Image Gently: A Pediatric Neurosurgical Perspective
In the fall of 2016, the AANS/CNS Section on Pediatric Neurological Surgery became a sponsor of the Image Gently Think-A-Head Campaign. I personally became interested in radiation exposure early in my career. As a first-year medical student, I participated in an active spina bifida clinic with almost 250 patients. It was not uncommon for a whole trolley to be necessary to carry the x-rays jackets for a single patient to the clinic. I became concerned about the potential overuse of radiology when I tabulated the radiation exposure for the entire clinic population. The data suggested that the radiation burden from diagnostic radiographs (many of which had no medical utility) could contribute to carcinogenesis. The results were alarming and led to the publication of the paper “Radiation exposure in the myelomeningocele population.”1
As a result of my interests, I began to receive frequent calls from my colleagues about adult spina bifida patients with genitourinary cancers, and ultimately published the related article “The development of carcinoma in the aging myelodysplastic population.”2 These experiences significantly raised my awareness of the diagnostic radiographic studies being ordered on my patients both by myself and others. It is an issue we, as neurosurgeons, need to be aware of, as medical exposure now represents the majority effective dose of radiation exposure in the United States for the first time ever.
As pediatric neurosurgeons, we care for many patients with lifelong, chronic illnesses, including brain and spinal cord tumors, spina bifida, and shunted hydrocephalus (from prematurity, congenital or other causes). These populations are at an increased risk of being exposed to unnecessary radiographic imaging. While it is easier to justify images on patients with tumors, even these patients have a significant number of unnecessary images performed. Spina bifida patients have a complex medical condition and are often followed by multiple doctors in separate centers, which leads to many repetitious and questionably necessary films. Any child with a shunt is subject to the frequent policy of a CT and shunt series every time they have an office visit in some practices, or every time they show up in an emergency department. I saw a child once who was not quite three years old, and she had more than 300 CTs and shunt series done at a single institution, often within days of each other.
While I think most pediatric neurosurgeons recognize the need to image more carefully, I believe there continues to be room for improvement. Most of us will replace a CT for the evaluation of a shunt with a rapid sequence MRI, which gives us the advantage of a quick, non-sedated, no radiation evaluation of the ventricles. The Lancet article “Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study”3 in June 2012, represented the first direct association with prior CT scans and cancer, and has fueled public and specialty debate about imaging, particularly with CT in the pediatric population. Indeed, 30 percent of patients who undergo a single CT will have at least three CT scans.
The Image Gently Think-A-Head Campaign rolled out November 2, 2016, as a multispecialty campaign under the umbrella of the Image Gently Alliance, which has grown exponentially since its inception by the Alliance for Radiation Safety in Pediatric Imaging almost a decade ago. Image Gently is an organization dedicated to education and awareness. Over 100 health care organizations and agencies (>35 international) participate, and there are now over one million professionals worldwide (including radiologists, technologists, medical physicists, and other experts) actively involved in the campaign. It is important to note this is a communication campaign that benefits the market—not the “marketers.” This social marketing campaign has the goal of decreasing the radiation dose in children. We all recognize that children are more radiosensitive than adults, due to their growing tissues and developing central nervous system. As pediatric neurosurgeons, we have an obligation to do our part to reduce the number of unnecessary radiographs performed in children through modification of our own practices, and education of others in the health care profession.
For all neurosurgeons, it is important to remember that no level of radiation exposure is without consequence. If a study is necessary for the care of the patient, it is justified. If the information gathered from a radiographic study will not change the management, then it likely should not be obtained. I’m sure we can all do better with less imaging. So, Image Gently.
To learn more about Image Gently and the Think-A-Head Campaign visit imagegently.org.
1 Gaskill S, Marlin A. Radiation exposure in the myelomeningocele population. Pediatr Neurosurg. 1998 Feb;28(2):63-6. DOI:10.1159/000028622
2 Gaskill S. Development of Carcinoma in the Aging Myelodysplastic Population. Pediatr Neurosurg. 1991– 92;17:34–36 (DOI:10.1159/000120564)
3 Pearce, M, Salotti J, Little M, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4; 380(9840): 499–505. doi 10.1016/S0140-6736(12)60815-0.