Introduction
Evidence & Methods
The negative health effects of long-term exposure to ionizing radiation are well known. Patients with adolescent idiopathic scoliosis (AIS) have been shown to be at elevated risk of breast and thyroid cancer in the past. The impact of modern treatment algorithms, in terms of radiation exposure, remains unclear at present.
The authors retrospectively evaluated 267 patients treated nonoperatively, as well as surgically for AIS. They determined that patients treated surgically for AIS received as much as 14 times the radiation dose of individuals managed through nonoperative methods. Seventy-eight percent of radiation exposure in the operative group was due to fluoroscopy used at the time of surgery. The authors anticipate that the extent of radiation exposure in patients with AIS may elevate the lifetime risk of solid cancers to between 1.4% and 2.4%.
Although this was a retrospective cohort study, the findings are important from both a surgical, as well as a health policy perspective. In light of the topic, as well as the population under consideration, findings such as these may represent best available evidence. The authors correctly advocate that surgeons treating AIS patients need to be cognizant of cumulative radiation does at a minimum and carefully evaluate the strategic necessity of radiographs and computed tomography. The authors’ calls for broader approaches at the societal level and changes to postoperative surveillance algorithms are also laudable.
—The Editors
Adolescent idiopathic scoliosis (AIS) has a reported incidence of 25 adolescents per 1,000 in a population aged 10 to 18 years [1]. Full spinal radiographs in both posteroanterior (PA) and lateral projections remain central to the diagnosis and management of patients with scoliosis. Depending on the age, the initial curve magnitude, and any associated bracing or surgical interventions, patients may require repeated studies in intervals of 3 to 12 months. It has been estimated that the typical patient with scoliosis will have approximately 22 plain radiographic examinations over a 3-year treatment period [2]. As many as 618 plain films in a single patient have been reported [3], [4].
Multiple major scientific committee reports have shown that children are more sensitive to radiation than adults because they have more time to express a cancer and have more dividing cells on which the radiation acts [5], [6]. There is particular concern about the risk of breast cancer because progressive scoliosis is seen most commonly in the female population and the breast tissue of teenage girls is particularly sensitive to radiation [3], [6]. Nash et al. [7] reported a 110% increase in breast cancer risk after routine radiographic follow-up for AIS. Bone et al. repeated the study by Nash et al. almost 20 years later and found a 4.2% increased lifetime risk of developing breast cancer with a 3% increased risk of birth defects [8].
The magnitude of radiation exposure in the modern treatment of scoliosis is unclear. Although modern plain radiographic techniques have been able to reduce a patient's exposure, new diagnostic imaging technologies and surgical techniques such as intraoperative fluoroscopy, computed tomography (CT), and pedicle screw instrumentation necessarily increase a patient's exposure. The purpose of this study is to determine the average radiation exposure for a child undergoing management of AIS over a minimum duration of 2 years in the modern era.