are often at the forefront in deciding if a pediatric patient needs
medical imaging. Pediatric patients are particularly vulnerable to radiation exposure
from medical imaging, according to numerous studies, potentially raising
their risk to develop cancer later in life.
Now, a new analysis looks at the available evidence on radiation
exposure in medical imaging in pediatric orthopedic care - and
provides recommendations aimed at optimizing decision-making to reduce
unnecessary exposure. The findings are being presented at a Scientific
Exhibit at the American Academy of Orthopedic Surgeons 2017 Annual
Meeting March 14-18 in San Diego.
‘The NYU Langone's Hospital has provided recommendations to reduce radiation exposure in pediatric orthopedic patients.’
"Traditionally, there has not been enough discussion on how we can
disseminate information to best treat children with the least possible
exposure to radiation," says senior research author David H. Godfried, clinical associate professor of orthopedic surgery and pediatrics,
and director of the Center for Children at NYU Langone's Hospital for
Joint Diseases. "A CT scan may be absolutely necessary for a child. But
whenever there is an option, physicians should choose to obtain this
information another way."
For their research, Godfried and Ayesha Rahman, a fifth-year
resident in the department of Orthopedic Surgery at NYU Langone,
reviewed peer-reviewed literature on different options in imaging
technology that may be used in pediatric orthopedic injuries, including
X-rays and CT scans of the spine, pelvis, hip, knees, shoulder, elbow,
hand and wrist, and foot and ankle. They then quantified the amount of
radiation in each of these scans.
They subsequently identified that pediatric patients who require
surgery for hip dysplasia, scoliosis and leg-length discrepancy are
among those most likely to undergo imaging such as X-rays or CT scans,
and therefore may be among those children who are most vulnerable to
For example, their analysis found that pediatric patients with hip
dysplasia that required surgery received two times more X-rays and
underwent multiple CT scans compared to non-surgical pediatric patients,
which cumulatively increased their overall risk of fatal cancer or
genetic defects by less than 1%, a small but significant risk.
In another finding, female scoliosis patients received two times more
X-rays than non-surgical patients, amounting to twice the radiation
exposure to the breasts, ovaries and bone marrow, and correlating to an
over 2% increased lifetime risk of fatal breast cancer, almost 1% risk of fatal leukemia, and three percent risk of genetic
defects. Non-surgical patients had approximately half that risk.
Best Practices to Reduce Radiation Exposure in Children
Based on the available evidence, the authors developed the following
list of best practices that orthopedic surgeons should follow:
- Follow the ALARA, or "as low as reasonably achievable"
principle, to limit exposure to parts of the body that are absolutely
essential for diagnosis
- Eliminate repeated exposures resulting from technical errors
- Limit precise collimation to the region of interest
- Limit fluoroscopy to short bursts as needed (don't "go live")
- Utilize low-dose CT protocols adjusted for the size of the patient
- Limit CTs of the spine and pelvis in pediatric patients
- Female patients are more susceptible to adverse effects than male patients
- Scoliosis patients should have limited follow-up X-rays
- Leg length, scoliosis, and hip dysplasia (anteversion) studies
should utilize EOS imaging technology rather than traditional X-rays
- X-rays are an acceptable diagnostic tool for extremities, such as the wrist, ankle, etc.
- CT scans are an acceptable diagnostic tool for triplane fractures
"We have examined our use of X-rays in different clinical situations
and the effect on patient outcomes, and have been able to reduce or
eliminate the need for X-rays in many instances including certain
post-operative and routine follow-up visits," says Dr. Rahman. "While
X-rays are still a necessary and important diagnostic tool in the
pediatric population, our goal is to reduce radiation exposure to these
patients wherever possible without compromising patient care."
Several of these practices have been implemented at NYU Langone in
collaboration with institution-wide efforts put forth by the Department
of Radiology to reduce radiation exposure. One example, according to the
researchers, is children with scoliosis or suspected spine problems now
are often imaged with EOS imaging machines that provided useful
information with about one-tenth the radiation exposure than a
conventional CT or X-ray of the spine.
In hip dysplasia cases, orthopedic surgeons work with
musculoskeletal radiologists to reduce the number of slices from a CT
scan of the hip, from a typical five to 10 slices to only one or two, which
may provide enough helpful information to ensure a successful surgery
with less radiation exposure.
Orthopedic surgery and radiology collaborators have also
implemented intraoperative use of low-dose protocols on fluoroscopy
machines, which reduces radiation exposure to both patients as well as
physicians and staff in the operating room.
NYU Langone Orthopedic surgeons reported at the AAOS 2016 meeting
results from a joint effort with radiologists to reduce radiation in CT
scans for joint fractures with one-fourteenth the amount of normal CT
radiation - without compromising image quality or a surgeon's ability to
effectively diagnose an injury. This ultra-low dose protocol is also
being used in other musculoskeletal imaging studies.