Hugh Anton, MD, FRCPC (biography and disclosures)
What I did before
As a physiatrist, I frequently see patients with chronic spinal pain who have already had imaging studies. The correlation between symptoms and findings on imaging is poor. My prior practice has been to order additional imaging based on clinical judgment and the question of whether the results would change my treatment recommendations. CT scans and nuclear medicine bone scans are among the most common procedures I ordered.
What changed my practice
It has been suggested as many as 2% of cancers may be attributable to radiation exposure during CT scanning. A recent study of nearly one million adults in the US determined that more than 2/3 of the subjects had at least one imaging procedure during the three year study period. CT and nuclear imaging accounted for 75.4% of the cumulative radiation dose. Since I often order those investigations, I have potentially exposed my patients to ionizing radiation that could increase their risk for cancer. The emerging evidence has made me rethink my approach to ordering imaging.
What I do now
My decision to order imaging still begins with a basic question – will the results of this study change my recommendations for management of the patient? I now ask two additional questions – 1. What other exposure to radiation has this patient had in the past (including prior imaging studies)? 2. Would the patient be better served by an alternative imaging modality (such as MRI or ultrasound) that does not involve exposure to ionizing radiation? The answer to those questions may not change my decision to order imaging, but at least will make me think carefully about the potential adverse consequences before proceeding.
References: (Note: Article requests require a login ID with the BC College of Physicians website or UBC)
- Deyo RA, Weinstein JN Low Back Pain. New England Journal of Medicine 2001; 344(5):363-370. (View article with CPSBC or UBC)
- Brenner DJ, Hall EJ Computed Tomography – an increasing source of radiation exposure. New England Journal of Medicine 2007; 357(22):2277-2284. (View article with CPSBC or UBC)
- Fazel R et al. Exposure to Low-Dose Ionizing Radiation from Medical Imaging Procedures New England Journal of Medicine 2009; 361(9) 849-857. (View article with CPSBC or UBC)
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Our local radiologist has definitely brought this problem to light for us especially in the use of CT scans and especially in young women of child bearing age. The article is very relevant in making us question the use of technology with the eye to potential unintended side effects whether the benefit outweighs the risk in each individual circumstances.
I would be happy to use MRIs when I find patients with lumbar problems & hard neurological signs BUT in Canada (which I believe has a similar number of MRIs to Egypt) this is impractical – CTs are hard & slow enough to get!
And you can get neither unless you first order an irrelevant & ionising lumbosacralspine X-ray.dougacce its
I absolutely agree with this approach. I was fortunate to receive a copy of the Canadian Radiological Society manual of recommendations for imaging a few years ago. It was very useful in helping to decide the most appropriate imaging for a problem. Just as useful is the listing in the first few pages of the radiation exposure of various imaging. I don’t worry at all about chest Xrays and have been very wary of CT scans, expecially in young people.
the real question is what our patients would do if given $500 and the option of keeping the money or paying for the CT scan.
I agree with this approach. I recently discussed this with a radiologist friend who said a CT chest is equivalent to 100 chest x-rays in terms of radiation exposure.