Patients Markedly Underestimate Radiation Exposure From Spinal Imaging

Kern Singh, MD, and S. Samuel Bederman, MD, PhD, FRCSC, comment

Peer Reviewed

In a recent survey, patients with spinal conditions substantially underestimated the radiation dose of computed tomography (CT) scans, and more than three-fourths mistakenly believed that magnetic resonance imaging (MRI) scans are associated with radiation exposure. The findings were reported in the March issue of The Spine Journal.

These findings indicate a deficiency in patient knowledge regarding the risks of their care,” said senior author Kern Singh, MD, Professor of Orthopedic Surgery and Co-Director of the Minimally Invasive Spine Institute at Rush University Medical Center, Chicago. “Physicians have a duty of nonmaleficence, or doing no harm to the patient. This includes properly educating patients so that they can make appropriate decisions regarding their care. The results of this study suggest that physicians should spend more time educating patients regarding the risks and benefits of the medical interventions that they are receiving.”

Patient Survey Reveals Knowledge Gap
Dr. Singh and colleagues surveyed 100 patients before their first appointment with a single spine surgeon at an urban institution. Patients were asked to estimate how many chest x-rays (CXRs) worth of radiation were equivalent to various common spinal imaging modalities for the cervical and lumbar spine.

check x-ray“The implications here are that physicians need to educate their patients on risks they are exposed to, and that more work needs to be done to educate physicians on the risks that they subject their patients to.”Patients were relatively accurate in their estimates of radiation from cervical x-rays, but markedly underestimated the CXRs for cervical spine CT scans (2.0 vs 145.3 CXRs), lumbar x-rays (2 views, 3.0 vs. 123.3 CXRs), and lumbar spine CT scans (2.0 vs. 638.3 CXRs). In addition, the majority of patients incorrectly believed that MRIs are associated with radiation exposure (77%-78%).

Most patients reported that a physician had never discussed radiation exposure associated with x-rays (66%) or CT scans (63%) with them. While most patients said they would not forgo surgeon-recommended imaging because of fear of radiation exposure, the researchers noted that these patients were not informed during the survey of the actual amount of radiation in imaging scans.

“The authors have demonstrated that there is a clear knowledge gap that patients have regarding risks associated with common clinical practices,” commented S. Samuel Bederman, MD, PhD, FRCSC, Orthopaedic Spine Surgeon, RESTORE Orthopedics and Spine Center in Orange, CA “The implications here are that physicians need to educate their patients on risks they are exposed to, and that more work needs to be done to educate physicians on the risks that they subject their patients to.”

Patient Education May Reduce Unnecessary Radiation Exposure
“Patient autonomy is crucial in today’s healthcare system,” Dr. Singh said. “In order for a patient to make an informed decision regarding their care, the patient must be properly educated about all risks and benefits. With this knowledge, a patient may choose to proceed or opt out of any given treatment or diagnostic intervention, including imaging. This may reduce the frequency of unnecessary imaging tests and reduce the risk for serious long-term consequences of excessive radiation exposure that could occur as a result. Additionally, healthcare costs associated with unnecessary diagnostic testing would also decrease substantially as more patients become educated about the risks associated with these interventions.”

“While much has focused on costs and risks associated with invasive procedures, radiation risks have received little attention,” Dr. Bederman said. “In empowering patients with the autonomy to make informed decisions, improved awareness of these risks is imperative.”

“While individual imaging tests hold minimal risk to patients, it is the accumulative effects associated with excessive and prolonged radiation exposure that can lead to harmful outcomes,” Dr. Singh noted. “As such, it is always important to note a patient’s previous history of radiation exposure and weigh the risks and benefits of medical imaging before proceeding with these diagnostic tests. This requires not only communication between the patient and physician but also thorough patient counseling.”

Physician Education on Radiation Exposure Also Is Needed
“As previous studies have identified, even physician knowledge regarding radiation dose of common imaging modalities is limited,” Dr. Singh told SpineUniverse. “It is imperative for physicians to become more familiar with radiation exposure associated with medical imaging in order to improve their medical decision making abilities and better counsel their patients. Furthermore, as physician reimbursement becomes more reliant on the efficacy of healthcare delivery, reducing excessive expenditure through unnecessary imaging tests will benefit physicians in addition to patients.”

Surgery and Injection Procedures Requiring Intraoperative Imaging Also Pose Risk
Greater awareness also is needed on radiation risks during surgical procedures requiring use of intraoperative fluoroscopy or CT with or without navigation or robotic guidance, Dr. Bederman said. “Major differences in radiation risks have been reported with different imaging and guidance modalities,” he explained.

“Furthermore, fluoroscopically-guided injection procedures are commonly used in the treatment of degenerative spinal disorders, such as epidural injections,” Dr. Bederman noted. “The amount of radiation exposure during these procedures is technician dependent, and with the use of multiple procedures accumulated over time. However, little is known about the cumulative radiation risks of these injection procedures.”

Updated on: 03/20/18
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S. Samuel Bederman, MD, PhD, FRCSC
Orthopaedic Spine Surgeon
RESTORE Orthopedics and Spine Center
Orange, CA
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