Estimation of radiation doses to patients and surgeons from various fluoroscopically guided orthopaedic surgeries

In this study, a mathematical method was used to estimate the entrance surface dose (ESD) to the patient and the scattered dose (Ds) to the operating surgeon during various fluoroscopically guided surgical orthopaedic procedures. For 204 patients, the procedure type, the fluoroscopy time and the highest tube potential and current values observed during fluoroscopy were recorded. For the most often performed procedures (intramedullary nailing of peritrochanteric fractures, open reduction and internal fixation of malleolar fractures and intramedullary nailing of diaphyseal fractures of the femur), the respective mean fluoroscopy times were 3.2, 1.5 and 6.3 min while the estimated mean ESDs were 183, 21 and 331 mGy, respectively. The estimated Ds rates for the hands, chest, thyroid, eyes, gonads and legs of the operating surgeon were on average to 0.103, 0.023, 0.013, 0.012, 0.066 and 0.045 mGy min(-1), respectively, and compare well with the literature. The mathematical estimation of doses cannot replace actual measurements; however, it can be used for a preliminary assessment of the radiation dose levels during various surgical procedures, so that the operator, the surgeon and the rest of the medical staff involved could be aware of the associated radiation risk and the radiation protection measures required.     

Comparison of operator radiation exposure between C-arm and O-arm fluoroscopy for orthopaedic surgery

The O-arm system has recently been introduced and has the capability of combined two-dimensional (2-D) fluoroscopy imaging and three-dimensional computed tomography imaging. In this study, an orthopaedic surgical procedure using C-arm and O-arm systems in their 2-D fluoroscopy modes was simulated and the radiation doses to susceptible organs to which operators can be exposed were investigated. The experiments were performed in four configurations of the location of the X-ray source and detector. Shielding effects on the thyroid surface and the direct exposure delivered to the surgeon's hands were also compared. The results obtained show that the O-arm delivered higher doses to the sensitive organs of the operator in all configurations. The thyroid shield cut-off 89 % of the dose in the posteroanterior configuration of both imaging systems. Thus, the operators need to pay more attention to managing radiation exposure, especially when using the O-arm system.     

Investigation of occupational radiation exposure during interventional cardiac catheterisations performed via radial artery

The purpose of this study was to determine the thyroid, sternum and hand radiation doses of radiologists who perform angiographies and angioplasties via the radial artery. Staff radiation dose was estimated for 21 cardiac interventional catheterisations. Thermoluminescence dosemeters (TLDs) were used to determine radiation dose for each procedure at the right and left wrist, at the sternum and the thyroid. A dose area product (DAP) meter was also attached to give a direct value in Gy cm2 for each procedure. Staff radiation doses varied between 34 and 235 microGy per procedure at the left wrist, 28 and 172 microGy at the right wrist, 16 and 106 microGy at the level of the thyroid and 16 and 154 microGy at the level of the sternum. The DAP values varied between 25 and 167 Gy cm2. Radiation doses in this study are comparable to those reported in previous studies. Moreover, good correlation was found between the DAP values and the occupational dose measured with TLDs.     

Equipment performance and radiation protection status in X-ray fluoroscopy units in Sudan

The number of fluoroscopy and fluoroscopically guided procedures has been substantially growing in developing countries at the same time advanced and sophisticated equipment are used in some hospitals. However, radiation protection requirements are not necessarily well adopted. In this study nine fluoroscopy X-ray units in Sudan were examined for compliance with international standards. The tests included: beam quality, entrance surface air kerma, image quality and radiation field measurements. Staff radiation protection tools such as lead aprons and eye glasses were also visually examined to find out whether international recommendations were fulfilled and to determine the level of staff awareness. The measured peak tube voltage deviation exceeded the recommended tolerance level in 30 % of the measurements. The results of patient doses measurements exceeded the recommended reference dose levels in 43 % of the measurements; however image quality and radiation field generally fulfilled the requirements for most units. The study revealed that a considerable number of fluoroscopy units were not performing according to the international standards and highlights the need of optimisation of radiation protection.     

Entrance radiation doses during paediatric cardiac catheterisations performed for diagnosis or the treatment of congenital heart disease

The purpose of this study was to estimate the radiation exposure of children, during cardiac catheterisations for the diagnosis or treatment of congenital heart disease. Radiation doses were estimated for 45 children aged from 1 d to 13 y old. Thermoluminescent dosemeters (TLDs) were used to estimate the posterior entrance dose (DP), the lateral entrance dose (DLAT), the thyroid dose and the gonads dose. A dose-area product (DAP) meter was also attached externally to the tube of the angiographic system and gave a direct value in mGy cm2 for each procedure. Posterior and lateral entrance dose values during cardiac catheterisations ranged from 1 to 197 mGy and from 1.1 to 250.3 mGy, respectively. Radiation exposure to the thyroid and the gonads ranged from 0.3 to 8.4 mGy to 0.1 and 0.7 mGy, respectively. Finally, the DAP meter values ranged between 360 and 33,200 mGy cm2. Radiation doses measured in this study are comparable with those reported to previous studies. Moreover, strong correlation was found between the DAP values and the entrance radiation dose measured with TLDs.     

Estimation of the peak entrance surface air kerma for patients undergoing computed tomography-guided procedures

The purpose of this work was to develop a method for estimating the patient peak entrance surface air kerma from measurements using a pencil ionisation chamber on dosimetry phantoms exposed in a computed tomography (CT) scanner. The method described is especially relevant for CT fluoroscopy and CT perfusion procedures where the peak entrance surface air kerma is the risk-related quantity of primary concern. Pencil ionisation chamber measurements include scattered radiation, which is outside the primary radiation field, and that must be subtracted in order to derive the peak entrance surface air kerma. A Monte Carlo computer model has therefore been used to calculate correction factors, which may be applied to measurements of the CT dose index obtained using a pencil ionisation chamber in order to estimate the peak entrance surface air kerma. The calculations were made for beam widths of 5, 7, 10 and 20 mm, for seven positions of the phantom, and for the geometry of a GE HiSpeed CT/i scanner. The program was validated by comparing measurements and calculations of CTDI for various vertical positions of the phantom and by directly estimating the peak ESAK using the program. Both validations showed agreement within statistical uncertainties (standard deviation of 2.3% or less). For the GE machine, the correction factors vary by approximately 10% with slice width for a fixed phantom position, being largest for the 20 mm beam width, and at that beam width range from 0.87 when the phantom surface is at the isocentre to 1.23 when it is displaced vertically by 24 cm.     

Comparison of the NIST and NPL Air Kerma Standards Used for X-Ray Measurements Between 10 kV and 80 kV

A direct comparison was made between the air kerma primary standards used for the measurements of low-energy x rays at the National Institute of Standards and Technology (NIST) and the National Physical Laboratory (NPL). The comparison was conducted at the NPL using NPL reference radiation qualities between 10 kV and 80 kV. The results show the primary air-kerma standards to agree within 0.6 % of their values for beam qualities up to 80 kV.     

Patient effective dose and radiogenic risks from fluoroscopically assisted surgical reconstruction of femoral fractures

The objectives were to assess patient effective radiation dose from fluoroscopically guided surgical reconstruction of femoral fractures and provide normalized data for the estimation of patient effective dose and risks associated with such procedures performed in any laboratory. The fluoroscopic control required during surgical reconstruction of femoral fractures was classified into two types identified by beam orientation, i.e., posterior-anterior (PA) and lateral crosstable (LC) exposures. The duration and the dose area product (DAP) of each exposure were monitored in 24 patients with femoral fractures. Patient dose per DAP unit and per minute of fluoroscopy were measured at 14 radiosensitive organs/tissues using an anthropomorphic phantom and thermoluminescence dosimetry. The typical effective dose to patients with femoral fracture treated surgically in our institution was 11.6-21.7 microSv. This effective dose is estimated to cause an excess of 1.4 fatal cancers per million patients treated, and an excess of 0.4 hereditary disorders per million of births. Induction of deterministic skin injuries to treated patients is highly improbable at the dose levels found in this study. Patient effective dose and associated risks from a typical fluoroscopically guided surgical fixation of femoral fracture are low. However, they may be significantly elevated if treated patients are young individuals and/or the fluoroscopic exposure is prolonged. The present data may be used to determine effective dose to patients undergoing surgical reconstruction of femoral fracture in any institution.     

Dose measurement for medical staff with glass dosemeters and thermoluminescence dosemeters during 125I brachytherapy for prostate cancer

Photoluminescence glass dosemeters (PLDs) and thermoluminescence dosemeters (TLDs) are commonly used as a personal monitoring dosemeter. PLDs and TLDs were used for surface dose monitoring of medical staff involved in (125)I brachytherapy for prostate cancer because these dosemeters have a wide dose-response linearity and high sensitivity for low photon energy. Surface doses measured with PLDs agreed with those with TLDs within ～20 % except for a few cases. Surface doses at a surgeon's left hand and arm were higher than those at the other measuring points. A surgeon received a maximum dose of 650 μGy at the back of left hand. Surface doses to an assistant were <100 μGy. Surface doses to a nurse, a radiologist, an anaesthesiologist and a radiological technologist were <10 μGy. The occupational exposure to a surgeon could be reduced by the adjustment of fluoroscopic parameters and the use of lead gloves.     

Monte Carlo study of a 60Co calibration field of the Dosimetry Laboratory Seibersdorf

The gamma radiation fields of the reference irradiation facility of the Dosimetry Laboratory Seibersdorf with collimated beam geometry are used for calibrating radiation protection dosemeters. A close-to-reality simulation model of the facility including the complex geometry of a (60)Co source was set up using the Monte Carlo code MCNP. The goal of this study is to characterise the radionuclide gamma calibration field and resulting air-kerma distributions inside the measurement hall with a total of 20 m in length. For the whole range of source-detector-distances (SDD) along the central beam axis, simulated and measured relative air-kerma values are within +/-0.6%. Influences on the accuracy of the simulation results are investigated, including e.g., source mass density effects or detector volume dependencies. A constant scatter contribution from the lead ring-collimator of approximately 1% and an increasing scatter contribution from the concrete floor for distances above 7 m are identified, resulting in a total air-kerma scatter contribution below 5%, which is in accordance to the ISO 4037-1 recommendations.     

Comparison of the NIST and PTB Air-Kerma Standards for Low-Energy X-Rays

A comparison has been made of the air-kerma standards for low-energy x rays at the National Institute of Standards and Technology (NIST) and the Physikalisch-Technische Bundesanstalt (PTB). The comparison involved a series of measurements at the PTB and the NIST using the air-kerma standards and two NIST reference-class transfer ionization chamber standards. Results are presented for the reference radiation beam qualities in the range from 25 kV to 50 kV for low energy x rays, including the techniques used for mammography dose traceability. The tungsten generated reference radiation qualities, between 25 kV and 50 kV used for this comparison, are new to NIST; therefore this comparison will serve as the preliminary comparison for NIST and a verification of the primary standard correction factors. The mammography comparison will repeat two previously unpublished comparisons between PTB and NIST. The results show the standards to be in reasonable agreement within the standard uncertainty of the comparison of about 0.4 %.     

Radiation measurements around X-ray cabinet systems

Security personnel who operate X-ray units for the control of hand luggage and personal items at airports are generally not under dosimetric surveillance. A significant increase in the number of inspected items per passenger, due to rigorous air traffic security measures, raises a question of extended exposure of these workers to scattered X-ray radiation. A new approach to investigating directions of breaches of scattered X-ray radiation in the area near to an X-ray cabinet system, which is based on using active electronic dosemeters is presented. Influence of the increase in the number of inspected items in time on the dose rate is described. Time-dependent dose rates have showed a very good correlation with passengers undergoing security control prior to boarding an airplane. Measurements confirmed that an increase in the dose rate, coinciding with rush hours, was caused by scattered radiation passing through incompletely closed lead curtains. It is found that the doses at the entrance to the inspection tunnel are 50% higher than those at the exit, which is a consequence of inherent operational characteristics of X-ray cabinet systems.     

Status of radiation protection in interventional cardiology in four East European countries

Level of staff and patient radiation protection in interventional cardiology in four counties (Bosnia and Herzegovina, Croatia, Montenegro and Serbia) as a part of International Atomic Energy Agency project (RER/9/093) are presented. Patient doses were assessed in terms of air kerma area product (KAP), peak skin dose (PSD) or air kerma at interventional reference point (K(IRP)). Results were available from nine hospitals: 775 patients for KAP, 157 for PSD and 437 for K(IRP). Eight centres reported KAP >100 Gy cm(2) and five centres reported values >200 Gy cm(2). From patients monitored in terms of PSD, 14 (9 %) had PSD >2 Gy and 6 (3 %) patients from those monitored in terms of K(IRP) had value >5 Gy, indicating risk of skin injury. The results indicate need for optimisation and dose monitoring in complex fluoroscopically guided cardiology interventions.     

Occupational exposure to staff during endoscopic retrograde cholangiopancreatography in Sudan

Endoscopic retrograde cholangiopancreatography (ERCP) procedure is an invasive technique that requires fluoroscopic and radiographic exposure. The purpose of this study was to determine the occupational dose of ionising radiation at three gastroenterology departments (Fedial, Soba and Ibn seena hospitals) in Khartoum, Sudan. The radiation dose was measured during 55 therapeutic ERCP procedures. Thermoluminescence dosemeters were used. The mean radiation dose for the first operator was 0.27 mGy for the eye lens, 0.21 for the thyroid, 0.32 for the chest, 0.17 for the hand and 0.22 for the leg. The mean radiation dose for the second operator was 0.21 mGy for the hand and 0.20 mGy for the chest, while the mean radiation dose for the nurse was 0.44 mGy for the hand and 0.19 for the chest. The radiation dose received by the staff in these hospitals was found to be higher than most of the values in the literature. The radiation absorbed dose received by the different organs is relatively low. Additional studies need to be conducted for radiation dose optimisation.     

Measurements of finger doses in x-ray guided surgery, nuclear medicine and research

The Norwegian Radiation Protection Authority has performed measurements of finger doses to nuclear medicine staff exposed to 99Tc(m), researchers handling 32P, surgeons performing X-ray guided orthopaedic surgery and surgeons and radiologists performing X-ray guided endovascular treatment of abdominal aortic aneurysms (AAA). Calibrations were done with X-ray qualities N-40, N-60 and N-300 and with the beta source 90Sr + 90Y. Annual doses were estimated for the nuclear medicine staff and the orthopaedic surgeons. The mean annual finger dose to nuclear medicine staff exposed to 99Tc(m) was estimated to be 18.8 mSv, and the mean annual finger dose to surgeons performing X-ray guided orthopaedic surgery was 13.7 mSv. The surgeons and radiologists performing X-ray guided endovascular treatment of AAA received a mean finger dose of 0.35 mSv per treatment. The majority of researchers handling 32P received no finger dose at all, and the maximum reading was 1.65 mSv. All occupational groups received finger doses well below the annual finger dose limit of 500 mSv.     

Comparison of the NIST and BIPM Standards for Air Kerma in Medium-Energy X-Rays

A comparison has been made of the air-kerma standards for medium-energy x-rays of the National Institute of Standards and Technology (NIST) and the Bureau International des Poids et Mesures (BIPM). The comparison involved a series of measurements at the BIPM and the NIST using the air-kerma standards and three NIST reference-class transfer ionization chamber standards. Reference beam qualities in the range from 100 kV to 250 kV were used. The results show the standards to be in reasonable agreement within the combined standard uncertainty of the comparison of 0.37 %, although a significant trend with radiation quality is observed and the possible sources discussed.     

Patient dose in neonatal units

Lung disease represents one of the most life-threatening conditions in prematurely born children. In the evaluation of the neonatal chest, the primary and most important diagnostic study is therefore the chest radiograph. Since prematurely born children are very sensitive to radiation, those radiographs may lead to a significant radiation detriment. Hence, knowledge of the patient dose is necessary to justify the exposures. A study to assess the patient doses was started at the neonatal intensive care unit (NICU) of the University Hospital in Leuven. Between September 2004 and September 2005, prematurely born babies underwent on average 10 X-ray examinations in the NICU. In this sample, the maximum was 78 X-ray examinations. For chest radiographs, the median entrance skin dose was 34 microGy and the median dose area product was 7.1 mGy.cm(2). By means of conversion coefficients, the measured values were converted to organ doses. Organ doses were calculated for three different weight classes: extremely low birth weight infants (<1000 g), low birth weight infants (1000-2500 g) and normal birth weight infants (>2500 g). The doses to the lungs for a single chest radiograph for infants with extremely low birth weights, low birth weights and normal birth weights were 24, 25 and 32 microGy, respectively.     

The field of scattered radiation in the tunnel of the proton storage ring HERA: measurements and calculations

The field of scattered radiation produced by a stored 820 GeV proton beam in the HERA tunnel is studied. Neutron spectra and doses as well as fluences of charged particles were measured by means of conventional detectors. Secondary particles emitted at both small and large angles with respect to the beam are investigated. They were produced by interactions of the primary beam with a collimator and by interactions in the beam pipe with the rest gas, respectively. The results are compared with simulations performed by the Monte Carlo code FLUKA. Simplified geometries of the accelerator structure and its surroundings were used for the calculation. Measured and calculated doses agree within a factor of 2. On the basis of this agreement an analysis of the scattered radiation was performed by FLUKA to obtain fluences and doses due to scattered neutrons, protons, pions, electrons, positrons, and photons.     

Preliminary study of using imaging plates to map skin dose of patients in interventional radiology procedures

A method using europium-doped BaFBr imaging plates (IPs) has been studied for mapping entrance skin doses during interventional radiology (IR); the mapping is useful for detecting overlap between irradiation fields and determining the most exposed skin areas. IPs, which are two-dimensional radiation sensors made of photostimulated luminescence materials, have a linear dose response up to approximately 100 Gy, can accurately measure doses from 1 microGy to 10 Gy and can be used repeatedly. Because the energy dependence of IPs is rather high, the IPs were characterised in this study and a sensitivity variation of approximately 13% was observed for effective energies of 32.7 to 44.7 keV, which are used in IR procedures. Simulation of actual interventional cardiology procedures showed that the variation of sensitivity was within 5%, meaning that IPs are practical for measuring skin doses during IR. Moreover, the patient data can be stored online and easily called up when IR procedures must be repeated, helping to prevent radiation injuries.     

A simple method to irradiate blood cells in vitro with radon gas

Surface dose monitoring in patients and physicians during 29 uterine artery embolisation (UAE) procedures was performed using photoluminescence dosemeters and thermo-luminescence dosemeters. Organ or tissue doses were measured with an anthropomorphic phantom using UAE exposure conditions averaged from the 29 cases, and effective doses were estimated for the patient. Entrance surface dose of the patients at the maximum dose position ranged from 121.5 to 1650 mGy. Estimated doses ranged from 3.16 to 43 mGy for the ovary and from 3.8 to 51.8 mGy for the uterus. The effective dose was 1.09-14.8 mSv. Monitored doses on the body surface of physicians were relatively high in the upper arm (5.41+/-1.52 to 163+/-17.25 microGy) and the hand and fingers (0.85+/-1.18 to 222+/-16.4 microGy).