Interventional Cardiology
Cardiovascular diagnostic and therapeutic interventions are responsible for 40% of cumulative effective dose of radiation to the U.S. population exclusive of radiation oncology. A concerted effort from industry and cath lab staff is required to attain the lowest achievable radiation exposure for patients and operators.
Abbott JD. Controlling radiation exposure in interventional cardiology. Circ Cardiovasc Interv. 2014 Aug;7:425-8.
Compared to healthcare professionals not exposed to radiation, cath lab workers (including doctors, nurses and technicians) exposed to radiation for a median of 10 years had higher odds of having skin lesions by 2.8X, cancer 3X, orthopedic problems 7.1X, hypertension 1.5X and cataracts 6.3X.
Andreassi MG, et al. Occupational health risks in cardiac catheterization laboratory workers. Circulation: Cardiovascular Interventions 2016 Apr;9(4).
Long-term radiation exposure in a cath lab may be associated with increased subclinical CIMT (carotid intima-media thickness) and telomere length shortening, suggesting evidence of accelerated vascular aging and early atherosclerosis.
Andreassi, et al. Subclinical Carotid Atherosclerosis and Early Vascular Aging From Long-Term Low-Dose Ionizing Radiation Exposure: A Genetic, Telomere, and Vascular Ultrasound Study in Cardiac Catheterization Laboratory Staff. JACC: Cardiovascular Interventions 2015;8(4):616-27.
Effects of ionizing radiation exposure on the fetus of pregnant staff in the interventional lab can include intrauterine growth retardation, microcephaly, reduced IQ, and congenital malformations.
Best P, et al. SCAI Consensus Document on Occupational Radiation Exposure to the Pregnant Cardiologist and Technical Personnel. Catheterization and Cardiovascular Interventions 2011;77(2):232-241.
PSC lens opacities occur in interventional cardiologists 5.7X and in nurses 5X more frequently than unexposed individuals in medical professions of the same age and sex.
Ciraj-Bjelac O, Rehani MM, Sim KH, et al. Risk for radiation-induced cataract for staff in interventional cardiology: Is there reason for concern? Catheter Cardiovasc Interv. 2010 Nov;76(6):826-34.
Acute DNA damage was detected in operators immediately after performing fluoroscopically guided aortic procedures.
El-Sayed T, Patel A, et. al. Radiation-Induced DNA Damage in Operators Performing Endovascular Aortic Repair. Circulation 2017;136:2406-16.
Complex PCI and the use of radial access are associated with increased radiation exposure. Complex PCI now accounts for approximately 40% of all PCIs and radial access grew 13-fold in 2007-2012.
Feldman DN, Swaminathan RV, et al. Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention: An updated report from the National Cardiovascular Data Registry (2007-2012). Circulation 2013 June;127(23):2295-2306.
Initiation of brain tumors during cardiac fluoroscopic procedures is plausible. The diagnosis of two additional brain tumours in Canadian interventional cardiologists during the past 10 years would confirm the occupational causation theory.
Finkelstein MM. Is brain cancer an occupational disease of cardiologists? Can J Cardiol. 1998 Nov;14(11):1385-8.
60% of interventionalists with ≥21 years of experience reported musculoskeletal problems.
Goldstein JA, Balter S, Cowley M, Hodgson J, et al. Occupational hazards of interventional cardiologists: Prevalence of orthopedic health problems in contemporary practice. Catheter Cardiovasc Interv. 2004 Dec;63(4):407-11.
Data strongly indicates that working in the interventional lab over time is associated with a high prevalence of orthopedic problems, particularly related to the spine (giving the name “interventionalists disc disease”). The high incidence uncommonly results in missed days of work, surgery and in some cases, curtailed careers. Results may also represent a disquieting “signal” that chronic exposure to ionizing radiation could be associated with breast cancer.
Goldstein JA. Orthopedic afflictions in the interventional laboratory: tales from the working wounded. J Am Coll Cardiol. 2015 Mar;65(8):827-9.
Interventional cardiology teams face increasing amounts of scatter radiation exposure because of an increase in the number of complex and radial PCIs performed in the cath lab. The number of peripheral vascular interventions (PVIs) for lower limb ischemia is increasing, driven by demographics and the prevalence of diabetes, as well as advancements in endovascular tools and techniques.
Goodney PP, Beck AW, Nagle J, Welch HG, Zwolak RM. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg. 2009 Jul;50(1):54-60.
Out of 106 interventional cardiologists in the study, 17% had posterior subcapsular lens opacities. Although those who regularly wore lead glasses had the lowest risk of PSOs, their risk was still more than twice that of unexposed individuals.
Jacob S, Boveda S, et al. Interventional cardiologists and risk of radiation-induced cataract: results of a French multicenter observational study. Int J Cardiol 2013;167(5):1843-7.
Because catheter-based technologies continue to advance, procedures have become more complex and require longer fluoroscopic time, health risks from both exposure of the physician and cath lab staff to increasing levels of ionizing radiation and the wearing of burdensome personal protection are inevitable.
Klein LW, Bazavan M. The economic imperatives underlying the occupational health hazards of the cardiac catheterization laboratory. Circ Cardiovasc Interv. 2016;9:e0033742.
Surveys of cardiologists and radiologists conclude a relationship between wearing leaded aprons and spine problems. The interventional laboratory poses workplace hazards that must be acknowledged, better understood and mitigated to the greatest extent possible and vigorously advocated on behalf of efforts to reduce these hazards. Interventional physicians and their professional societies, working together with industry, should strive toward the ultimate zero radiation exposure work environment that would eliminate the need for personal protective apparel and prevent its orthopedic and ergonomic consequences.
Klein LW, et al. Occupational health hazards in the interventional laboratory: time for a safer environment. Radiology 2009 Feb;250(2).
Of the 314 Society for Cardiovascular Angiography and Interventions (SCAI) survey responders, 72% wear lightweight lead garments, 47% report no or variable use of dosimeters, 6.9% limited their caseload because of radiation exposure, 9.3% took a health-related leave of absence and 49.4% had at least one orthopedic injury: 24.7% cervical spine disease, 34.4% lumbar spine problems, and 19.6% hip, knee or ankle joint problems. Five years of practice was associated with development of orthopedic pain or injury for 85% of respondents.
Klein LW, et al. Occupational health hazards of interventional cardiologists in the current decade: results of the 2014 SCAI membership survey. Catheterization and Cardiovascular Interventions 2015 Nov;86(5):913-24.
In a review of 73 cases of radiation-induced skin injury directly related to interventional work, the most prevalent common factor for injury is long exposure times to a single skin site. Because of the low penetrability of X-rays, much greater entrance skin dose rates are required with large patients and steep beam angles through thick body parts, thus the associated injuries. Proper use of collimation and field of view will contribute to an appropriately low skin dose.
Koenig TR, et al. Skin injuries from fluoroscopically guided procedures. American Journal of Roentgenology 2001;177:3-11.
Surveyed interventional cardiologists reported frequent occupation-related health hazards including orthopedic injury (49.4%), radiation-related skin disease (4.8%), cataracts (5.5%), and hematologic and malignant conditions (4.8%). Further advances are needed to increase operator and staff safety to prevent future orthopedic injuries and radiation-related diseases.
Lange DC, Henry TD. A “prospective” and “retrospective” view of the hazards of a career in interventional cardiology. Catheter Cardiovasc Interv. 2015 Nov;86(5):925-6.
When interventional staff were compared to a control group of non-interventional medical personnel and given neuropsychological tests, the interventional group showed significantly lower scores on verbal long-term memory, fluency and short-term visual memory. These reduced skills suggest alterations of some left hemisphere structures that are more exposed to IR in interventional cardiology staff. The data suggest a premature aging of the brain, which is a “neglected and underestimated” repercussion of chronic exposure to ionizing radiation.

Marazziti D, Tomaiuolo F, Dell’Osso L, Demi V, et al. Neuropsychological testing in interventional cardiology staff after long-term exposure to ionizing radiation. J Int Neuropsychol Soc. 2015 Oct;21(9):670-6.
Of 570 surveyed cardiac cath lab surgeons, 43% had back pain due to lead use, 6.3% reported radiation-related health complications including cataracts and malignancies, 21% had never attended a radiation safety course, 32% were “very worried” about chronic radiation exposure, 8% limited number of cases performed or hadn’t worn their dosimeter to avoid surpassing exposure limits and 12% didn’t report patient radiation dose.

Menon R, et al. Radiation safety in the catheterization laboratory: current perspectives and practices. J Invas Cardiol 2018;30(8):296-300.
In comparison with angiography, PCI exposes the patient to 3.4X more radiation. Deep muscle injury may result from a single, isolated treatment. When skin cells are damaged due to high levels of radiation, the skin loses its ability to effectively regenerate, which can lead to ulceration, hypergranulosis and necrosis. Increased cumulative radiation also leads to an increased risk of squamous and basal cell carcinoma.
Monaco JL, Bowen K, Tadros PN, Witt PD. Iatrogenic deep musculocutaneous radiation injury following percutaneous coronary intervention. J Invasive Cardiol 2003;15(10):451–3.
A survey of 1,543 Mayo Clinic employees demonstrated a significantly higher incidence of work-related orthopedic pain among interventional HCPs compared to non-interventional HCPs. Three variables were associated with experiencing work-related pain: more time spent in the cath lab, use of leaded aprons, and female sex. Interventional workers were also more likely to seek treatment for pain than the control group. There was a higher incidence of breast cancer among interventional medical staff compared to a control group of non-interventional HCPs at 19% and 9%, respectively.
Orme NM, Rihal CS, Gulati R, et al. Occupational health hazards of working in the interventional laboratory: A multisite case control study of physicians and allied staff. J Am Coll Cardiol. 2015 Mar;65(8):820-6.
Interventional cardiologists have a radiation exposure rate 2 to 10 times higher than that of diagnostic radiologists.
Picano E, et al. Occupational Risks of Chronic Low Dose Radiation Exposure in Cardiac Catheterisation Laboratory: The Italian Healthy Cath Lab Study. European Medical Journal International 2013:50-8.
An interventional cardiologist is exposed to an estimated 50 mSv-200 mSv of ionizing radiation, which equates to 2,500-10,000 chest X-rays. The career exposure to the head is estimated to be 1,000 mSv, which is equivalent to 50,000 chest X-rays. Exposure to radiation has been associated with both macrovascular and microvascular abnormalities.
Picano E, Vano E, Domenici L, et al. Cancer and non-cancer brain and eye effects of chronic low-dose ionizing radiation exposure. BMC Cancer 2012;12(1):157.
Women find the risk of even greater concern during childbearing years as radiation exposure is listed as a reason for altering a career plan in cardiology to a minimally exposed field in 24% of women. Although women account for 49% of all medical students, only 8.7% of interventional cardiology fellows are women.
Poppas A, et al. Survey results: A decade of change in professional life in cardiology: A 2008 report of the ACC women in cardiology council. J Am Coll Cardiol 2008;52(25):2215-26.
The left side and center of invasive cardiologist’s head is exposed to more than double the amount of radiation versus the right side (106.1 mrad vs 50.2 mrad). Subtracting ambient radiation, the left hemisphere receives 4.7x more radiation than the right hemisphere.
Reeves RR, Ang L, Bahadorani J, et al. Invasive cardiologists are exposed to greater left sided cranial radiation: The BRAIN study (Brain Radiation Exposure and Attenuation during Invasive Cardiology Procedures). JACC Cardiovascular Interventions 2015 Aug;8(9):1197-1206.
The interventional cardiologist’s head and neck area is generally exposed to approximately 20-30 mSv per year and 10- to 20-fold higher than dose recorded beneath the apron. As such, a primary health complication observed most often in cath lab team members is cataract development.
Renaud L, et al. A 5-year follow-up of the radiation exposure to in-room personnel during cardiac catheterization. Health Physics 1992;62:10-5.
Research links brain tumors, both benign and malignant, to low-level radiation exposure. For interventionalists who develop brain tumors, 85% of tumors originated on the left side of the brain.
Roguin A, et al. Brain and neck tumors among physicians performing interventional procedures. American Journal of Cardiology 2013 May;111:1368-72.
6 interventional cardiologists and 3 interventional radiologists were diagnosed with brain tumours. The left side of the head is known to be more exposed to radiation than the right. Since interventional cardiologists have the highest radiation exposure among health professionals, major awareness of radiation safety and training in radiological protection are essential and imperative and should be used in every procedure.
Roguin A, et al. Brain tumours among interventional cardiologists: a cause for alarm? EuroIntervention 2012;7:1081-6.
Out of 859 patients undergoing radiofrequency catheter ablation procedures, the average duration of fluoroscopy was 53 minutes, skin dose was 1300 mGy and the dose needed to cause radiation skin injury was exceeded in 22% of procedures. This degree of radiation exposure would result in estimated 1400 excess fatal malignancies in female patients and 2600 in male patients per 1 million patients.
Rosenthal LS, Mahesh M, Beck TJ, et al. Predictors of fluoroscopy time and estimated radiation exposure during radiofrequency catheter ablation procedures. Am J Cardiol 1998 Aug;82(4):451-8.
In a SCAI survey, 53% of interventional cardiologists reported they had been treated for neck or back pain, a rate substantially higher than that of orthopedic surgeons and the general population. Interventional cardiologists also were significantly more likely to have cervical disc disease and multiple level disc disease—and were nearly twice as likely to miss work because of orthopedic complaints—as other physician groups.
Ross AM, Segal J, Borenstein D, Jenkins E, Cho S. Prevalence of spinal disc disease among interventional cardiologists. Am J Cardiol. 1997 Jan;79(1):68-70.
When comparing radiologists, cardiologists and orthopedic specialists to non-exposed controls, occupational exposure to low-dose ionizing radiation can lead to morphological and functional alterations of the dermal microcirculation, which can be identified early by capillary microscopy.
Tomei F, et al. Vascular effects of occupational exposure to low-dose ionizing radiation. Am J Ind Med 1996 Jul;30(1):72-7.
Posterior subcapsular lens changes characteristic of ionizing radiation exposure were found in 50% of interventional cardiologists and 41% of nurses and technicians compared with findings of similar lens changes in <10% of controls. HCPs with documented lens opacities had 2.8X higher cumulative radiation dose to the eye than those who did not have lens opacities.
Vano E, Kleiman NJ, Duran A, et al. Radiation-associated lens opacities in catheterization personnel: results of a survey and direct assessments. J Vasc Interv Radiol 2013;24(2):197-204.
The relative risk of posterior subcapsular opacities in interventional cardiologists compared to unexposed controls was 3.2 (38% compared to 12%). 21% of nurses and techs had radiation-associated posterior lens changes typically associated with ionizing radiation exposure.
Vano E, Kleiman NJ, et al. Radiation cataract risk in interventional cardiology personnel. Radiat Res 2010;174(4):490-5.
Cumulative professional radiological exposure is associated with a non-negligible lifetime attributable risk of cancer for the most exposed contemporary cardiac cath lab staff.
Venneri, L et al. Cancer risk from professional exposure in staff working in cardiac catheterization laboratory: Insights from the National Research Council’s biological effects of ionizing radiation VII report. American Heart Journal 2009;157(1): 118-124.
Survey of interventional cardiologists indicated transradial access (TRA) was used in 54% of percutaneous coronary interventions (PCI) and radial access increased radiation exposure by more than 30% and procedure times by 23%. Nearly half of respondents indicated they would perform radial procedures more frequently if operator radiation exposure could be reduced. U.S. interventional cardiologists ranked ALARA as less important for radiation protection than interventionalists in other parts of the world. This attitudinal difference suggests a lack of clarity regarding the implementation of ALARA in the U.S. and signifies a need for raising awareness. 
Vidovich MI, Khan AA, Xie H, Shroff AR. Radiation safety and vascular access: attitudes among cardiologists worldwide. Cardiovasc Revasc Med. 2015 Mar;16(2):109-15.
Vascular and Interventional Radiology
Radiation protection is a serious issue for vascular surgeons because most complex endovascular procedures are delivering measurable radiation to the eyes. The analysis of endovascular procedures estimated that the European threshold of 20 mSv could be reached with <23 hours (1,404 minutes) of fluoroscopy.
Attigah N, et al. Radiation exposure to eye lens and operator hands during endovascular procedures in hybrid operating rooms. J Vasc Surg. 2016 Jan;63(1):198-203.
Data strongly indicates that working in the interventional lab over time is associated with a high prevalence of orthopedic problems, particularly related to the spine (giving the name “interventionalists disc disease”). The high incidence uncommonly results in missed days of work, surgery and in some cases, curtailed careers. Results may also represent a disquieting “signal” that chronic exposure to ionizing radiation could be associated with breast cancer.
Goldstein JA. Orthopedic afflictions in the interventional laboratory: tales from the working wounded. J Am Coll Cardiol. 2015 Mar;65(8):827-9.
Because catheter-based technologies continue to advance, and procedures have become more complex and require longer fluoroscopic time, health risks from both exposure of the physician and cath lab staff to increasing levels of ionizing radiation, and the wearing of burdensome personal protection, are inevitable.
Klein LW, Bazavan M. The economic imperatives underlying the occupational health hazards of the cardiac catheterization laboratory. Circ Cardiovasc Interv. 2016;9:e0033742.
Surveys of cardiologists and radiologists conclude a relationship between wearing leaded aprons and spine problems. The interventional laboratory poses workplace hazards that must be acknowledged, better understood and mitigated to the greatest extent possible and vigorously advocated on behalf of efforts to reduce these hazards. Interventional physicians and their professional societies, working together with industry, should strive toward the ultimate zero radiation exposure work environment that would eliminate the need for personal protective apparel and prevent its orthopedic and ergonomic consequences.
Klein LW, et al. Occupational health hazards in the interventional laboratory: time for a safer environment. Radiology 2009 Feb;250(2).
In a review of 73 cases of radiation-induced skin injury directly related to interventional work, the most prevalent common factor for injury is long exposure times to a single skin site. Because of the low penetrability of X-rays, much greater entrance skin dose rates are required with large patients and steep beam angles through thick body parts, thus the associated injuries. Proper use of the collimation and field of view will contribute to an appropriately low skin dose.
Koenig TR, et al. Skin injuries from fluoroscopically guided procedures. American Journal of Roentgenology 2001;177:3-11.
Of 570 surveyed cardiac cath lab surgeons, 43% had back pain due to lead use, 6.3% reported radiation-related health complications including cataracts and malignancies, 21% had never attended a radiation safety course, 32% were “very worried” about chronic radiation exposure, 8% limited number of cases performed or hadn’t worn their dosimeter to avoid surpassing exposure limits and 12% didn’t report patient radiation dose.
Menon R, et al. Radiation safety in the catheterization laboratory: current perspectives and practices. J Invas Cardiol 2018;30(8):296-300.
An interventional radiology procedure can deliver the effective dose equivalent to 250-3,500 chest X-rays (using head/neck angiography to TIPS placements as comparisons).
Mettler FA Jr, et al. Effective Doses in Radiology and Diagnostic Nuclear Medicine: A Catalog. Radiology 2008 July;248(1):254-63.
Out of 800 instances and 21 interventional radiology procedures observed, most of the procedures produced a peak skin dose sufficient to cause deterministic effects in skin. Some instances of hepatic chemoembolization, other tumor embolization and neuroembolization in the head and spine produced PSDs greater than 5 Gy.
Miller DL, Balter S, Cole PE, et al. Radiation doses in interventional radiology procedures: the RAD-IR study. Part II. Skin dose. J Vasc Interv Radiol 2003;14(8):977–90.
Our DNA is not designed to tolerate chronic daily radiation at the doses we now receive. Our institutions and healthcare systems need to acknowledge our inherent risk of working with radiation and we should act as our own regulators so that every professional can safely practice without compromising their health, as there is no safe dose of radiation and a fundamental cultural shift is needed. Their dismissive attitude is most likely due to the inherent inability to feel threatened by something they cannot see or feel.
Murphy K, et al. Should future interventional neuroradiologists be screened for mutations that impair radiation-induced DNA repair? Interventional Neuroradiology 2016:23.
Within 87 patients who underwent interventional neuroradiologic procedures, 10% experienced temporary or long-term scalp epilation (loss of hair). Radiation-induced disorders of tooth bud growth include agenesis, enamel dysplasia, and abnormal root formation.
Norbash AM, Busick D, Marks MP. Techniques for reducing interventional neuroradiologic skin dose: tube position rotation and supplemental beam filtration. AJNR Am J Neuroradiol 1996 Jan;17(1):41–9.
A survey of 1,543 Mayo Clinic employees demonstrated a significantly higher incidence of work-related orthopedic pain among interventional HCPs compared to non-interventional HCPs. Three variables were associated with experiencing work-related pain: more time spent in the cath lab, use of leaded aprons, and female sex. Interventional workers were also more likely to seek treatment for pain than the control group. There was a higher incidence of breast cancer among interventional medical staff compared to a control group of non-interventional HCPs at 19% and 9%, respectively.
Orme NM, Rihal CS, Gulati R, et al. Occupational health hazards of working in the interventional laboratory: A multisite case control study of physicians and allied staff. J Am Coll Cardiol. 2015 Mar;65(8):820-6.
Research links brain tumors, both benign and malignant, to low-level radiation exposure. For interventionalists who develop brain tumors, 85% of tumors originated on the left side of the brain.
Roguin A, et al. Brain and neck tumors among physicians performing interventional procedures. American Journal of Cardiology 2013 May;111:1368-72.
6 interventional cardiologists and 3 interventional radiologists were diagnosed with brain tumours. The left side of the head is known to be more exposed to radiation than the right. Since interventional cardiologists have the highest radiation exposure among health professionals, major awareness of radiation safety and training in radiological protection are essential and imperative and should be used in every procedure.
Roguin A, et al. Brain tumours among interventional cardiologists: a cause for alarm? EuroIntervention 2012;7:1081-6.
Ionizing radiation damages dividing cells in the anterior lens epithelium, forming a crystalline protein that migrates to the posterior pole of the lens. Because the lens is avascular, there is no means to remove damaged cells, leading to irreversible cataract formation.
Seals KF, Lee EW, Cagnon CH, Al-Hakim RA, Kee ST. Radiation-induced cataractogenesis: a critical literature review for the interventional radiologist. Cardiovasc Intervent Radiol 2016;39(2):151–60.
When comparing radiologists, cardiologists and orthopedic specialists to non-exposed controls, occupational exposure to low-dose ionizing radiation can lead to morphological and functional alterations of the dermal microcirculation, which can be identified early by capillary microscopy.
Tomei F, et al. Vascular effects of occupational exposure to low-dose ionizing radiation. Am J Ind Med 1996 Jul;30(1):72-7.
Lens doses during FGPs would easily exceed the old ICRP annual dose limits in 1 year and would surpass the dose threshold for lens opacities and radiation-induced cataracts after only several years.
Vano E, Gonzalez L, Fernández JM, Haskal ZJ. Eye lens exposure to radiation in interventional suites: caution is warranted. Radiology 2008;248(3):945–53.
Orthopedic Surgery
Female orthopedic surgeons had prevalence of cancer that was 85% higher than that of the general U.S. female population. They also had 2.9 times higher prevalence of breast cancer when compared to general U.S. female population.
Chou LB, et al. Increased breast cancer prevalence among female orthopedic surgeons. J Womens Health (Larchmt) 2012 Jun;21(6):683-9.
Nearly half of all fluoroscopic orthopedic procedures expose the physician to enough radiation to increase the risk of thyroid cancer (exceeded 65 microSv).
Devalia KL, Peter VK, Madanur MA, Braithwaite IJ. Exposure of the thyroid to radiation during routine orthopaedic procedures. Acta Orthop Belg 2006 Oct;72(5):615-20.
Orthopedic surgeons have 5X risk of cancer than radiation-exposed medical staff and 3X the risk of non-orthopedic physicians. These findings caution against surgeons’ underestimation of the potential radiation risk and insufficient promotion of safe work practices by their health care institutions.
Mastrangelo G, Fedeli U, Fadda E, et al. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med 2005;55(6):498-500.
Surgeons and medical staff in the study received 0-2.99 mSv over the previous year, well below the limit established by the ICRP, but an increased level of chromosomal aberrations was observed among workers exposed in the operating rooms. We recommend that OR radiation safety programs be improved and better supervised, in particular for orthopedic surgeons and personnel performing fluoroscopically guided procedures.
Shafiee M, et al. Chromosomal aberrations in C-arm fluoroscopy, CT-scan, lithotripsy, and digital radiology staff. Mutat Res 2020 Jan;849:503131.
When comparing radiologists, cardiologists and orthopedic specialists to non-exposed controls, occupational exposure to low-dose ionizing radiation can lead to morphological and functional alterations of the dermal microcirculation, which can be identified early by capillary microscopy.
Tomei F, et al. Vascular effects of occupational exposure to low-dose ionizing radiation. Am J Ind Med 1996 Jul;30(1):72-7.
Novice surgeons performing PAO had the highest use of fluoroscopy compared with more experienced surgeons, which represents the learning curve related to the complex surgery. Male patients required more fluoroscopy time, possibly due to having more dense bone, which increases the difficulty of the osteotomy. Increased patient BMI led to increased fluoroscopy dose due to fluoroscopy machines having to produce more tube voltage and current in order to maintain image resolution.
Wylie JD, et al. What factors affect fluoroscopy use during Bernese periacetabular osteotomy for acetabular dysplasia? Journal of Hip Preservation Surgery 2019 Sept;6(3):259-64.
Spine Surgery
MIS limits visualization compared to a traditional open approach because it uses a smaller incision size, resulting in an increased reliance on fluoroscopy. The potential exists for both the surgeon and the patient to become exposed to significant amounts of radiation. 84% of the radiation that hits the spine surgeon’s chest gets through the lead apron and hits the level of the groin.
Bindal RK, Glaze S, Ognoskie M, et al. Surgeon and patient radiation exposure in minimally invasive transforaminal lumbar interbody fusion. J Neurosurg Spine 2008;9(6)570-3.
66% of spine patients reported that a physician never discussed radiation exposure associated with their X-rays. 14% of patients would consider forgoing their X-ray procedure recommended by their surgeon out of concern for radiation exposure. Increased counseling and educational materials regarding radiation exposure to the patient could reduce the frequency of unnecessary imaging tests and reduce risk of serious long-term consequences of excessive radiation exposure that could occur as a result.
Bohl D, et al. Patient knowledge regarding radiation exposure from spinal imaging. Spine J. 2017 Mar;17(3):305-12.
During LLIF and MI-TLIF cases, the surgeon and medical staff's radiation exposure was positively correlated with increasing patient age (due to their complex anatomy). The surgeon had the highest dose levels followed by the assistant surgeon.
Godzik J, et al. Surgeon and staff radiation exposure in minimally invasive spinal surgery: prospective series using a personal dosimeter. J Neurosurg Spine. 2020 Feb;1-7.
Even wearing lead, spine surgeons will exceed their radiation exposure lifetime limit in 10 years of practice, per the National Council on Radiation Protection’s current recommendations of lifetime dose limits. About a third of the radiation the surgeon is exposed to gets through the thyroid shield.
Haque UM, Shufflebarger HL, O’Brien M, et al. Radiation exposure during pedicle screw placement in adolescent idiopathic scoliosis: is fluoroscopy safe? Spine 2006;31(21):2516-20.
MIS TLIF procedures require more than 2X the amount of intraoperative fluoroscopy when compared to a similar open procedure; MIS lumbar disc herniation procedures require more than 10X the amount.
McClelland S, Goldstein J. Minimally invasive versus open spine surgery: What does the best evidence tell us? J Neurosci Rural Pract 2017;8(2):194-8.
The number of radiologic procedures in the U.S. increased 10X to 380 million from 1980 to 2006. Spinal studies account for 7% fluoroscopic procedures in the U.S. but accounts for 21% of the collective dose from procedures.
Mettler FA Jr, et al. Radiological Society of North America. Radiology and Nuclear Medicine Studies in the United States and Worldwide: Frequency, Radiation Dose, and Comparison with Other Radiation Sources – 1950-2007. Radiology 2009 Nov;253(2).
The average surgeon radiation dose per screw in image-guided thoracolumbar instrumentation procedures: conventional fluoroscopy without navigation (6.0 mSv), conventional fluoroscopy with navigation (1.8 mSv), 3D Fluoroscopy (0.3 mSv), intraoperative CT-based navigation (0 mSv), and robot-assisted instrumentation (2.0 mSv). Intraoperative CT-based (iCT) navigation produced the lowest radiation exposure to surgeon albeit at the cost of increased radiation exposure to the patient relative to conventional fluoroscopy-based methods.
Pennington Z, et al. Evaluation of surgeon and patient radiation exposure by imaging technology in patients undergoing thoracolumbar fusion: systematic review of the literature. Spine J 2019 Aug;19(8):1397-1411.
For patients treated for adolescent idiopathic scoliosis (AIS), operative patients received 8X more radiation and 2X the number of radiographs received per year than braced patients.
Presciutti S, Karukanda T, Lee M. Management decisions for adolescent idiopathic scoliosis significantly affect patient radiation exposure. Spine J 2014;14(9):1984-90.
Spine surgeons can sustain 10-12X greater radiation exposure compared to surgeons using fluoroscopy for non-spinal procedures as observed in fluoroscopically assisted pedicle screw insertion procedures.
Rampersaud YR, Foley KT, Shen AC, et. al. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine 2000;25(20):2637-45.
There is a 5X increased risk of cancer, most frequently endometrial and breast cancer, in patients surgically treated for scoliosis 25 years post-operatively with a mean radiation exposure of 0.8-1.4 mSV per exam.
Simony A, Hansen EJ, Christensen SB, et al. Incidence of cancer in adolescent idiopathic scoliosis patients treated 25 years previously. Eur Spine J 2016;25:3366–70.
Safe distances from fluoroscopy machines might be much farther than commonly believed. Radiation values return to baseline at 14 ft in front of the X-ray source and 8 ft behind it. Protective barriers with a 0.5-mm lead-equivalence reduced radiation exposure to baseline at 6 ft and were 20% effective at 2 ft from the emitter. Spine surgeons who wear lead gowns during fluoroscopy could still be exposed to <80% of the radiation produced. Alternatives to reduce the use of fluoroscopy for intraoperative imaging should be explored.
Urakov TM. Practical assessment of radiation exposure in spine surgery. World Neurosurg. 2018 Dec;120:e752-4.
Within 165 patients undergoing TLIFs with pedicle screw insertion, the fluoro-MIS group showed the highest total procedure (82 mGy average) and per level radiation exposure to the patient, followed by robotic assistance (59.8 mGy), intraoperative CT IGN (50.2 mGy), and open method (22.6 mGy).
Wang, Buckland, et al. Radiation Exposure in Posterior Lumbar Fusion: A Comparison of CT Image-Guided Navigation, Robotic Assistance, and Intraoperative Fluoroscopy. Global Spine Journal 2020 Feb.
C-arms in the lateral position increased the risk of direct and scatter radiation exposure by more than 200X and more than 30X, respectively, compared to when the X-ray source is positioned under the table. Medical staff, especially surgeons, should consider how to best protect themselves and reduce radiation exposure.
Yamashita K, et al. Radiation exposure to the surgeon and patient during a fluoroscopic procedure: how high is the exposure dose? A cadaveric study. Spine (Phila PA 1976) 2016 Aug;41(15):1254-60.
Neurosurgery residents' exposure to radiation over the course of 7 years of training was equivalent to 6 CT head scans per resident.
Zaidi HA, Montoure A, Nakaji P, Bice A, Tumialán LM. A 5-Year Retrospective Analysis of Exposure to Ionizing Radiation by Neurosurgery Residents in the Modern Era. World Neurosurg 2016 Feb;86:220-5.
Pain Management
Because of serious radiographic-induced skin injuries that may have been caused by the inappropriate use of fluoroscopy during the performance of radiograph-guided invasive procedures, FDA issued an advisory in 1994 suggesting the key to preventing such unfortunate mishaps may be physician education, training and credentialing in the safe operation of fluoroscopic equipment.
Broadman LM, et al. Radiation risk management during fluoroscopy for interventional pain medicine physicians. Curr Pain Headache Rep 2004 Feb; 8(1):49-55.
Interventional pain physicians are at risk for both types of radiation exposure injury (stochastic and deterministic effects) because of the chronic, low-dose radiation exposure over a lifetime. Individuals ideally should not receive more than 10% of the EDE limits annually. An occupational worker’s lifetime effective dose should be limited to their age in years times 1 rem.
Hagedorn J and Provenzano D. Radiation safety for the chronic pain physician. ASRA. February 2019.
In a survey of pain interventionalists, only 39% were educated on radiation safety, 8% knew the annual maximum permissible radiation doses, 39% used a dosimeter, 38% wore lead goggles and 18% wore lead gloves.
Kim TH, et al. The radiation safety education and the pain physicians’ efforts to reduce radiation exposure. The Korean Journal of Pain 2017 April;30(2):104-15.
1,000 patients underwent 1,729 interventional pain procedures with average radiation exposure of 7.7 seconds per procedure. Patients with higher body mass index required larger radiation doses - Non-obese patients showed 12.2 seconds/patient and 7.4 seconds/procedure in contrast to obese patients with 14.9 seconds/patient and 8.9 seconds/procedure.
Manchikanti L, et al. Radiation exposure to the physician in interventional pain management. Pain Physician 2002 Oct;5(4):385-93.
The primary source of ionizing radiation exposure during interventional pain procedures comes from scatter radiation that is reflected by the patient, which is difficult to avoid given the close proximity that the physician must maintain with the patient. Cumulative dose becomes of more concern if pain physicians routinely perform high volumes of interventional procedures with higher fluoroscopy times such as spinal cord stimulator and vertebral augmentation.
Nicol AL, et al. Radiation exposure in interventional pain management: we still have much to learn. Pain Practice 2015 Jun; 15(5):389-92.
While performing fluoroscopy-guided selective nerve root blocks, the radiation exposure per unit time of surgeons’ fingers were 0.67 mSv/s in direct exposure group vs 0.19 mSv/s with lead gloves vs 0.001 mSv/s if used forceps to hold the needle. Using a radiation reduction glove or forceps increased the annual exposure time limit for SNRB.
Omi H, et al. Protecting surgeons’ fingers from radiation exposure during lumbosacral selective nerve root block. Spine Surg Relat Res. 2019;3(2):178-82.
Fluoroscopy exposure time for various interventional procedures performed in the university settings (where supervision of trainees occur) are significantly higher than radiation exposure periods in private practice settings. Pulsed fluoroscopy was used in less than 10% of cases.
Zhou Y, et al. Fluoroscopy radiation safety for spine interventional pain procedures in university teaching hospitals. Pain Physician 2005;8:49-53.
Hospital Administration
Concerns have been raised about the risks associated with patients’ exposure to radiation. Because ionizing radiation can cause damage to DNA, exposure can increase a person’s lifetime risk of developing cancer. Although the risk from a single exam may not itself be large, millions of exams are performed each year, making radiation exposure from medical imaging an important public health issue.
Center for Devices and Radiological Health & U.S. Food and Drug Administration, Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging (February 2010).
The economic cost of adverse health effects of occupational exposure to interventional fluoroscopy is estimated conservatively to be at least $49 million annually in the US. The economic cost of excess cancer risk associated with occupational exposure to interventional fluoroscopy is estimated to be $36.8 million annually. The economic cost of major MSDs for interventional HCPs is estimated to be $12.2 million each year based on conservative assumptions of an incidence of 1.8% and an average cost of $45,000 per significant MSD for physicians and $12,000 for nurses and technicians. This does not take into account reduction in number of procedures performed annually, physician replacement costs, lawsuits or diminished competitive position of hospitals.
Economic Impacts of Radiation Exposures Associated with Interventional Fluoroscopy. Organization for Occupational Radiation Safety in Interventional Fluoroscopy (ORSIF). December 2018.
Data strongly indicates that working in the interventional lab over time is associated with a high prevalence of orthopedic problems, particularly related to the spine (giving the name “interventionalists disc disease”). The high incidence uncommonly results in missed days of work, surgery and in some cases, curtailed careers. Results may also represent a disquieting “signal” that chronic exposure to ionizing radiation could be associated with breast cancer.
Goldstein JA. Orthopedic afflictions in the interventional laboratory: tales from the working wounded. J Am Coll Cardiol. 2015 Mar;65(8):827-9.
Surveys of cardiologists and radiologists conclude a relationship between wearing leaded aprons and spine problems. The interventional laboratory poses workplace hazards that must be acknowledged, better understood and mitigated to the greatest extent possible and vigorously advocated on behalf of efforts to reduce these hazards. Interventional physicians and their professional societies, working together with industry, should strive toward the ultimate zero radiation exposure work environment that would eliminate the need for personal protective apparel and prevent its orthopedic and ergonomic consequences.
Klein LW, et al. Occupational health hazards in the interventional laboratory: time for a safer environment. Radiology 2009 Feb;250(2).
Of the 314 Society for Cardiovascular Angiography and Interventions (SCAI) survey responders, 72% wear lightweight lead garments, 47% report no or variable use of dosimeters, 6.9% limited their caseload because of radiation exposure, 9.3% took a health-related leave of absence and 49.4% had at least one orthopedic injury: 24.7% cervical spine disease, 34.4% lumbar spine problems, and 19.6% hip, knee or ankle joint problems. Five years of practice was associated with development of orthopedic pain or injury for 85% of respondents.
Klein LW, et al. Occupational health hazards of interventional cardiologists in the current decade: results of the 2014 SCAI membership survey. Catheterization and Cardiovascular Interventions 2015 Nov;86(5):913-24.
Surveyed interventional cardiologists reported frequent occupation-related health hazards including orthopedic injury (49.4%), radiation-related skin disease (4.8%), cataracts (5.5%), and hematologic and malignant conditions (4.8%). Further advances are needed to increase operator and staff safety to prevent future orthopedic injuries and radiation-related diseases.
Lange DC, Henry TD. A “prospective” and “retrospective” view of the hazards of a career in interventional cardiology. Catheter Cardiovasc Interv. 2015 Nov;86(5):925-6.
From 1980 to 2006, the U.S. per capita annual effective dose from medical procedures increased from 0.54 mSv to about 3.0 mSv or by 600%. This increase is due to increased frequency of relatively high dose procedures.
Mettler FA Jr, et al. Medical radiation exposure in the U.S. in 2006: preliminary results. Health Phys. 2008 Nov; 95(5):502-7.
The number of radiologic procedures in the U.S. increased 10X to 380 million from 1980 to 2006. Spinal studies account for 7% fluoroscopic procedures in the U.S. but accounts for 21% of the collective dose from procedures.
Mettler FA Jr, et al. Radiological Society of North America. Radiology and Nuclear Medicine Studies in the United States and Worldwide: Frequency, Radiation Dose, and Comparison with Other Radiation Sources – 1950-2007. Radiology 2009 Nov;253(2).
Our DNA is not designed to tolerate chronic daily radiation at the doses we now receive. Our institutions and healthcare systems need to acknowledge our inherent risk of working with radiation and we should act as our own regulators so that every professional can safely practice without compromising their health, as there is no safe dose of radiation and a fundamental cultural shift is needed. Their dismissive attitude is most likely due to the inherent inability to feel threatened by something they cannot see or feel.
Murphy K, et al. Should future interventional neuroradiologists be screened for mutations that impair radiation-induced DNA repair? Interventional Neuroradiology 2016:23.
In 2006, Americans were exposed to more than 7X as much ionizing radiation from medical procedures as was the case in early 1980s.
National Council on Radiation Protection and Measurements: Ionizing radiation exposure of the population of the United States (2009). NCRP Report No. 160, Bethesda, MD:142-6.
Many medical societies believe existing evidence already demonstrates that interventional laboratories are rife with occupational hazards, given the health risks related to fluoroscopic technology and PPE, as well as the poor ergonomic design of labs and equipment. The Joint Task Force demand “as close to a zero radiation exposure work environment as possible.” They reinforce the need to reduce radiation dose to patient and provider including appropriate use of imaging technologies and dose optimization.
Occupational exposure to ionizing radiation in interventional fluoroscopy: Severity of adverse effects of a growing health problem. Organization for Occupational Radiation Safety in Interventional Fluoroscopy (ORSIF). February 2015.
A survey of 1,543 Mayo Clinic employees demonstrated a significantly higher incidence of work-related orthopedic pain among interventional HCPs compared to non-interventional HCPs. Three variables were associated with experiencing work-related pain: more time spent in the cath lab, use of leaded aprons, and female sex. Interventional workers were also more likely to seek treatment for pain than the control group. There was a higher incidence of breast cancer among interventional medical staff compared to a control group of non-interventional HCPs at 19% and 9%, respectively.
Orme NM, Rihal CS, Gulati R, et al. Occupational health hazards of working in the interventional laboratory: A multisite case control study of physicians and allied staff. J Am Coll Cardiol. 2015 Mar;65(8):820-6.
In a SCAI survey, 53% of interventional cardiologists reported they had been treated for neck or back pain, a rate substantially higher than that of orthopedic surgeons and the general population. Interventional cardiologists also were significantly more likely to have cervical disc disease and multiple level disc disease—and were nearly twice as likely to miss work because of orthopedic complaints—as other physician groups.
Ross AM, Segal J, Borenstein D, Jenkins E, Cho S. Prevalence of spinal disc disease among interventional cardiologists. Am J Cardiol. 1997 Jan;79(1):68-70.
Survey of interventional cardiologists indicated transradial access (TRA) was used in 54% of percutaneous coronary interventions (PCI) and radial access increased radiation exposure by more than 30% and procedure times by 23%. Nearly half of respondents indicated they would perform radial procedures more frequently if operator radiation exposure could be reduced. U.S. interventional cardiologists ranked ALARA as less important for radiation protection than interventionalists in other parts of the world. This attitudinal difference suggests a lack of clarity regarding the implementation of ALARA in the U.S. and signifies a need for raising awareness. 
Vidovich MI, Khan AA, Xie H, Shroff AR. Radiation safety and vascular access: attitudes among cardiologists worldwide. Cardiovasc Revasc Med. 2015 Mar;16(2):109-15.
Patients
66% of spine patients reported that a physician never discussed radiation exposure associated with their X-rays. 14% of patients would consider forgoing their X-ray procedure recommended by their surgeon out of concern for radiation exposure. Increased counseling and educational materials regarding radiation exposure to the patient could reduce the frequency of unnecessary imaging tests and reduce risk of serious long-term consequences of excessive radiation exposure that could occur as a result.
Bohl D, et al. Patient knowledge regarding radiation exposure from spinal imaging. Spine J. 2017 Mar;17(3):305-12.
Concerns have been raised about the risks associated with patients’ exposure to radiation. Because ionizing radiation can cause damage to DNA, exposure can increase a person’s lifetime risk of developing cancer. Although the risk from a single exam may not itself be large, millions of exams are performed each year, making radiation exposure from medical imaging an important public health issue.
Center for Devices and Radiological Health & U.S. Food and Drug Administration, Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging (February 2010).
Chronic radiodermatitis may be considered a frequent side effect after FGIs in high-risk patients. The lesions are commonly benign, but extensive sclerosis can occur.
Guesnier-Dopagne M, et al. Incidence of Chronic Radiodermatitis after Fluoroscopically Guided Interventions: A Retrospective Study. J Vasc Interv Radiol, 2019 May;30(5):692-8.
If a patient receives repeated doses, harm can also occur as the cumulative effect of those multiple doses over time.
Holmberg O, et al. Current issues and actions in radiation protection of patients. European Journal of Radiology 2010 Oct;76(1):15-9.
In a review of 73 cases of radiation-induced skin injury directly related to interventional work, the most prevalent common factor for injury is long exposure times to a single skin site. Because of the low penetrability of X-rays, much greater entrance skin dose rates are required with large patients and steep beam angles through thick body parts, thus the associated injuries. Proper use of collimation and field of view will contribute to an appropriately low skin dose.
Koenig TR, et al. Skin injuries from fluoroscopically guided procedures. American Journal of Roentgenology 2001;177:3-11.
Several factors are considered when estimating the likelihood and severity of patient radiation effects. These include demographic factors, medical history factors (coexisting diseases and genetic factors, medication use, radiation history, and pregnancy), and procedure factors.
Miller DL, Balter S, et al. Clinical radiation management for fluoroscopically guided interventional procedures. Radiology 2010 Nov;257(2).
Out of 800 instances and 21 interventional radiology procedures observed, most of the procedures produced a peak skin dose sufficient to cause deterministic effects in skin. Some instances of hepatic chemoembolization, other tumor embolization and neuroembolization in the head and spine produced PSDs greater than 5 Gy.
Miller DL, Balter S, Cole PE, et al. Radiation doses in interventional radiology procedures: the RAD-IR study. Part II. Skin dose. J Vasc Interv Radiol 2003;14(8):977–90.
In comparison with angiography, PCI exposes the patient to 3.4X more radiation. Deep muscle injury may result from a single, isolated treatment. When skin cells are damaged due to high levels of radiation, the skin loses its ability to effectively regenerate, which can lead to ulceration, hypergranulosis and necrosis. Increased cumulative radiation also leads to an increased risk of squamous and basal cell carcinoma.
Monaco JL, Bowen K, Tadros PN, Witt PD. Iatrogenic deep musculocutaneous radiation injury following percutaneous coronary intervention. J Invasive Cardiol 2003;15(10):451–3.
Within 87 patients who underwent interventional neuroradiologic procedures, 10% experienced temporary or long-term scalp epilation (loss of hair). Radiation-induced disorders of tooth bud growth include agenesis, enamel dysplasia, and abnormal root formation.
Norbash AM, Busick D, Marks MP. Techniques for reducing interventional neuroradiologic skin dose: tube position rotation and supplemental beam filtration. AJNR Am J Neuroradiol 1996 Jan;17(1):41–9.
For patients treated for adolescent idiopathic scoliosis (AIS), operative patients received 8X more radiation and 2X the number of radiographs received per year than braced patients.
Presciutti S, Karukanda T, Lee M. Management decisions for adolescent idiopathic scoliosis significantly affect patient radiation exposure. Spine J 2014;14(9):1984-90.
There is a 5X increased risk of cancer, most frequently endometrial and breast cancer, in patients surgically treated for scoliosis 25 years post-operatively with a mean radiation exposure of 0.8-1.4 mSv per exam.
Simony A, Hansen EJ, Christensen SB, et al. Incidence of cancer in adolescent idiopathic scoliosis patients treated 25 years previously. Eur Spine J 2016;25:3366–70.
Within 165 patients undergoing TLIFs with pedicle screw insertion, the fluoro-MIS group showed the highest total procedure (82 mGy average) and per level radiation exposure to the patient, followed by robotic assistance (59.8 mGy), intraoperative CT IGN (50.2 mGy), and open method (22.6 mGy).
Wang, Buckland, et al. Radiation Exposure in Posterior Lumbar Fusion: A Comparison of CT Image-Guided Navigation, Robotic Assistance, and Intraoperative Fluoroscopy. Global Spine Journal 2020 Feb.
Others
Potential adverse effects of irradiation are numerous and can include coronary artery disease, pericarditis, cardiomyopathy, valvular disease and conduction abnormalities. The risk is life long, and absolute risk increases with length of time since exposure.
Adams MJ, Hardenbergh PH, Constine LS, et al. Radiation-associated cardiovascular disease. Crit Rev Oncol Hematol 2003;45(1):55-75.
The higher the dose of radiation delivered at any one time, the greater the risk for long-term damage. X-rays are officially classified as a carcinogen by the World Health Organization’s International Agency for Research on Cancer, the Agency for Toxic Substances and Disease Registry of the Centers for Disease Control and Prevention, and the National Institute of Environmental Health Sciences.
Amis ES Jr, et al. American College of Radiology white paper on radiation dose in medicine. Journal of the American College of Radiology 2007;4:272-84.
The degree of injury to skin and subcutaneous tissue increases with dose. Skin irradiated to a dose higher than 3-5 Gy often looks normal but reacts abnormally when irradiation is repeated. Specialized wound care may be needed when irradiation exceeds 10 Gy.
Balter S, et al. Fluoroscopically guided interventional procedures: a review of radiation effects on patients’ skin and hair. Radiology 2010 Feb;254(2):326-41.
From 57 million CT scans, 29,000 incident cancers including 14,500 cancer deaths could develop due to the radiation.
Berrington de Gonzalez A, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Archives of Internal Medicine 2009;169(22):2071-7.
Ionizing radiation is a well-established mutagen, inducing mutation through a variety of molecular mechanisms including double-stranded DNA breaks, single-stranded DNA breaks, nucleotide substitution, and sugar ribose alterations.
Bhogal N, Jalali F and Bristow RG. Microscopic imaging of DNA repair foci in irradiated normal tissues. Int J Radiat Biol 2009 Sep; 85(9):732-46.
Adjusting for current CT use, it is estimated that 1.5-2% of all cancers in the U.S. may be attributable to radiation from CT studies.
Brenner DJ, Hall EJ. Computed tomography - an increasing source of radiation exposure. N Engl J Med 2007; 357:2277–84.
Occupational exposure to low-dose ionizing radiation may also put HCPs’ reproductive capability at risk. If cumulative exposure “below the apron” reaches 0.5-1.0 Sv, sperm count can be reduced. Occupational exposure may directly affect the outcome of pregnancy, such as spontaneous miscarriage, pre-term birth, small-for-gestational age and low birth weight.
Budorf A. Effects of occupational exposure on the reproductive system: core evidence and practical implications. Occupational Medicine 2006;56:516-20.
About 6 additional fatal cancers per year per 500 people exposed to the maximum-allowable occupational radiation dose of 50 mSv per year is estimated. Although the average staff exposure is relatively low (20 mSV cumulative radiation dose), 1% to 2% of the cohort’s lifetime fatal cancers are attributable to these occupational doses.
Cardis E, et al. Risk of Cancer After Low Doses of Ionizing Radiation: Retrospective Cohort Study in 15 Countries. BMJ 2005;331: 77–80.
Radiation-induced cataracts in U.S. radiologic techs can occur at doses much lower than previously established thresholds (annual equivalent dose limit to lens of 150 mSv) and may occur without a dose threshold.
Chodick G, Bekiroglu N, Hauptmann M, et al. Risk of cataract after exposure to low doses of ionizing radiation: a 20-year prospective cohort study among US radiologic technologists. Am J Epidemiol 2008;168(6):620–31.
A conservative estimate is that the risk of childhood fatal cancer is approximately 5%-15% per Gy.
Dauer LT, Thornton RH, Miller DL, et al. Society of Interventional Radiology Safety and Health Committee; Cardiovascular and Interventional Radiology Society of Europe Standards of Practice Committee. Radiation management for interventions using fluoroscopic or computed tomographic guidance during pregnancy: a joint guideline of the SIR and the CIRS of Europe with endorsement by the Canadian Interventional Radiology Association. J Vasc Interv Radiol 2012;23(1):19–32.
Depending on the pregnancy phase and amounts of radiation exposure, possible conceptus health effects include IQ reduction, severe mental retardation and cancer.
Diagnostic ionizing radiation and pregnancy. Is there a concern? Pennsylvania Patient Safety Advisory 2008 Mar;5(1):3-15.
Prolonged fluoroscopic procedures, such as neuroembolization, placement of transjugular intrahepatic portosystemic shunts and pain management, led to an increase in reports of high skin doses causing significant tissue injury. Even typical dose rates can result in skin injury after less than one hour of fluoroscopy.
FDA Public Health Advisory. Avoidance of serious x-ray-induced skin injuries to patients during fluoroscopically-guided procedures. Rockville, MD: Food and Drug Administration, September 9, 1994.
CT is an incredibly valuable imaging tool, but there are unique concerns with pediatric patients, including the increase of sensitivity to radiation, increase risk of cancer formation with the longer life expectancy, and larger radiation doses received when adult CT settings are used.
Firestine, K. CT dose reduction in pediatric patients. Radiology Management March/April 2011.
The European Commission addressed the importance of training in radiological protection, publishing a guideline suggesting specific learning objectives and 20-40 hours of training for medical students.
Guidelines on education and training in radiation protection for medical exposures. Radiation Protection 116. European Commission. Directorate General Environment, Nuclear Safety and Civil Protection. Luxembourg, 2000.
Fluoroscopically guided techniques are being used by an increasing number of clinicians not adequately trained in radiation safety. Patients are suffering radiation-induced skin injuries due to unnecessarily high radiation doses. Younger patients may face an increased risk of future cancer. Interventionists are having their practice limited or suffering injury and are exposing their staff to high doses.
ICRP Publication 85. Avoidance of radiation injuries from medical interventional procedures. Annals ICRP 2000;30(2).
Most adverse health effects of radiation exposure may be grouped into: deterministic effects (harmful tissue reactions) due in large part to the killing/malfunction of cells following high doses; and stochastic effects, i.e., cancer and heritable effects involving either cancer development in exposed individuals owing to mutation of somatic cells or heritable disease in their offspring own to mutation of reproductive cells.
International Commission on Radiological Protection. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP 2007; 37:1–332.
Every exposure to the maximum-allowable occupational radiation dose—50 mSv per year—induces about 1 additional fatal cancer per year in every 500 people exposed.
International Commission on Radiological Protection. 1990 Recommendations of the ICRP (Oxford, England: Pergamon, 1991).
The awareness of referring physicians (who order radiation-based studies) or radiologists (who perform the studies) about the risk of radiation is low. 76% of radiologists, 73% of emergency department doctors, and 100% of patients underestimate the radiation exposure dose from CT scans. According a 2014 radiation safety audit report, management of radiation exposure to radiation-related healthcare professionals exposed to radiation via mobile C-arms is substandard.
Kim Y. Are we being exposed to radiation in the hospital? Environ Health Toxicol 2016; 31:e2016005.
While evaluating neuro-cognitive effects of low-dose brain irradiation in patients with brain tumors, negative changes observed included reduction in olfactory neurons that lead to long-term memory dysfunction.
Lazarini F, et al. Cellular and behavioral effects of cranial irradiation of the subventricular zone in adult mice. PLOS One 2009;4: 7017.
The excess relative risk of leukaemia mortality was 2.96 per Gy, most notably because of an association between radiation dose and mortality from chronic myeloid leukaemia.
Leuraud K, et al. Ionising radiation and risk of death from leukaemia and lymphoma in radiation-monitored workers: an international cohort study. Lancet Haematology 2015 Jul;2(7):e276-81.
Results indicated a radiation effect for cortical and PSC cataract at doses less than the annual limit of the ICRP guidelines.
Lian Y, Xiao J, Ji X, et al. Protracted low-dose radiation exposure and cataract in a cohort of Chinese industry radiographers. Occup Environ Med 2015;72(9):640–7.
When an accessory lead shield is placed between the staff member and the patient during cardiac catheterization, scrub techs reported 34% reduction and nurse circulators 36% reduction in dose area product exposure.
Madder RD, LaCombe A, et al. Radiation exposure among scrub technologists and nurse circulators during cardiac catheterization: the impact of accessory lead shields. JACC Cardiovasc Interv. 2018 Jan;11(2):206-12.
Single-dose threshold for early transient erythema is 2 Gy, temporary epilation 3 Gy, main erythema 6 Gy and permanent epilation 7 Gy.
Mahesh M. Fluoroscopy: patient radiation exposure issues. Radiographics 2001;21(4):1033-45.
Doses to the eye lenses of clinicians undertaking fluoroscopically guided procedures can exceed the dose annual limit of 20 mSv, so optimization of radiation protection is essential.
Martin CJ. Eye lens dosimetry for fluoroscopically guided clinical procedures: practical approaches to protection and dose monitoring. Radiat Prot Dosimetry. 2016 Jun;169(1-4):286-91.
Of the Medicare patients who underwent CT scans, the incidence of cancers related to ionizing radiation were estimated to be 0.036%.
Meer AB, et al. Exposure to ionizing radiation and estimate of secondary cancers in the era of high-speed CT scanning: projections from the Medicare population. J Am Coll Radiol 2012 Apr;9(4):245-50.
Each 10 mSv per year of radiation exposure, for a 70-year lifetime, causes a 5% (lifetime) increase in fatal cancers, or about 1 additional fatal cancer per year for every 300 people exposed.
National Research Council. Health Risks From Exposure to Low Levels of Ionizing Radiation, BEIR VII (Washington, DC: National Academy Press, 2005), 6.
Lead gloves can provide a false sense of security when a worker must position the hands in the primary radiation beam, so they can result in an increase in the radiation dose to hands. In addition, they do not substantially lower radiation exposure.
NCRP Report No. 168. Radiation dose management for fluoroscopically guided interventional procedures. July 2010.
In some cases, dosimeters are not worn because of a lack of training in radiation protection, which leads staff to disregard the dosimeters or the information that they provide, or to avoid problems with the regulatory authority in cases of exceeding the dose limits.
Niklason LT, Marx MV, Chan HP. Interventional radiologists: occupational radiation doses and risks. Radiology 1993 Jun; 187(3):729-33.
They examined the data from 522 interventional neuroradiological procedures for the probability of specific types of procedures causing skin doses greater than levels recommended for monitoring (>1 Gy) or implicated in radiation-induced skin damage (>2 Gy). Six percent of embolization procedures and 1% of cerebral angiographic studies were estimated to have potential for main erythema (entrance skin dose >6 Gy). 
O’Dea TJ, Geise RA, Ritenour ER. The potential for radiation-induced skin damage in interventional neuroradiological procedures: a review of 522 cases using automated dosimetry. Med Phys 1999;26(9):2027-33.
Radiation-induced alopecia after fluoroscopically guided procedures is becoming more common due to an increasing use of endovascular procedures. Jung et al. reported that 7% of 135 patients treated for aneurysm by coiling embolization suffered from alopecia.
Ounsakul V, et al. Radiation-induced alopecia after endovascular embolization under fluoroscopy. Case Rep Dermatol Med. 2016;2016:8202469.
Exposure to even moderate doses (<1 Sv) of radiation is associated with an elevated incidence of nervous system tumors.
Preston DL, et al. Tumors of the nervous system and pituitary gland associated with atomic bomb radiation exposure. Journal of the National Cancer Institute 2002;94:1555-6.
34% increase in stroke incidence in techs who perform fluoro-guided procedures compared to those who do not.
Rajaraman P, et al. Incidence and mortality risks for circulatory diseases in US radiologic technologists who worked with fluoroscopically guided interventional procedures, 1994-2008. Occup Environ Med 2016;73(1):21-7.
2X increased risk of brain cancer mortality and modest elevations in incidence of melanoma and breast cancer among techs who perform fluoro-guided procedures compared to medical staff who do not.
Rajaraman P. Cancer risks in U.S. radiologic technologists working with fluoroscopically guided interventional procedures, 1994-2008. American Journal of Roentgenology 2016 May;206(5):1101-9.
Structural changes of the thyroid, such as malignant and benign thyroid tumors, develop at a linear rate at low to moderate radiation dose exposure.
Ron E, Brenner A. Non-malignant thyroid diseases following a wide range of radiation exposures. Radiation Research 2010; 174:877-88.
Structural and functional changes as a result of radiation exposure have been reported in the thyroid gland. The degree of exposure has been correlated with a linear increase in the development of both benign and malignant thyroid neoplasms.
Schneider AB, Ron E, Lubin J, et al. Dose-response relationships for radiation-induced thyroid cancer and thyroid nodules: evidence for the prolonged effects of radiation on the thyroid. J Clin Endocrinol Metab 1993 Aug;77(2):362-9.
An estimated 1 in 270 women who underwent coronary angiography CT at age 40 will develop cancer from that CT scan (1 in 600 men). For 20-year-old patients, the risks were approximately doubled, and for 60-year-olds, the risks were approximately 50% lower.
Smith-Bindman R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of Internal Medicine 2009;169(22):2078-86.
15% of patients undergoing CT scans acquired a cumulative effective dose of more than 100 mSv and 4% received 250-1375 mSv. Associated LAR had mean and maximum values of 0.3% and 12% for cancer incidence and 0.2% and 6.8% for cancer mortality, respectively.
Sodickson A, Baeyens PF, Andriole KP, et al. Recurrent CT, cumulative radiation exposure, and associated radiation-induced cancer risks from CT of adults. Radiology 2009;251(1):175–84.
Radiation-induced skin injuries are occurring in patients due to the use of inappropriate equipment and, more often, poor operational technique. Acute radiation doses to patients may cause erythema at 2 Gy, cataract at 2 Gy, permanent epilation at 7 Gy, and delayed skin necrosis at 12 Gy.
Valentin J. Avoidance of radiation injuries from medical interventional procedures. Ann ICRP. 2000;30(2):7-67.