Accepted Manuscript

Title: Effective dose reduction in spine radiographic imaging by choosing the

less radiation sensitive side of the body

Author: Avi Ben-Shlomo, Gabriel Bartal, Morris Mosseri, Boaz Avraham,

Yosef Leitner, Shay Shabat

PII: S1529-9430(15)01795-7
DOI: http://dx.doi.org/doi: 10.1016/j.spinee.2015.12.012
Reference: SPINEE 56765

To appear in: The Spine Journal

Received date: 12-4-2015

Revised date: 21-10-2015
Accepted date: 7-12-2015

Please cite this article as: Avi Ben-Shlomo, Gabriel Bartal, Morris Mosseri, Boaz Avraham,
Yosef Leitner, Shay Shabat, Effective dose reduction in spine radiographic imaging by choosing
the less radiation sensitive side of the body, The Spine Journal (2015), http://dx.doi.org/doi:
10.1016/j.spinee.2015.12.012.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service
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 1Effective Dose Reduction in Spine Radiographic Imaging by Choosing the

2 Less Radiation Sensitive Side of the Body

Avi3Ben-Shlomo, PhD1, Gabriel Bartal, MD2, Morris Mosseri, MD3, Boaz Avraham, MHA2, Yosef

4 Leitner MD4, Shay Shabat, MD4

Running
5 head: Effective Dose Reduction in Spine Radiography

6
1
Radiation
7 Protection Domain, Soreq NRC, Yavne, Israel
2
Department
8 of Radiology, Meir Medical Center, Kfar Saba, Israel
3
Cardiology
9 Division, Meir Medical Center, Kfar Saba, Israel
4
Orththopedic
10 Surgery Department, Spinal Care Unit, Meir Medical Center, Kfar Saba, Israel

11

Corresponding
12 author

Dr. 13
Avi Ben-Shlomo

Radiation
14 Protection Domain

Soreq
15 NRC

Yavne
16 81800, Israel

Email:
17 avibenshlomo@gmail.com

Phone:
18 +972-506-292310
Abstract
19

20 Background context: X-ray absorption is highest in organs and tissues located closest to the

21 radiation source. The photon flux that crosses the body decreases from the entry surface

22 toward the image receptor. The internal organs absorb x-rays and shield each other during

23 irradiation. Therefore, changing the x-ray projection angle relative to the patient for specific

24 spine procedures, changes the radiation dose each organ receives. Every organ has different

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1 radiation sensitivity, so irradiation from different sides of the body changes the biological

2 influence and radiation risk potential on the total body, i.e. the effective dose (ED).

3 Purpose: To determine the less radiation sensitive sides of the body during lateral and AP/PA

4 directions.

5 Design: Exposure of patient phantoms and Monte Carlo simulation of the effective doses.

7 Patient sample: Calculations for adults and 10-year-old children were included because the

8 pediatric population has a greater life-time radiation risk than adults.

9 Outcome Measures: Pediatric and adult tissue/organ doses and ED from cervical, thoracic

10 and lumbar x-ray spine examinations were performed from different projections.

11 Methods: Standard mathematical phantoms for adults and 10-year-old children, using

12 PCXMC 2.0 software based on Monte Carlo simulations were used to calculate pediatric and

13 adult tissue/organ doses and ED. The study was not funded. The authors have no conflicts of

14 interest to declare.

15 Results: Spine x-ray exposure from various right (RT) LAT projection angles was associated

16 with lower ED compared with the same left (LT) LAT projections (up to 28% and 27% less,

17 for age 10 and adults, respectively). Posterior anterior (PA) spine projections showed up to

18 64% lower ED for age 10 and 65% for adults, than anterior posterior (AP) projections. AP

19 projection at the thoracic spine causes an excess breast dose of 543.3% and 597.0% for age 10

20 and adults, respectively.

21 Conclusions: Radiation ED in spine procedures can be significantly reduced by performing x-

22 ray exposures through the less radiation sensitive sides of the body, which are PA in the

23 frontal position and RT LAT in the lateral position.

24

25 Key words: radiography; spine, positioning; dosimetry; projection; effective dose

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 3

2 Classifications

3 Technical report

4
5

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 4

1 Introduction

3 Spine radiography usually includes two dimensional exposures: lateral (LAT) projection and

4 either anterior-posterior (AP) or posterior-anterior (PA) projection. Because the spine is

5 located in the middle of the body for the lateral projection, practitioners often choose the

6 lateral positioning method: right lateral view (RT LAT, i.e., left x-ray projection) or left

7 lateral view (LT LAT), without knowing the influence of the effective dose (ED). AP or PA,

8 as well as LT LAT or RT LAT projections are used without considering the potential for

9 major differences in ED. Choosing the side of the body that is less sensitive to radiation can

10 significantly reduce the ED during spine radiography for all patients, including children.

11 Figure 1 illustrates various spine x-ray projections.

12

13 Greater life-time radiation risk for exposed children has been estimated [1,2]. There is no

14 doubt that every effort should be made to reduce the ED for adults and children based on the

15 "as low as reasonably achievable" (ALARA) principle. This can be attained simply, by using

16 x-ray projection towards the less radiation sensitive side of the body.

17

18 Due to Compton and photoelectric interactions, the photon flux decreases inside the body

19 from the entry area of the beam toward the image receptor. As it passes through the body, the

20 number of photons diminishes, with decreasing absorbed dose to tissues and organs along the

21 path. Organs and tissues located closest to the x-ray tube absorb the largest radiation dose.

22

23 Each organ or tissue has different radiation sensitivity. The International Commission on

24 Radiological Protection (ICRP) set tissue weighting factors for radiation-sensitive tissues and

25 organs that were chosen to represent the contribution of individual tissues and organs to the

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 5

1 overall radiation detriment from genetic effects and stochastic effects like cancer [3]. The ED

2 represents the total body radiation detriment from the exposure and is calculated by summing

3 the mean absorbed dose of each tissue/organ multiplied by the relevant radiation tissue

4 weighting factor, over all the radiation sensitive organs and tissues (stochastic effects). The

5 directional projection causes differences in the ED [4,5,6]. These differences arise from the

6 asymmetrical position of tissues and organs inside the body, x-ray shielding of organs by

7 other organs, and the unique radiation sensitivity of each organ.

9 This study focused on reducing the ED in models representing 10-year-old children and

10 adults. Based on these models, we calculated the differences in ED with various imaging

11 projections. We chose to demonstrate this phenomenon using conventional spine x-ray

12 examinations, but the results can also be applied to spine fluoroscopy procedures.

13

14

15 Materials and methods

16

17 Monte Carlo simulations estimate the ED for the various organs and use the information to

18 calculate the total body influence, i.e. the ED [7]. Cervical, thoracic, and lumbar spine

19 examinations were simulated to observe differences in ED obtained with AP, PA, RT LAT

20 and LT LAT x-ray projections. Simulation software PCXMC 2.0, published by the Radiation

21 and Nuclear Safety Authority in Finland (STUK) was used [7]. The PCXMC 2.0 uses

22 hermaphrodite mathematical phantoms. We chose the standard PCXMC 2.0 phantoms for

23 children 10 years-of-age (139.8 cm height, 32.4 kg weight) and adults (178.6 cm height, 73.2

24 kg weight).

25

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1 The PCXMC 2.0 simulation was performed with a focus to skin surface distance (FSD) of

2 100 cm. The beam filtration was taken as 2.5 mm Al. ED calculations were based on ICRP

3 103 [3]. We located the phantom simulated radiation field according to a common

4 radiography method [8]. The tube voltage (kV) and the exposure charge (mAs) parameters of

5 the examinations are presented in Table 1. Each value represents an average of 3-7 data sets.

7 The calculations include standard absolute error uncertainties. Hospital x-ray tubes are tested

8 under quality assurance standards of the IPEM [9] for kV and mAs variations of ±5%, each.

9 The PCXMC 2.0 simulation of each examination was performed with 2.5*106 photons to

10 reduce the uncertainty of the ED calculations to a minimum of ±0.2% (purely statistic

11 uncertainty that has a small contribution to the uncertainty of the total results). The entrance

12 surface skin dose accuracy was taken as 5%.

13

14 The nature of this study is comparative. We used the same parameters, exposure techniques

15 and calculations of the ED for each comparison: AP versus PA and R LAT versus L LAT

16 projections.

17

18 Theory

19

20 Due to Compton and photoelectric interactions, the photon flux decreases inside the body

21 from the point of entry of the beam toward the image receptor. In Compton interactions, the

22 energy absorbed when the incident photon interacts with an electron inside an organ’s atom,

23 produces a recoil electron and a secondary photon with less energy than the incident photon

24 [10, 11]. This secondary photon scatters and can be absorbed by the patient’s organs inside

25 the direct x-ray field area, but it can also scatter towards organs located outside the direct x-

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1 ray field or even outside the patient’s body, towards the medical staff in operating rooms. In

2 the photoelectric effect, all the photon energy is absorbed by the atom in one event, causing

3 one of the electrons to eject from the organ’s atom. Both Compton and photoelectric

4 interactions cause energy absorption through ionization as the atoms hit the cells. The

5 absorbed energy inside the cells during x-ray imaging creates free radicals and cancer/genetic

6 risks. The biological characteristics of each organ’s cells, makes the cells react differently,

7 with the risk of free radicals. Varying radiation sensitivity of organs and the absorbed energy

8 of each organ, determine the biological risk. The total accumulation of this biological risk

9 over all radiation sensitive tissues and organs of the body comprises the ED. Further work is

10 needed to estimate the organs’ radiation risk, mainly for low radiation doses. Significant

11 differences in the cells’ relative biological effectiveness (RBE) at various diagnostic x-ray

12 energies (like the low x-ray energy used for mammography versus the higher x-ray energy

13 used for spine imaging) were observed [12].

14
15 The Monte Carlo method for medical radiation transport simulations can be used in

16 diagnostic radiology [e.g. 14, 15], nuclear medicine [e.g. 16, 17] and radiotherapy [e.g. 18-

17 20]. By using this method, we can estimate the radiation absorption of each organ of interest.

18 Knowledge of the physics behind interactions of radiation with matter is used for simulations

19 of low energy x-ray radiation transport in the body for diagnostic radiology, just as high

20 energy x-rays or other particles, such as protons are used for radiotherapy. The method is

21 based on three points, which include simulation of the beam characteristics that enter the

22 patient, simulation of the patient’s body by using mathematical phantoms and simulation of

23 the interaction between the radiation particles and the patient’s organs. The method uses the

24 probability of occurrence of each interaction, so it follows the behavior of a statistical model.

25 In statistics, a large number of events increases the accuracy of the results, so in this study,

26 we simulated the penetration of 2.5 million independent photons into the body for each

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1 effective dose calculation. The calculated output is the energy absorbed by each simulated

2 organ. By knowing the mass of each organ in our standard phantom, we can calculate the

3 organ’s radiation dose. Combining the organ’s radiation sensitivity data provided the

4 effective dose, which represents the total body radiation detriment. The theory behind the

5 PCXMC program and its use of Monte Carlo simulation methods is described by Tapiovaara

6 and Siiskonen [7].

7 The PCXMC 2.0 hermaphrodite mathematical phantoms were based on the work of Cristy

8 and Eckerman [21]. These include voxel-phantoms, which are based on CT and MR images

9 of actual human beings and computational models, where body contours and organs are

10 defined by mathematical expressions. The standard phantoms in the program include

11 newborn, 1, 5, 10 and 15 year old children, and adults. The program lets the user change the

12 height and mass of each selected phantom with a proportional change in the size of the

13 organs. The stochastic effects of the size and structure of radiation sensitive organs were

14 characterized for each age group. The elemental composition of the phantom’s organs was

15 based on percentage of weight, for example, the newborn skeleton structure (density 1.22

16 gr/cc) is taken as 7.995% H, 9.708% C, 2.712% N, 66.811% O, 4.623% each Na, Mg, P, S,

17 and Cl, and 8.151% by grouping elements with atomic numbers of K or higher together and

18 treating them as calcium [20].

19

20 Results

21 PCXMC 2.0 Monte Carlo simulations of spine x-ray examinations were performed and show

22 ED differences when imaging the same anatomical area using different projected angles. The

23 results are shown in Table 2. There was no difference in ED between the right and left lateral

24 directions in cervical spine exposures. However, the thoracic spine examination had 18% and

25 19% lower ED in the RT LAT projection compared with the LT LAT, in 10 year old children

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 9

1 and adults, respectively. Lumbar spine radiography required 28% and 27% less ED in the RT

2 LAT projection compared with LT LAT projection in 10 years and adults, respectively.

4 The differences in ED between AP and PA directions are larger than those in the lateral

5 exposures. PA cervical spine examination had 64% and 65% lower ED than the AP

6 projection, PA thoracic spine examination represents a lower ED of 57% and 50% and PA

7 lumbar spine examination a lower ED of 48% and 46% than the same examination in AP

8 projections, for age 10 years and adults, respectively. The breast dose in thoracic spine

9 examination was 5.4 and 6.6 times higher in AP projection than in PA projection, for 10

10 years old and adult, respectively. Figures 2-3 present the ED differences for 10 years and

11 adults. The results are much higher ED for adults than for age 10 (an average of 290%) due to

12 the need for higher kV and mAs. The age 10 calculation of the breast ED in thoracic x-ray

13 examinations was 0.030 mSv at PA projection and 0.163 mSv for AP projection. The same

14 calculations for adults show 0.033 mSv at PA projection and 0.197 mSv for AP projection.

15

16 Discussion

17 We performed Monte Carlo ED simulations for spine x-ray examinations. Due to the

18 differences in organ radiation sensitivity, the position of organs and tissues, and the shielding

19 of organs by neighboring organs, it is clear that x-ray exposure to the body from the RT LAT

20 projections was associated with lower ED than the same exposures from LT LAT projections

21 (18% and 19% less for thoracic spine examinations and 28% and 27% less for lumbar spine

22 examinations, for 10 year olds and adults, respectively). LAT cervical spine examination had

23 no ED difference. It was also shown that PA spine projections resulted in a much lower ED

24 than AP projections (64% and 65% less for cervical spine examinations, 57% and 50% less

25 for thoracic spine examinations and 48% and 46% less for lumbar spine examination, for age

Page 9 of 20
 10

1 10 years and adults, respectively). The major organs that count for the differences in absorbed

2 dose are breast, colon, stomach, liver, and urinary bladder in the PA projections, and

3 stomach, spleen, lower large intestine, small intestine, and pancreas in the RT LAT

4 projections. The organ dose arises mostly from the direct x-ray beam, and from the scattered

5 photons inside the body which are absorbed by organs that are located outside the direct path

6 of the beam.

8 Since image quality improves when the target object is closer to the image receptor, it is

9 important to mention that in some instances, such as prior to surgery, a specific projection

10 (such as AP) is required despite its higher dose. However, many procedures do not always

11 require the best image quality and with modern x-ray equipment and improved image quality,

12 less sharp imaging of the spine (such as PA rather than AP) may be ‘good enough’ for

13 general radiographic exams for clinical purposes. For most examinations, it does not matter if

14 the lateral exposure is from the right or left side of the body.

15

16 As children have thinner bodies than adults, the ED for adult spine examinations is greater

17 than that of age 10 years by an average of 290%. The increased differences between adult and

18 child ED range from a factor of 2.5 for thoracic spine PA examinations to a factor of 3.5 for

19 thoracic spine LT LAT examinations. However, children are much more sensitive to

20 stochastic effects of radiation than adults [22]. The multiplicative model shows that the

21 attributable lifetime death risk for 0-10 year old children from a single radiation dose is about

22 3 times higher than the average population risk [2].

23

24 Although the ED is the major factor to consider, we simulated the breast equivalent dose

25 during thoracic spine radiography. Using AP rather than PA projection in thoracic spine

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 11

1 examinations causes an excess breast dose of 543.3% and 597.0% for 10 year olds and for

2 adults, respectively. These numbers illustrate the importance of using PA projections,

3 particularly in the sensitive group of pediatric patients. This observation is also well-

4 documented in clinical trials.

6 The breast is one of the most radiation sensitive organs to stochastic effects (it contributes

7 12% to the whole body radiation sensitivity). A higher incidence of breast cancer in female

8 scoliosis patients following childhood radiation exposure has been observed [23]. A recent

9 paper by Presciutti et al. stated that patients with adolescent idiopathic scoliosis have a 1-2%

10 increased lifetime risk for developing cancer [24]. Increased breast cancer mortality was

11 found by another group who examined 5,573 women with scoliosis from 14 medical centers

12 in the United States [25].

13

14 Conclusions

15 Based on the results of this simulation study, use of projections that incur a lower radiation

16 effective dose in spine x-ray imaging is advocated. RT LAT projection for the lateral view

17 and PA projection for the anterior-posterior view expose the less radiation sensitive sides of

18 the body. Cervical, thoracic and lumbar spine x-ray radiography examinations were selected

19 to illustrate the heterogeneous sensitivity of the body to radiation, but the results could also

20 be applied when choosing the proper x-ray projections for radiography, as well as

21 fluoroscopy during spine surgery and other procedures.

22

23 Funding

24 This work was not supported by external funding.

25

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1 Acknowledgements

2 The authors have no conflicts of interest to declare.

3 Acknowledgements

4 We thank Ronit Burla for professional graphics assistance and Faye Schreiber for editorial

5 assistance with this article. The authors have no conflicts of interest to declare.

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1 References

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12 ICRP Publication 74. Pergamon Press, 1996.

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18 17. Zaidi, H. Relevance of accurate Monte Carlo modeling in nuclear medical imaging.

19 Medical Physics, 26(4), 574-608, 1999.

20 18. Seco, J., Reza, H., Oh, K., Doppke, K., & Spadea, M. Stereotactic Body Radiation

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1 Spine in the Presence of Titanium Hardware. International Journal of Radiation

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6 58(20), 7107, 2013.

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8 internal photon sources. I Methods. Report ORNL/TM-8381/V1. Oak Ridge National

9 Laboratory, TN, USA: Oak Ridge, 1987.

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20

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Figures

Figure 1: Imaging of cervical, thoracic and lumbar spine x-ray examinations.

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Figure 2: Effective dose comparison of cervical, thoracic and lumbar spine x-ray examinations for 10

year old children.

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 18

Figure 3: Effective dose comparison of cervical, thoracic and lumbar spine x-ray examinations for

adults.

Page 18 of 20
Table
1 1: Spine radiography exposure parameters

Cervical spine Thoracic spine Lumbar spine

AP/PA RT/LT LAT AP/PA RT/LT LAT AP/PA RT/LT LAT

a
kV 62 (58-66) 63 (58-70) 66 (60-70) 66 (60-70) 69 (65-75) 76 (70-85)
10 y
b
mAs 5 (4-6) 7 (4-16) 10 (5-16) 13 (5-18) 13 (6-25) 16 (6-30)

kV 67 (65-70) 68 (65-70) 74 (66-80) 85 (73-90) 78 (75-81) 88 (80-90)

Adult
mAs 14 (8-18) 19 (18-20) 21 (12-32) 31 (22-40) 34 (25-41) 53 (40-68)

AP, 2anterior posterior; PA, posterior anterior; RT LAT, right lateral; LT LAT, left lateral
a
3 voltage
Tube
b
4
Exposure charge

5
Numbers in parentheses represent the minimum and maximum values.

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1

Table
2 2: Spine x-ray examinations effective dose at different projection angles

Ratio Ratio
Projection 10-years (mSv) Adult (mSv)
(mSv/mSv) (mSv/mSv)

PA 0.004 ±0.001 0.011 ±0.001

0.36 0.35
Cervical AP 0.011 ±0.001 0.033 ±0.004

spine RT LAT 0.011 ±0.001 0.029 ±0.003

1.00 1.00
LT LAT 0.011 ±0.001 0.029 ±0.003

PA 0.051 ±0.006 0.128 ±0.016

0.43 0.50
Thoracic AP 0.117 ±0.014 0.258 ±0.031

spine RT LAT 0.043 ±0.005 0.148 ±0.018

0.82 0.81
LT LAT 0.053 ±0.006 0.184 ±0.022

PA 0.046 ±0.006 0.154 ±0.019

0.52 0.54
Lumbar AP 0.089 ±0.011 0.283 ±0.034

spine RT LAT 0.056 ±0.007 0.163 ±0.020

0.72 0.73
LT LAT 0.077 ±0.009 0.223 ±0.027

AP,3anterior posterior; PA, posterior anterior; RT LAT, right lateral; LT LAT, left lateral; mSv, the units of the radiation effective dose (ED).

The4± values represent standard absolute error uncertainties.

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