AAOS 2017

Assessing the appropriateness of CT scans among pediatric ortho patients

March 17, 2017
by Lee Nelson, Contributing Reporter
A presentation this week at the American Academy of Orthopaedic Surgeons annual meeting in San Diego, California, focused on pediatric orthopaedic patients and recommendations for limiting exposure to radiation through unwarranted imaging.

“Traditionally, there has not been enough discussion on how we can disseminate information to best treat children with the least possible exposure to radiation,” Dr. David H. Godfried told HCB News. “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.”

He is senior research author of the analysis, and serves as clinical associate professor of orthopaedic surgery and pediatrics at NYU Langone Medical Center. Dr. Ayesha Rahman, a fifth-year resident in the department of Orthopedic Surgery at NYU Langone, helped in the research.

Sifting through peer-reviewed studies on different options in imaging technology used in pediatric orthopedic injuries, the two doctors quantified the amount of radiation in each of the CT scans and X-rays for spines, pelvis, hip and other body parts. They discovered that children who require surgery for hip dysplasia, scoliosis and leg-length discrepancy undergo X-rays or CT scans, and are the children most vulnerable to exposure risk.

“Many doctors revert back to practices that they learned while still in training. However, when presented with the current data, virtually all were willing to change practice,” he said. “Although there is consensus among experts about methods to decrease frequency of imaging for specific pediatric orthopaedic conditions, there does not seem to be a readily available summary of "best practices" that practitioners routinely refer to.”

Organizations such as "The Image Gently Alliance" have done much to bring together current information and compile information and best practices. This approach needs to be woven into presentations at local grand rounds and national meetings so that the physicians on the front lines are exposed to this information, he added.

“X-rays used judiciously play a very important role in providing care for scoliosis. We need to focus on efforts to keep X-rays to a minimum and employ newer technology to decrease the amount of X-ray exposure,” Godfried said. “If patients are too fearful of X-ray, it may compromise physicians' ability to provide appropriate screening and treatment. This being said, there a very few reasons CT scans should be used for pediatric spine conditions, short of preoperative planning in very complex cases.”

Hospital audits of the number of X-rays obtained for pediatric scoliosis patients in a given year may provide data for individual physicians to assess their usage versus local and national norms.

“My experience is that the vast majority of physicians want to do what is best for their patients,” Godfried said.

The most important lessons learned from this analysis are that child/family and health care providers must work as team. All must acknowledge that patient safety is a priority and that imaging technology used appropriately can improve care, but that current practices need to be reexamined based on nationally accepted best practices, he said.

The research that Godfried and Rahman reviewed included a lot of variation in age and radiation doses.

"Radiation doses generally increase with patient age proportional to the size and weight of the patient,” Rahman told HCB News. “The risk of cancer, however, is increased in younger children compared to older children. The relationship between female patients having twice the risk of adverse events as male patients remains generally constant throughout all age groups. These numbers really highlight the unique susceptibility of younger patients and female patients to radiation exposure."

For example in one 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. That correlated to an over two percent increased lifetime risk of fatal breast cancer, almost one percent risk of fatal leukemia and three percent risk of genetic defects. Non-surgical patients had approximately half that risk.