Nicholas Theocharopoulos

Occupational exposure from common fluoroscopic projections used in orthopaedic surgery

BACKGROUND Personnel assisting in or performing fluoroscopically guided procedures may be exposed to high doses of radiation. Accurate occupational dosimetric data for the orthopaedic theater staff are of paramount importance for practicing radiation safety. METHODS Fluoroscopic screening was performed on an anthropomorphic phantom with use of four projections common in image-guided orthopaedic surgery. The simulated projections were categorized, according to the imaged anatomic area and the beam orientation, as (1) hip joint posterior-anterior, (2) hip joint lateral cross-table 45 degrees, (3) lumbar spine anterior-posterior, and (4) lumbar spine lateral 90 degrees. The scattered air kerma rate was measured on a grid surrounding the operating table. For each grid point, the effective dose, eye lens dose, and face skin dose values, normalized over the tube dose area product, were derived. For the effective dose calculations, three radiation protection conditions were considered: (1) with the exposed personnel using no protection measures, (2) with the exposed personnel wearing a 0.5-mm lead-equivalent protective apron, and (3) with the exposed personnel wearing both an apron and a thyroid collar. Maximum permissible workloads for typical hip, spine, and kyphoplasty procedures were derived on the basis of compliance with effective dose, eye lens dose, and skin dose limits. RESULTS We found that the effective dose, eye lens dose, and face skin dose to an orthopaedic surgeon wearing a 0.5-mm lead-equivalent apron will not exceed the corresponding limits if the dose area product of the fluoroscopically guided procedure is <0.38 Gy m (2). When protective eye goggles are also worn, the maximum permissible dose area product increases to 0.70 Gy m (2), while the additional use of a thyroid shield allows a workload of 1.20 Gy m (2). The effective dose to the orthopaedic surgeon working tableside during a typical hip, spine, kyphoplasty procedure was 5.1, 21, and 250 micro Sv, respectively, when a 0.5-mm lead-equivalent apron alone was used. The additional use of a thyroid shield reduced the effective dose to 2.4, 8.4, and 96 micro Sv per typical hip, spine, and kyphoplasty procedure, respectively. CONCLUSIONS The levels of occupational exposure vary considerably with the type of fluoroscopically assisted procedure, staff positioning, and the radiation protection measures used. The data presented in the current study will allow for accurate estimation of the occupational dose to orthopaedic theater personnel.

Estimation of Patient Dose and Associated Radiogenic Risks From Fluoroscopically Guided Pedicle Screw Insertion

Study Design. An experimental model for the assessment of patient dose and associated radiogenic risks associated with pedicle screw internal fixation surgical procedures. Objectives. To provide data for the accurate determination of patient effective dose, gonadal dose, and entrance skin dose from fluoroscopically assisted pedicle screw insertion procedures and to investigate the potential of both stochastic and deterministic radiogenic effects to occur following such procedures. Summary of Background Data. There is increased concern on radiation exposure of patients undergoing fluoroscopically guided interventional procedures. Methods. The cumulative screening time and dose area product, for each fluoroscopic projection used, were monitored in 20 patients undergoing pedicle screw internal fixation. The dose absorbed by each radiosensitive organ/tissue was determined from direct measurements obtained using an anthropomorphic phantom appropriately loaded with thermoluminescence dosimeters. Results. An average pedicle screw insertion procedure requires 1.2 minutes and 2.1 minutes of fluoroscopic exposure along anteroposterior and lateral projections, respectively, resulting in a dose area product of 232 cGy cm2 and 568 cGy cm2, correspondingly. Gender-specific normalized data for the determination of effective, gonadal, and entrance skin dose to patients undergoing fluoroscopically guided pedicle screw internal fixation procedures were derived. The effective dose from an average procedure was 1.52 and 1.40 mSv and the gonadal dose 0.67 and 0.12 mGy for female and male patients, respectively. The average radiogenic risks for fatal cancer and genetic defects were 115 and 4 per million of patients treated, respectively. Induction of skin injuries might be induced when fluoroscopy along the lateral projection is highly extended and the source to skin distance is kept low. Conclusions. Patient dose and radiogenic risks associated with an average pedicle screw internal fixation procedure are tolerable. However, for young patients with complex spinal disorders requiring extended fluoroscopy, radiogenic risks may be considerable. Present data may beused for estimation of effective dose, gonadal dose, and entrance skin exposure and associated radiogenic risks to patients undergoing fluoroscopically guided pedicle screw insertion in any institution.

Reduction of eye lens radiation dose by orbital bismuth shielding in pediatric patients undergoing CT of the head: a Monte Carlo study.

Our aim in the study was to assess the eye lens dose reduction resulting from the use of radioprotective bismuth garments to shield the eyes of pediatric patients undergoing head CT. The Monte Carlo N-particle transport code and mathematical humanoid phantoms representing the average individual at different ages were used to determine eye lens dose reduction accomplished with bismuth shielding of the eye in the following simulated CT scans: (a) scanning of the orbits, (b) scanning of the whole head, and (c) 20 degrees angled scanning of the brain excluding the orbits. The effect of bismuth shielding on the eye lens dose was also investigated using an anthropomorphic phantom and thermoluminescence dosimetry (TLD). Eye lens dose reduction achieved by bismuth shielding was measured in 16 patients undergoing multiphase CT scanning of the head. The patients scans were divided in the following: CT examinations where the eye globes were entirely included (n=5), partly included (n=6) and excluded (n=5) from the scanned region. The eye lens dose reduction depended mainly on the scan boundaries set by an operator. The average eye lens dose reduction determined by Monte Carlo simulation was 38.2%, 33.0% and <1% for CT scans of the orbits, whole head, and brain with an angled gantry, respectively. The difference between the Monte Carlo derived eye lens dose reduction factor values and corresponding values determined directly by using the anthropomorphic phantom head was found less than 5%. The mean eye lens dose reduction achieved by bismuth shielding in pediatric patients were 34%, 20% and <2% when eye globes were entirely included, partly included and excluded from the scanned region, respectively. A significant reduction in eye lens dose may be achieved by using superficial orbital bismuth shielding during pediatric head CT scans. However, bismuth garments should not be used in children when the eyes are excluded from the primarily exposed region.

Estimation of effective doses to adult and pediatric patients from multislice computed tomography: A method based on energy imparted

The purpose of this study is to provide a method and required data for the estimation of effective dose (E) values to adult and pediatric patients from computed tomography (CT) scans of the head, chest abdomen, and pelvis, performed on multi-slice scanners. Mean section radiation dose (dm) to cylindrical water phantoms of varying radius normalized over CT dose index free-in-air (CTDIF) were calculated for the head and body scanning modes of a multislice scanner with use of Monte Carlo techniques. Patients were modeled as equivalent water phantoms and the energy imparted (epsilon) to simulated pediatric and adult patients was calculated on the basis of measured CTDI(F) values. Body region specific energy imparted to effective dose conversion coefficients (E/epsilon) for adult male and female patients were generated from previous data. Effective doses to patients aged newborn to adult were derived for all available helical and axial beam collimations, taking into account age specific patient mass and scanning length. Depending on high voltage, body region, and patient sex, E/epsilon values ranged from 0.008 mSv/mJ for head scans to 0.024 mSv/mJ for chest scans. When scanned with the same technique factors as the adults, pediatric patients absorb as little as 5% of the energy imparted to adults, but corresponding effective dose values are up to a factor of 1.6 higher. On average, pediatric patients absorb 44% less energy per examination but have a 24% higher effective dose, compared with adults. In clinical practice, effective dose values to pediatric patients are 2.5 to 10 times lower than in adults due to the adaptation of tube current. A method is provided for the calculation of effective dose to adult and pediatric patients on the basis of individual patient characteristics such as sex, mass, dimensions, and density of imaged anatomy, and the technical features of modern multislice scanners. It allows the optimum selection of scanning parameters regarding patient doses at CT.

Determination of the weighted CT dose index in modern multi-detector CT scanners

The aim of the present study was to (a) evaluate the underestimation in the value of the free-in-air (CTDI(air)) and the weighted CT dose index (CTDI(w)) determined with the standard 100 mm pencil chamber, i.e. the CTDI(100) concept, for the whole range of nominal radiation beam collimations selectable in a modern multi-slice CT scanner, (b) estimate the optimum length of the pencil-chamber and phantoms for accurate CTDI(w) measurements and (c) provide CTDI(w) values normalized to free-in-air CTDI for different tube-voltage, nominal radiation beam collimations and beam filtration values. The underestimation in the determination of CTDI(air) and CTDI(w) using the CTDI(100) concept was determined from measurements obtained with standard polymethyl-methacrylate (PMMA) phantoms and arrays of thermoluminescence dosimeters. The Monte Carlo N-Particle transport code was used to simulate standard CTDI measurements on a 16-slice CT scanner. The optimum pencil-chamber length for accurate determination of CTDI(w) was estimated as the minimum chamber length for which a further increase in length does not alter the value of the CTDI. CTDI(w)/CTDI(air) ratios were determined using Monte Carlo simulation and the optimum detector length for all selectable tube-voltage values and for three different values of beam filtration. To verify the Monte Carlo results, measured values of CTDI(w)/CTDI(air) ratios using the standard 100 mm pencil ionization chamber were compared with corresponding values calculated with Monte Carlo experiments. The underestimation in the determination of CTDI(air) using the 100 mm pencil chamber was less than 1% for all beam collimations. The underestimation in CTDI(w) was 15% and 27% for head and body phantoms, respectively. The optimum detector length for accurate CTDI(w) measurements was found to be 50 cm for the beam collimations commonly employed in modern multi-detector (MD) CT scanners. The ratio of CTDI(w)/CTDI(air) determined using the optimum detector length was found to be independent of beam collimation. Percentage differences between measured and calculated corresponding CTDI(w)/CTDI(air) ratios were always less than 8% for head and less than 5% for body PMMA phantoms. In conclusion, the CTDI(air) of MDCT scanners may be measured accurately with a 100 mm pencil chamber. However, the CTDI(100) concept was found to be inadequate for accurate CTDI(w) determination for the wide beam collimations commonly used in MDCT scanners. Accurate CTDI(w) determination presupposes the use of a pencil chamber and PMMA phantoms at least 50 cm long.

Comparison of four methods for assessing patient effective dose from radiological examinations.

Three methods of indirect effective dose estimation were reviewed and compared to a direct effective dose determination method. An anthropomorphic phantom and thermoluminescence dosimetry were used to obtain dosimetric data associated with anterior-posterior (AP) abdominal radiography, posterior-anterior (PA) chest radiography, PA head radiography, and AP heart fluoroscopy. Effective dose was determined using: (i) organ specific dose values directly determined by thermoluminescence dosimeters, (ii) data published by National Radiological Protection Board (NRPB) and entrance surface dose (ESD), (iii) NRPB data and dose area product (DAP), (iv) energy imparted derived from DAP. The effective dose values estimated from the Rando phantom measurements were 161, 32.3, and 8.4 microSv/projection for the abdomen, chest, and head radiographs, respectively. Cardiac fluoroscopy yielded an effective dose value of 111 microSv/min. The effective dose values obtained indirectly using NRPB data and DAP were in good agreement with directly assessed values in all simulated exposures (difference <8%). The effective doses using NRPB data and ESD values differed from directly assessed values by less than 15% for the radiographic exposures and 60% for heart fluoroscopy. The energy imparted method yielded 136, 31, and 6.6 microSv/projection for the abdomen, chest, and head radiographs, respectively, and 111 microSv/min for heart fluoroscopy. Indirect patient effective dose determination using the NRPB dosimetric data and the measured value of incident radiation allows for reliable patient effective dose estimates. The use of DAP rather than ESD is recommended because it yields accurate results even for complex radiologic exposures involving fluoroscopy. The value of energy imparted may be used for the accurate determination of patient effective dose, especially when specific organ dose values are not of interest. The calculation of energy imparted with the use of EAP provides a reliable starting point for estimation of effective dose from radiologic examinations for which dosimetric data are not provided by NRPB.

Patient effective radiation dose and associated risk from transmission scans using 153Gd line sources in cardiac spect studies.

The aim of the present study was to determine the contribution of transmission measurements acquisition to total patient effective dose from cardiac SPECT studies. A dual-head L-shaped gamma camera equipped with a transmission scan acquisition system based on two 153Gd line sources was used to simulate transmission measurements acquisition exposure on an anthropomorphic phantom. Thermoluminescence dosimeters were used to directly monitor the dose to 550 measuring points in the phantom. The effective dose and associated risk from transmission scans acquisition were estimated and compared to those associated to the radiopharmaceutical injected. The maximum effective dose from a typical transmission measurements acquisition was 1.3 &mgr;Sv and 1.9 &mgr;Sv for male and female patients, respectively. The contribution of the typical transmission scans acquisition to total patient radiation risk from a cardiac SPECT study is less than 10−3. Thus, radiation exposure may not be considered as a limiting factor for the clinical application of attenuation correction methods based on transmission measurements in cardiac SPECT.

Energy imparted-based estimates of the effect of z overscanning on adult and pediatric patient effective doses from multi-slice computed tomography.

In the present study effective dose values normalized to computed tomography dose index measured free in air were calculated for adult, newborn, 1, 5, 10 and 15 year old patients regarding scans of the head, chest, abdomen, pelvis, abdomen and pelvis, and trunk, using the energy imparted method. The effect of z overscanning on patient doses was accounted for, and normalized doses are provided for varying beam collimation, pitch and reconstruction slice width values. The contribution of overscanning depends on patient age, anatomic region imaged, acquisition and reconstruction settings. For a head scan it constitutes 15% of the adult effective dose and 24% of the effective dose to a newborn but for an abdomen scan it may be as high as 58% for a newborn and 31% for an adult. The ratios of normalized pediatric doses relative to that for adults for helical scans depend not only on age but also on acquisition and reconstruction parameters, because of variations in the relative distance between the primary beam and the radiosensitive tissues/organs of the body. Regarding scans of the trunk, pediatric doses are up to a factor of 2.5 times higher compared to adult doses (abdominal scans), whereas for scans of the head up to a factor of 1.5. Increasing the pitch value of helical scans while maintaining the same effective mAs setting, and hence noise levels, leads to an increase in patient doses which depends on age, body region, scan and reconstruction parameters. The % difference between doses at pitch 1.5 and pitch 1 is more pronounced in the abdominal region (14% increase for adults) and in young patients (31% in a newborn and 18% in a 10 year old patient) and it is minimal in head scans (4% increase in newborns and 1% in adults). If multiple body regions are to be imaged, doses to adults can be reduced by up to 15% and 36% to children by performing single long-range scans. Scanning adult patients at 100 kVp instead of 120 kVp, results in a 32% reduction in effective dose from head scans and 38% for scans of the torso. The corresponding reduction for a 5 year old patient is 31% for the head and 37% for the trunk. Due to the combined overbeaming and overscanning effect the 24 mm collimation is more dose effective in the head mode and the 12 mm collimation in the body mode. Provided data enable informed design of examination protocols, calculation of effective dose values and familiarization with the technical features of multi-detector technology.

Dosimetric characteristics of a 16-slice computed tomography scanner

Standard CT dose measurements were performed on a Siemens Sensation 16 scanner. CT dose indices, free-in-air (CTDIF) and weighted (CTDIW), were measured in all available axial and helical beam collimations of the head and body scanning modes. The effect of tube current, high voltage, rotation time, beam collimation and pitch on the CT doses was investigated. CT doses increased as a power function of high voltage. The kVp exponent n varied with beam collimation from 2.7 to 3.1 for CTDIW, and from 2.4 to 2.6 for CTDIF. Automatic change of the focal spot size increased radiation doses up to a factor of 1.18. Measured small-focus CTDIW values differed from those displayed at the console from –24 to 14%. Peripheral doses in the head phantom were higher compared to the body phantom by a factor of 1.5 to 2. Central doses are 2.7 to 4.1 times higher. Differences in beam collimation resulted in 50% variation in the CTDIW in the body phantom and 60% in the head phantom. In conclusion, our study has confirmed the great impact of technique factors and acquisition parameters on CT doses. The provided comprehensive dosimetric data will facilitate the dose-effective use of the scanner studied.

Fluoroscopically assisted surgical treatments of spinal disorders: conceptus radiation doses and risks.

Study Design. A series of anterior-posterior and lateral fluoroscopic exposures at 5 spinal levels were performed on anthropomorphic phantoms simulating the 3 trimesters of gestation. Objectives. To provide normalized data for the determination of conceptus dose specific to gestational stage and treated spinal level. To estimate the conceptus radiation dose and risk associated with typical fluoroscopically guided spinal treatments performed on the pregnant patient. Summary of Background Data. To our knowledge, there are no available data on conceptus doses and radiogenic risks resulting from fluoroscopically guided spinal surgery of the expectant mother. Methods. Direct measurement of conceptus doses from simulated fluoroscopic projections involved in orthopedic surgery at different spinal levels for the 3 trimesters of gestation with use of anthropomorphic phantoms and thermoluminescent dosimetry. Estimation of conceptus radiation risks from a typical pedicle screw fixation and kyphoplasty procedure using the experimentally derived data. Results. Conceptus doses from fluoroscopically guided spinal treatments are smaller than 4 mGy during all gestational stages, provided that the conceptus lies outside the primarily irradiated region. The associated risks of fatal cancer during childhood and congenital malformation on its progeny are at least 2 and 1500 times, respectively, lower than the spontaneous incidence rates. When the embryo is primarily irradiated, mean conceptus dose can be as high as 105 mGy from a nonoptimized exposure. At least 35 minutes of fluoroscopy are required for the induction of deterministic effects. Conclusions. Individual dose assessment is paramount in every pregnancy. Variations in fluoroscopy practices and gestational stage significantly affect fetal doses.