New Recommendations on Reducing Radiation Exposure in Children

New work from the NYU (New York University) Langone Hospital for Joint Diseases has tackled the issue of pediatric exposure to medical imaging. Researchers examined peer-reviewed literature on different imaging options, 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.

“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, M.D., clinical associate professor of orthopedic surgery and pediatrics, and director of the Center for Children at NYU Langone, in the March 14, 2017 news release. “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.”

Ayesha Rahman, M.D., chief resident in the Department of Orthopaedic Surgery at NYU Langone Medical, told OTW, “These are tricky decisions for orthopedic surgeons when weighing the risk and benefits of when to obtain an imaging study. Our goal as pediatric orthopaedic surgeons should be to do as much as necessary with as little as possible. We want to optimize the imaging studies we do in children in order to reduce the radiation exposure and risks but without compromising that ability to provide care. In that regard, I think the important decision-making process that these surgeons have to go through is asking themselves, ‘Will this imaging study either affect the treatment or the outcome for the patient?’ I think if the answer is ‘no’ or ‘maybe,’ then we have to consider whether the study is necessary or whether low-dose radiation or alternative imaging studies can be used instead.”

“It is important for surgeons to understand a number of factors when deciding whether to order a study or which study to order. The first is to understand the difference between studies that involve radiation to the extremities versus axial body parts that have more radiosensitive tissue and put the patient at an increased risk for an adverse event. Orthopaedic surgeons should understand the differences in radiation exposure between X-rays and low-dose options (such as EOS imaging) and the difference between CT scans and low-dose CT scans, and when each of those studies would be beneficial for the patient. Another important point to understand is which pediatric patents are at higher risk for adverse events, such as scoliosis patients and female patients, who have uniquely increased adverse events because of the increased risk they have in their lifetimes due to orthopedic surgeries.”

“Given that the majority of radiation exposure patients undergo is from CT scans, perhaps the highest yield best practice would be reducing CT scans in pediatric patients by using low-dose alternatives or non-radiation alternatives. Additionally, the most common imaging study patients undergo are X-rays, and in that regard, we should utilize low dose forms of X-rays whenever possible. It’s important to recognize patients who are high risk and have higher lifetime risk for the effects of radiation exposure, including young patients with scoliosis, developmental hip dysplasia, and leg length discrepancy, and being able to differentiate when an imaging study is indicated in certain patients, such as tri-plane fractures.”

Here is their list of best practices that orthopedic surgeons should follow.

• follow the “as low as reasonably achievable,” or ALARA, 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
• 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
• children with scoliosis 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 or ankle
• CT scans are an acceptable diagnostic tool for triplane fractures