abdomen, and pelvis may be required for full evaluation. Patients with thoracic insufficiency or early-onset scoliosis often undergo multiple chest CT scans to monitor lung volumes and changes over time with growth and treatment. Overall as hospitals update their CT scanners they can provide sharper images and faster scans. We should be aware, however, that the amount of radiation associated with this improved image quality may not necessarily decrease. Pediatric patients may also be exposed to radiation during orthopaedic surgical procedures.13 Intraoperative
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
fluoroscopy is used for intramedullary nailing of long bone fractures using both reamed nailing and flexible nailing techniques.14 It is also used commonly for closed reduction and percutaneous pinning of pediatric fractures. In cases of slipped capital femoral epiphysis pinning, the table and carm positioning have been shown to influence the radiation to the patient.15 Studies of hip arthroscopy have shown a relatively low dose to patients.16 Pedicle screw insertion techniques in scoliosis surgery often use intraoperative fluoroscopy. This can expose patients and surgeons to a much higher radiation dose, especially if c-arm images are used to place pedicle screws in a resident teaching setting where more images might be used. Intraoperative CT navigation is increasingly used for pedicle screw placement in pediatric spine surgery. This has the potential to offer a lower dose to the surgeons and staff, who can step away behind a lead shield during the scanning, but still exposes the patient to a CT scan. The patient may require multiple CT scans to image multiple levels for long-instrumentation constructs, and obese patients may require higher doses to acquire adequate images for navigation. Here protocols or judicious use of CT is warranted.
SURGEON AND STAFF RADIATION EXPOSURE Most exposure to ionizing radiation for surgeons and staff in pediatric orthopaedics occurs through intraoperative spot c-arm views and fluoroscopy.17–23 This exposure is primarily from scatter, which is high close to the radiation source and decreases to negligible levels at a distance of 2 m.24 Direct radiation exposure also occurs especially to the hands, which are often used for positioning of images.25 Studies of exposure to orthopaedic surgeons have been conducted in multiple surgical procedures, including placement of reamed and flexible intramedullary nails for fractures, foot and ankle surgery,26 lumbar interbody fusion,27 kyphoplasty, and pedicle screw insertion.28–30 Spine surgery often risks significant radiation exposure to the surgeon with studies of fluoroscopically aided pedicle screw placement demonstrating dose rates to surgeons of 10 to 12 times greater than nonspine fluoroscopy procedures and the possibility of exceeding lifetime dose limits in as few as 10 years.29,30
METHODS TO DECREASE EXPOSURE There are a number of methods for reducing the radiation exposure of pediatric orthopaedic patients. First, we should use care with ordering imaging studies. If the evaluation requires ionizing radiation we can limit the number of views; for example, in scoliosis monitoring a PA view alone may be adequate for decision making and decrease exposure over PA and lateral views. We should ask before ordering if the study will change our management. This is being investigated in postoperative scoliosis monitoring protocols in which many plain films may be unnecessary. We should ask before ordering a test with ionizing radiation if another test with lower or no radiation might provide the needed information. In evaluation of many pediatric orthopaedic conditions, magnetic resCopyright
r
Radiation Safety in Pediatric Orthopaedics
onance imaging (MRI) and ultrasound imaging may give adequate, equivalent, or even better information than CT scan. For example, MRI may prove a good substitute for CT scan when evaluating the state of the physis in the case of a previous physeal injury. Another important method of decreasing exposure to pediatric patients is employing radiology technicians who have experience working with children and are comfortable performing studies on children. Increased ease and comfort with kids on the technician’s part can decrease the number of shots required to obtain adequate imaging studies. Experienced technicians are also familiar with adjusting tube current, columation, and mode of fluoroscopy shots to decrease patient doses. Technical improvements in scanners may decrease radiation exposure to patients. There should be a push to improve CT scans to lower and lower doses for images. Advancements in processing techniques may also reduce radiation exposure by decreasing the number of projections required to create an adequate image. In addition, it is important that the equipment allows technicians to adjust for patient size so studies can be individualized for pediatric patients.31 Intraoperative radiation exposure to patients can be minimized through careful and thoughtful use of c-arm and by limiting live fluoroscopy. We should consider changes in practice, including placement of pedicle screws with c-arm in the thoracic spine, but by anatomic landmarks in the placement of lumbar spine pedicle screws with limited c-arm spot images. In addition, limiting the number of imaging spins with intraoperative CT navigation can decrease patient exposure.32 Surgeon and staff exposure to radiation can primarily be reduced in the operating room. Here educational programs for orthopaedic residents and faculty can significantly reduce fluoroscopy time and the number of shots.33,34 As new equipment becomes available, education of all personnel is critical. Proper shielding is required: personnel should wear lead aprons and thyroid shields. Lead glasses decrease the dose to the eyes by 10 times.35 Gowns should be monitored regularly for integrity.36 All personnel who can do so should remain at least 2 m from the radiation source, at which distance scatter is negligible. Surgeons should position the patient, radiation source,37 and themselves to decrease exposure. Alternative techniques without c-arm have been developed for procedures such as placement of distal interlocks in intramedullary nailing of femur fractures38 and pedicle screw placement.39 Mini c-arm may be used as a lower radiation alternative to regular c-arm.40 Finally, care should be taken to comply with standard dose monitoring, and surgeons should regularly check their dose reports. Finally, further study and development of evidencebased guidelines for scoliosis monitoring, fracture treatment, and intraoperative imaging could play a great role in maximizing radiation safety in pediatric orthopaedics. REFERENCES 1. Hricak H, Brenner DJ, Adelstein SJ, et al. Managing radiation use in medical imaging: a multifaceted challenge. Radiology. 2011;258:889–905.
2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.pedorthopaedics.com |
S35
J Pediatr Orthop
Caird
2. Lipman RM, Tripathi BJ, Tripathi RC. Cataracts induced by microwave and ionizing radiation. Surv Ophthalmol. 1998;33: 200–210. 3. Rehani MM, Vano E, Ciraj-Bjelac O, et al. Radiation and cataract. Radiat Prot Dosimetry. 2011;147:300–304. 4. King EA, Hanauer DA, Choi SW, et al. Osteochondromas after radiation for pediatric malignancies: a role for expanded counseling for skeletal side effects. J Pediatr Orthop. 2014;34:331–335. 5. Almen AJ, Mattsson S. Dose distribution at radiographic examination of the spine in pediatric radiology. Spine (Phila Pa 1976). 1996;21:750–756. 6. Drummond D, Ranallo F, Lonstein J, et al. Radiation hazards in scoliosis management. Spine (Phila Pa 1976). 1983;8:741–748. 7. Dutkowsky JP, Shearer D, Schepps B, et al. Radiation exposure to patients receiving routine scoliosis radiography measured at depth in an anthropomorphic phantom. J Pediatr Orthop. 1990;10:532–534. 8. Gray JE, Hoffman AD, Peterson HA. Reduction of radiation exposure during radiography for scoliosis. J Bone Joint Surg Am. 1983;65:5–12. 9. Kluba T, Schafer J, Hahnfeldt T, et al. Prospective randomized comparison of radiation exposure from full spine radiographs obtained in three different techniques. Eur Spine J. 2006;15:752–756. 10. Levy AR, Goldberg MS, Mayo NE, et al. Reducing the lifetime risk of cancer from spinal radiographs among people with adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 1996;21:1540–1547. discussion 1548. 11. Nottage WM, Waugh TR, McMaster WC. Radiation exposure during scoliosis screening radiography. Spine (Phila Pa 1976). 1981;6:456–459. 12. Khorsand D, Song KM, Swanson J, et al. Iatrogenic radiation exposure to patients with early onset spine and chest wall deformities. Spine (Phila Pa 1976). 2013;38:E1108–E1114. 13. Giordano BD, Baumhauer JF, Morgan TL, et al. Cervical spine imaging using standard C-arm fluoroscopy: patient and surgeon exposure to ionizing radiation. Spine (Phila Pa 1976). 2008;33:1970–1976. 14. Kraus R, Schiefer U, Schafer C, et al. Elastic stable intramedullary nailing in pediatric femur and lower leg shaft fractures: intraoperative radiation load. J Pediatr Orthop. 2008;28:14–16. 15. Mohammed R, Johnson K, Bache E. Radiation exposure during insitu pinning of slipped capital femoral epiphysis hips: does the patient positioning matter? J Pediatr Orthop B. 2010;19:333–336. 16. Budd H, Patchava A, Khanduja V. Establishing the radiation risk from fluoroscopic-assisted arthroscopic surgery of the hip. Int Orthop. 2012;36:1803–1806. 17. Lee K, Lee KM, Park MS, et al. Measurements of surgeons’ exposure to ionizing radiation dose during intraoperative use of C-arm fluoroscopy. Spine (Phila Pa 1976). 2012;37:1240–1244. 18. Mehlman CT, DiPasquale TG. Radiation exposure to the orthopaedic surgical team during fluoroscopy: “how far away is far enough?”. J Orthop Trauma. 1997;11:392–398. 19. Sanders R, Koval KJ, DiPasquale T, et al. Exposure of the orthopaedic surgeon to radiation. J Bone Joint Surg Am. 1993;75:326–330. 20. Singer G. Occupational radiation exposure to the surgeon. J Am Acad Orthop Surg. 2005;13:69–76. 21. Theocharopoulos N, Perisinakis K, Damilakis J, et al. Occupational exposure from common fluoroscopic projections used in orthopaedic surgery. J Bone Joint Surg Am. 2003;85-A:1698–1703. 22. Uzoigwe CE, Middleton RG. Occupational radiation exposure and pregnancy in orthopaedics. J Bone Joint Surg Br. 2012;94:23–27.
S36 | www.pedorthopaedics.com
Volume 35, Number 5 Supplement 1, July/August 2015
23. Wakeford R. Radiation in the workplace-a review of studies of the risks of occupational exposure to ionising radiation. J Radiol Prot. 2009;29:A61–A79. 24. Alonso JA, Shaw DL, Maxwell A, et al. Scattered radiation during fixation of hip fractures. Is distance alone enough protection? J Bone Joint Surg Br. 2001;83:815–818. 25. Muller LP, Suffner J, Wenda K, et al. Radiation exposure to the hands and the thyroid of the surgeon during intramedullary nailing. Injury. 1998;29:461–468. 26. Singh PJ, Perera NS, Dega R. Measurement of the dose of radiation to the surgeon during surgery to the foot and ankle. J Bone Joint Surg Br. 2007;89:1060–1063. 27. Taher F, Hughes AP, Sama AA, et al. Young Investigator Award winner: how safe is lateral lumbar interbody fusion for the surgeon? A prospective in vivo radiation exposure study. Spine (Phila Pa 1976). 2013;38:1386–1392. 28. Mroz TE, Abdullah KG, Steinmetz MP, et al. Radiation exposure to the surgeon during percutaneous pedicle screw placement. J Spinal Disord Tech. 2011;24:264–267. 29. Rampersaud YR, Foley KT, Shen AC, et al. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976). 2000;25:2637–2645. 30. Ul Haque M, Shufflebarger HL, O’Brien M, et al. Radiation exposure during pedicle screw placement in adolescent idiopathic scoliosis: is fluoroscopy safe? Spine (Phila Pa 1976). 2006;31: 2516–2520. 31. Rehani MM, Vano E. Medical radiation protection in next decade. Radiat Prot Dosimetry. 2011;147:52–53. 32. Slomczykowski M, Roberto M, Schneeberger P, et al. Radiation dose for pedicle screw insertion. Fluoroscopic method versus computerassisted surgery. Spine (Phila Pa 1976). 1999;24:975–982. discussion 983. 33. Bar-On E, Weigl DM, Becker T, et al. Intraoperative C-arm radiation affecting factors and reduction by an intervention program. J Pediatr Orthop. 2010;30:320–323. 34. Lewall DB, Riley P, Hassoon AA, et al. A fluoroscopy credentialling programme for orthopaedic surgeons. J Bone Joint Surg Br. 1995;77:442–444. 35. Burns S, Thornton R, Dauer LT, et al. Leaded eyeglasses substantially reduce radiation exposure of the surgeon’s eyes during acquisition of typical fluoroscopic views of the hip and pelvis. J Bone Joint Surg Am. 2013;95:1307–1311. 36. Finnerty M, Brennan PC. Protective aprons in imaging departments: manufacturer stated lead equivalence values require validation. Eur Radiol. 2005;15:1477–1484. 37. Tremains MR, Georgiadis GM, Dennis MJ. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674–678. 38. Chan DS, Burris RB, Erdogan M, et al. The insertion of intramedullary nail locking screws without fluoroscopy: a faster and safer technique. J Orthop Trauma. 2013;27:363–366. 39. Erken HY, Burc H, Saka G, et al. Can radiation exposure to the surgeon be reduced with freehand pedicle screw fixation technique in pediatric spinal deformity correction? A prospective multicenter study. Spine (Phila Pa 1976). 2014;39:521–525. 40. Giordano BD, Baumhauer JF, Morgan TL, et al. Patient and surgeon radiation exposure: comparison of standard and mini-Carm fluoroscopy. J Bone Joint Surg Am. 2009;91:297–304.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Radiation Safety in Pediatric Orthopaedics Michelle S. Caird, MD
Abstract: Patients, surgeons, and staff are exposed to ionizing radiation in pediatric orthopaedic surgery from diagnostic studies and imaging associated with procedures. Estimating radiation dose to pediatric patients is based on complex algorithms and dose to surgeons and staff is based on dosimeter monitoring. Surgeons can decrease radiation exposure to patients with careful and thoughtful ordering of diagnostic studies and by minimizing exposure intraoperatively. Surgeon and staff radiation exposure can be minimized with educational programs, proper shielding and positioning intraoperatively, and prudent use of intraoperative imaging. Overall, better awareness among pediatric orthopaedic surgeons of our role in radiation exposure can lead to improvements in radiation safety.
composition in the plane of the beam, and the energy of the beam. In addition, estimating the dose to surgeons and staff working in the presence of ionizing radiation medical imaging modalities is based on monitoring from dosimeter badges and rings worn by the staff. There are annual recommended limits for radiation exposure for staff. Factors that influence the radiation dose include time of radiation exposure, distance between the source and person, and shielding (material and its thickness) between the radiation source and the person. Factors influencing an individual’s radiation risk have been estimated from exposures in Hiroshima and Nagasaki. These include genetic considerations, patient age, sex, and the estimated radiation exposure.
Key Words: radiation exposure, ionizing radiation, medical imaging, computed tomography, fluoroscopy (J Pediatr Orthop 2015;35:S34–S36)
BACKGROUND Ionizing radiation comes to us from many sources outside of medical practice, including cosmic rays, radon, and radionuclides that we encounter in foods such as potassium isotopes in salt substitutes. Medical sources of ionizing radiation include radionuclides used in nuclear medicine imaging such as technetium 99, and other imaging modalities such as computed tomography (CT) scans, plain radiography, and fluoroscopy.1 Radiation effects on humans are divided into deterministic effects, including hair loss, skin burns, nausea, and cataract formation,2,3 and stochastic effects, which cause carcinogenesis and teratogenesis. Sensitive tissues are the gonads, breasts, thyroid, gastrointestinal tract, and bone marrow.4 Radiation exposure to pediatric patients is especially concerning because children have greater radiosensitivity than adults and they have longer life expectancy following radiation exposure.1 Estimating the radiation dose to a patient is complex. Algorithms for estimations are based on patient size, thickness of the body in the plane of the beam, body From the Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI. The author declares no conflicts of interest. Reprints: Michelle S. Caird, MD, Department of Orthopaedic Surgery, University of Michigan, 1540 E Hospital Dr, Ann Arbor, MI 481094241. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
S34 | www.pedorthopaedics.com
PATIENT RADIATION EXPOSURE In pediatric orthopaedics, our patients are exposed to radiation through diagnostic studies and imaging associated with surgical procedures. Plain radiographs are used commonly for fracture treatment, for monitoring growth disturbances and limb-length and alignment problems, and for scoliosis monitoring. Much of the literature on patient exposure to radiation in orthopaedics comes to us from studies on scoliosis monitoring.5–11 Posteroanterior (PA) scoliosis films offer lower radiation dose to thyroid and breast tissue than anteroposterior films. Digital plain radiography has the potential for lower radiation if care is taken by the technician. We should give careful consideration to the monitoring protocols for growing scoliosis patients, especially those with early-onset scoliosis.12 CT scans account for one of the fastest growing areas of radiation exposure for patients in the United States, and CT scans in children are on the rise as well. Some of this increase in childhood CT scans stems from important advances in care such as CT scans of the cervical spine for trauma evaluations. This imaging has become much more common in trauma centers for full evaluation of the pediatric cervical spine. Also in pediatric trauma situations, CT scans of the chest, abdomen, and pelvis may be required for full evaluation. Patients with thoracic insufficiency or early-onset scoliosis often undergo multiple chest CT scans to monitor lung volumes and changes over time with growth and treatment. Overall as hospitals update their CT scanners they can provide sharper images and faster scans. We should be aware, however, that the amount of radiation associated with this improved image quality may not necessarily decrease. Pediatric patients may also be exposed to radiation during orthopaedic surgical procedures.13 Intraoperative
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
fluoroscopy is used for intramedullary nailing of long bone fractures using both reamed nailing and flexible nailing techniques.14 It is also used commonly for closed reduction and percutaneous pinning of pediatric fractures. In cases of slipped capital femoral epiphysis pinning, the table and carm positioning have been shown to influence the radiation to the patient.15 Studies of hip arthroscopy have shown a relatively low dose to patients.16 Pedicle screw insertion techniques in scoliosis surgery often use intraoperative fluoroscopy. This can expose patients and surgeons to a much higher radiation dose, especially if c-arm images are used to place pedicle screws in a resident teaching setting where more images might be used. Intraoperative CT navigation is increasingly used for pedicle screw placement in pediatric spine surgery. This has the potential to offer a lower dose to the surgeons and staff, who can step away behind a lead shield during the scanning, but still exposes the patient to a CT scan. The patient may require multiple CT scans to image multiple levels for long-instrumentation constructs, and obese patients may require higher doses to acquire adequate images for navigation. Here protocols or judicious use of CT is warranted.
SURGEON AND STAFF RADIATION EXPOSURE Most exposure to ionizing radiation for surgeons and staff in pediatric orthopaedics occurs through intraoperative spot c-arm views and fluoroscopy.17–23 This exposure is primarily from scatter, which is high close to the radiation source and decreases to negligible levels at a distance of 2 m.24 Direct radiation exposure also occurs especially to the hands, which are often used for positioning of images.25 Studies of exposure to orthopaedic surgeons have been conducted in multiple surgical procedures, including placement of reamed and flexible intramedullary nails for fractures, foot and ankle surgery,26 lumbar interbody fusion,27 kyphoplasty, and pedicle screw insertion.28–30 Spine surgery often risks significant radiation exposure to the surgeon with studies of fluoroscopically aided pedicle screw placement demonstrating dose rates to surgeons of 10 to 12 times greater than nonspine fluoroscopy procedures and the possibility of exceeding lifetime dose limits in as few as 10 years.29,30
METHODS TO DECREASE EXPOSURE There are a number of methods for reducing the radiation exposure of pediatric orthopaedic patients. First, we should use care with ordering imaging studies. If the evaluation requires ionizing radiation we can limit the number of views; for example, in scoliosis monitoring a PA view alone may be adequate for decision making and decrease exposure over PA and lateral views. We should ask before ordering if the study will change our management. This is being investigated in postoperative scoliosis monitoring protocols in which many plain films may be unnecessary. We should ask before ordering a test with ionizing radiation if another test with lower or no radiation might provide the needed information. In evaluation of many pediatric orthopaedic conditions, magnetic resCopyright
r
Radiation Safety in Pediatric Orthopaedics
onance imaging (MRI) and ultrasound imaging may give adequate, equivalent, or even better information than CT scan. For example, MRI may prove a good substitute for CT scan when evaluating the state of the physis in the case of a previous physeal injury. Another important method of decreasing exposure to pediatric patients is employing radiology technicians who have experience working with children and are comfortable performing studies on children. Increased ease and comfort with kids on the technician’s part can decrease the number of shots required to obtain adequate imaging studies. Experienced technicians are also familiar with adjusting tube current, columation, and mode of fluoroscopy shots to decrease patient doses. Technical improvements in scanners may decrease radiation exposure to patients. There should be a push to improve CT scans to lower and lower doses for images. Advancements in processing techniques may also reduce radiation exposure by decreasing the number of projections required to create an adequate image. In addition, it is important that the equipment allows technicians to adjust for patient size so studies can be individualized for pediatric patients.31 Intraoperative radiation exposure to patients can be minimized through careful and thoughtful use of c-arm and by limiting live fluoroscopy. We should consider changes in practice, including placement of pedicle screws with c-arm in the thoracic spine, but by anatomic landmarks in the placement of lumbar spine pedicle screws with limited c-arm spot images. In addition, limiting the number of imaging spins with intraoperative CT navigation can decrease patient exposure.32 Surgeon and staff exposure to radiation can primarily be reduced in the operating room. Here educational programs for orthopaedic residents and faculty can significantly reduce fluoroscopy time and the number of shots.33,34 As new equipment becomes available, education of all personnel is critical. Proper shielding is required: personnel should wear lead aprons and thyroid shields. Lead glasses decrease the dose to the eyes by 10 times.35 Gowns should be monitored regularly for integrity.36 All personnel who can do so should remain at least 2 m from the radiation source, at which distance scatter is negligible. Surgeons should position the patient, radiation source,37 and themselves to decrease exposure. Alternative techniques without c-arm have been developed for procedures such as placement of distal interlocks in intramedullary nailing of femur fractures38 and pedicle screw placement.39 Mini c-arm may be used as a lower radiation alternative to regular c-arm.40 Finally, care should be taken to comply with standard dose monitoring, and surgeons should regularly check their dose reports. Finally, further study and development of evidencebased guidelines for scoliosis monitoring, fracture treatment, and intraoperative imaging could play a great role in maximizing radiation safety in pediatric orthopaedics. REFERENCES 1. Hricak H, Brenner DJ, Adelstein SJ, et al. Managing radiation use in medical imaging: a multifaceted challenge. Radiology. 2011;258:889–905.
2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.pedorthopaedics.com |
S35
J Pediatr Orthop
Caird
2. Lipman RM, Tripathi BJ, Tripathi RC. Cataracts induced by microwave and ionizing radiation. Surv Ophthalmol. 1998;33: 200–210. 3. Rehani MM, Vano E, Ciraj-Bjelac O, et al. Radiation and cataract. Radiat Prot Dosimetry. 2011;147:300–304. 4. King EA, Hanauer DA, Choi SW, et al. Osteochondromas after radiation for pediatric malignancies: a role for expanded counseling for skeletal side effects. J Pediatr Orthop. 2014;34:331–335. 5. Almen AJ, Mattsson S. Dose distribution at radiographic examination of the spine in pediatric radiology. Spine (Phila Pa 1976). 1996;21:750–756. 6. Drummond D, Ranallo F, Lonstein J, et al. Radiation hazards in scoliosis management. Spine (Phila Pa 1976). 1983;8:741–748. 7. Dutkowsky JP, Shearer D, Schepps B, et al. Radiation exposure to patients receiving routine scoliosis radiography measured at depth in an anthropomorphic phantom. J Pediatr Orthop. 1990;10:532–534. 8. Gray JE, Hoffman AD, Peterson HA. Reduction of radiation exposure during radiography for scoliosis. J Bone Joint Surg Am. 1983;65:5–12. 9. Kluba T, Schafer J, Hahnfeldt T, et al. Prospective randomized comparison of radiation exposure from full spine radiographs obtained in three different techniques. Eur Spine J. 2006;15:752–756. 10. Levy AR, Goldberg MS, Mayo NE, et al. Reducing the lifetime risk of cancer from spinal radiographs among people with adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 1996;21:1540–1547. discussion 1548. 11. Nottage WM, Waugh TR, McMaster WC. Radiation exposure during scoliosis screening radiography. Spine (Phila Pa 1976). 1981;6:456–459. 12. Khorsand D, Song KM, Swanson J, et al. Iatrogenic radiation exposure to patients with early onset spine and chest wall deformities. Spine (Phila Pa 1976). 2013;38:E1108–E1114. 13. Giordano BD, Baumhauer JF, Morgan TL, et al. Cervical spine imaging using standard C-arm fluoroscopy: patient and surgeon exposure to ionizing radiation. Spine (Phila Pa 1976). 2008;33:1970–1976. 14. Kraus R, Schiefer U, Schafer C, et al. Elastic stable intramedullary nailing in pediatric femur and lower leg shaft fractures: intraoperative radiation load. J Pediatr Orthop. 2008;28:14–16. 15. Mohammed R, Johnson K, Bache E. Radiation exposure during insitu pinning of slipped capital femoral epiphysis hips: does the patient positioning matter? J Pediatr Orthop B. 2010;19:333–336. 16. Budd H, Patchava A, Khanduja V. Establishing the radiation risk from fluoroscopic-assisted arthroscopic surgery of the hip. Int Orthop. 2012;36:1803–1806. 17. Lee K, Lee KM, Park MS, et al. Measurements of surgeons’ exposure to ionizing radiation dose during intraoperative use of C-arm fluoroscopy. Spine (Phila Pa 1976). 2012;37:1240–1244. 18. Mehlman CT, DiPasquale TG. Radiation exposure to the orthopaedic surgical team during fluoroscopy: “how far away is far enough?”. J Orthop Trauma. 1997;11:392–398. 19. Sanders R, Koval KJ, DiPasquale T, et al. Exposure of the orthopaedic surgeon to radiation. J Bone Joint Surg Am. 1993;75:326–330. 20. Singer G. Occupational radiation exposure to the surgeon. J Am Acad Orthop Surg. 2005;13:69–76. 21. Theocharopoulos N, Perisinakis K, Damilakis J, et al. Occupational exposure from common fluoroscopic projections used in orthopaedic surgery. J Bone Joint Surg Am. 2003;85-A:1698–1703. 22. Uzoigwe CE, Middleton RG. Occupational radiation exposure and pregnancy in orthopaedics. J Bone Joint Surg Br. 2012;94:23–27.
S36 | www.pedorthopaedics.com
Volume 35, Number 5 Supplement 1, July/August 2015
23. Wakeford R. Radiation in the workplace-a review of studies of the risks of occupational exposure to ionising radiation. J Radiol Prot. 2009;29:A61–A79. 24. Alonso JA, Shaw DL, Maxwell A, et al. Scattered radiation during fixation of hip fractures. Is distance alone enough protection? J Bone Joint Surg Br. 2001;83:815–818. 25. Muller LP, Suffner J, Wenda K, et al. Radiation exposure to the hands and the thyroid of the surgeon during intramedullary nailing. Injury. 1998;29:461–468. 26. Singh PJ, Perera NS, Dega R. Measurement of the dose of radiation to the surgeon during surgery to the foot and ankle. J Bone Joint Surg Br. 2007;89:1060–1063. 27. Taher F, Hughes AP, Sama AA, et al. Young Investigator Award winner: how safe is lateral lumbar interbody fusion for the surgeon? A prospective in vivo radiation exposure study. Spine (Phila Pa 1976). 2013;38:1386–1392. 28. Mroz TE, Abdullah KG, Steinmetz MP, et al. Radiation exposure to the surgeon during percutaneous pedicle screw placement. J Spinal Disord Tech. 2011;24:264–267. 29. Rampersaud YR, Foley KT, Shen AC, et al. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976). 2000;25:2637–2645. 30. Ul Haque M, Shufflebarger HL, O’Brien M, et al. Radiation exposure during pedicle screw placement in adolescent idiopathic scoliosis: is fluoroscopy safe? Spine (Phila Pa 1976). 2006;31: 2516–2520. 31. Rehani MM, Vano E. Medical radiation protection in next decade. Radiat Prot Dosimetry. 2011;147:52–53. 32. Slomczykowski M, Roberto M, Schneeberger P, et al. Radiation dose for pedicle screw insertion. Fluoroscopic method versus computerassisted surgery. Spine (Phila Pa 1976). 1999;24:975–982. discussion 983. 33. Bar-On E, Weigl DM, Becker T, et al. Intraoperative C-arm radiation affecting factors and reduction by an intervention program. J Pediatr Orthop. 2010;30:320–323. 34. Lewall DB, Riley P, Hassoon AA, et al. A fluoroscopy credentialling programme for orthopaedic surgeons. J Bone Joint Surg Br. 1995;77:442–444. 35. Burns S, Thornton R, Dauer LT, et al. Leaded eyeglasses substantially reduce radiation exposure of the surgeon’s eyes during acquisition of typical fluoroscopic views of the hip and pelvis. J Bone Joint Surg Am. 2013;95:1307–1311. 36. Finnerty M, Brennan PC. Protective aprons in imaging departments: manufacturer stated lead equivalence values require validation. Eur Radiol. 2005;15:1477–1484. 37. Tremains MR, Georgiadis GM, Dennis MJ. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674–678. 38. Chan DS, Burris RB, Erdogan M, et al. The insertion of intramedullary nail locking screws without fluoroscopy: a faster and safer technique. J Orthop Trauma. 2013;27:363–366. 39. Erken HY, Burc H, Saka G, et al. Can radiation exposure to the surgeon be reduced with freehand pedicle screw fixation technique in pediatric spinal deformity correction? A prospective multicenter study. Spine (Phila Pa 1976). 2014;39:521–525. 40. Giordano BD, Baumhauer JF, Morgan TL, et al. Patient and surgeon radiation exposure: comparison of standard and mini-Carm fluoroscopy. J Bone Joint Surg Am. 2009;91:297–304.
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
