Routine
Oblique
Radiography
of the Pediatric
Lumbar
Spine:
Is It
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/22/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
Necessary? FRED
F. ROBERTS,1’2
PULLA
A. S. KISHORE,1’3
that oblique
routine
of the pediatric
radiography
views
be eliminated
lumbar
in the
spine.
At present,
films
to provide were
Roberts films
evaluated
evaluation
interpretation
part
a common a difference the findings
manner
University
of the
oblique
of the
study,
and lateral
sitting,
followed
films.
At the
end
a joint
review
was
by
of the made
to
radiographic diagnosis in those few cases existed. Then comparison was made beon the frontal-lateral series and the oblique
Results
In this series, 86 abnormal findings 77 patients. The diagnoses are shown Received
November
9, 1977;
accepted
after
were detected in in table 2. Of the revision
March
our
interest population
in the amount is receiving.
Of
of
Kansas
Medial
Center
had
lumbar
spine
abnormalities. This high percentage of abnormal studies reflects both the active interest at this institution in such structural problems as scoliosis and congenital abnormalities, as well as the ease with which these entities can be suspected on an adequate physical examination. The observation of greatest interest was the relative contribution of the oblique films as compared to the anteroposterior and lateral films. In only four cases in this series was a diagnosis made on an oblique film that had not previously been established by the anteropostenor and/or lateral films together. The diagnosis in all four of these cases was unilateral spondylolysis without evidence of spondylolisthesis. (It was not the purpose of this study to evaluate the clinical significance of spondylolysis, but many authors feel that no therapy is required unless there is subsequent development of a significant spondylolisthesis [18-1 1]). Therefore, while the oblique films in this series increased our diagnostic accuracy by 5%, the findings are of doubtful clinical significance.
The
at one
that
‘ ‘
by two of us (F. F.
The anteroposterior
independently
is considerable
concern is the risk to younger members of our Overuse of radiologic studies, as well as inhealth care costs, has received widespread attention in both medical and lay press [5-7]. Since the genetically significant dose is high in lumbar spine examinations, it becomes worthwhile to determine whether reduction in the number of films for routine” study could be accomplished without loss of significant information. Although no attempt was made to analyze the radiographic abnormalities relative to the chief complaint, it is noteworthy that 48 of the 86 patients examined at the
Methods
data for a total of 125 patients.
in a double-blind
and P. A. S. Kishore).
were
similar reach where tween films.
additional
studied
exposure
particular society. creased
Complete lumbar spine series (anteroposterior, lateral, both obliques, and L5-S1 spot film) obtained on all patients under the age of 18 years from July 1974 to December 1975 at the University of Kansas Medical Center were reviewed. To these 86 cases, 39 examinations from Children’s Mercy Hospital were
added
there
of radiation
,
and
E. CUNNINGHAM1’4
Discussion
Radiologic examination of the lumbar spine represents a small percentage of the work in most radiology departments. However, estimates of the genetically significant dose of this examination range from 18% to 40%, as high as any study in radiology [1 2]. In most general hospitals the routine radiographic evaluation of both the adult and pediatric patient with low back difficulty includes frontal, lateral, and both oblique projections with an occasional L5-S1 spot film. Since each radiation exposure contributes significantly to the gonadal dose (table 1), it would be desirable, especially in the pediatric patient, to reduce the number of routine films obtained in this examination if there were no significant loss of diagnostic information. This study was undertaken to evaluate the diagnostic contribution of oblique films of the lumbar spine to the information obtainable from frontal and lateral films. Subjects
MARY
86 abnormalities 43 (50%) were detected on the anteroposterior and lateral films but not on the oblique films; 39 (45%) were detected on both the frontal-lateral examnation and the oblique study. In only four cases (5%) was a diagnosis made on the oblique study that had not previously been detected on the combined frontal and lateral examination; in all four cases unilateral spondylolysis was identified without associated changes of spondylolisthesis.
A series of 86 pediatric lumbar spine abnormalities was evaluated to determine the diagnostic benefit of radiography in oblique projection as compared to frontal-lateral projections alone. In only four patients was an abnormality apparent on the oblique view which had not already been demonstrated by the frontal-lateral series; each of these represented an isolated spondylolysis. Because the diagnostic yield was low at a patient cost of more than double the gonadal radiation dose,
it is recommended
AND
30, 1978.
‘Department of Diagnostic Radiology, University of Kansas Medical Center, College of Health Sciences and Hospital, Kansas City, Kansas 66103. 2Present address: Department of Radiology, St. Joseph Hospital, 1000 Carondelet Drive, Kansas City, Missouri 64114. Address reprint requests to F. F. Roberts. 3Present
address:
4Present address: Am J Ro.ntgenol C
1978 American
Department
of Radiology,
Medical
Department
of Radiology,
Clatterbridge
131:297-298,
Roentgen
August
Ray Society
1978
College
of Virginia,
Hospital,
Richmond,
Wirral, Cheshire, 297
23298. Great Britain.
Virginia
0361
-803X/78/08-0297
$00.00
298
ROBERTS TABLE
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/22/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
Gonadal
1
Dose from Lumbar
Technique Adult
technique
(100-120
Male Female Pediatric technique Age 10: Male Female Age 4: Male Female .
t
Dose obtained Doses
Internally estimated using
there remains very little indication for the continued use of oblique films for routine evaluation of the pediatric lumbar spine. At the very least, the anteroposterior and lateral films should be reviewed with adequate clinical information before obtaining the oblique views.
Spine Studies (mrad)
kVp)
(70-75
ET AL.
[3]*: 15
10
20
70
62
94
5 214
1 52
6 270
3 114
1 28
4 145
kVp)t:
from adult phantom. data from [4].
ACKNOWLEDGMENTS We thank Joan Herring for help in obtaining the lumbar spine studies from Children’s Mercy Hospital and Or. A. W. Templeton for
reviewing
Larimore the pediatric
the
manuscript.
and Steve
We
Fritz for their
are
also
radiation
grateful
to
Emory
dose estimates
in
patient.
REFERENCES 1.
International tection
of the
Commission Patient
on Radiological in X-ray
Diagnosis,
Protection: Publication
Pro-
16,
1969
TABLE Classification Diagnosis
Scoliosis Schmorl’s nodes Spondylolisthesis Spondylosis (isolated) Congenital defect Fracture Infection Total
2
of Abnormalities cases
19 17 10 6 21 10 3 86
2. Penfil AL, Brown ML: Genetically significant dose to the United States population for diagnostic medical roentgenology, 1964. Radiology 90 :209-216, 1968 3, Antoku S, Russell WJ: Dose to the active bone marrow, gonads and skin from roentgenography and fluoroscopy. Radiology 101 : 669-678, 1971 4. U.S. Department of Health, Education, and Welfare: Organ Doses in Diagnostic Radiology, Publication 76-8030, May 1976 5. Hall FM: Overutilization of radiological examinations. Radiology 1 20 :443-448, 1976 6. McClenahan JL: Wasted x-rays. Pa Med 72 : 107-108, 1969 7. Rigler LG: Is this radiograph really necessary? Radiology 120:449-450,
There is no question that the intervertebral foramina, the pars interarticularis, and the apophyseal joints are seen well only in the oblique projection [12]. However, incidence of abnormalities in these areas is very low in the pediatric patient. Since the diagnosis of uncomplicated spondylolysis is of questionable clinical significance and there were no other lesions detected on the oblique films in this study,
1976
8. Epstein BS: The Spine: A Radiological Text and Atlas, 4th ad. Philadelphia, Lea & Febiger, 1976 9. Fullenlove TM, Williams AJ: Comparative roentgen findings in symptomatic and asymptomatic backs. Radiology 68:522-524, 1957 10. Nachemson A, Wiltse L: Spondylolisthesis. Clin Orthop 117:2-3, 1976 1 1 Wiltse LL, Jackson OW: Treatment of spondylolisthesis and spondylolysis in children. Clin Orthop 117:92-100, 1976 12. Schmorl G, Junghanns H: The Human Spine in Health and Disease, 2d American ed. New York, Grune & Stratton, 1971 .
Oblique
Radiography
of the Pediatric
Lumbar
Spine:
Is It
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/22/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
Necessary? FRED
F. ROBERTS,1’2
PULLA
A. S. KISHORE,1’3
that oblique
routine
of the pediatric
radiography
views
be eliminated
lumbar
in the
spine.
At present,
films
to provide were
Roberts films
evaluated
evaluation
interpretation
part
a common a difference the findings
manner
University
of the
oblique
of the
study,
and lateral
sitting,
followed
films.
At the
end
a joint
review
was
by
of the made
to
radiographic diagnosis in those few cases existed. Then comparison was made beon the frontal-lateral series and the oblique
Results
In this series, 86 abnormal findings 77 patients. The diagnoses are shown Received
November
9, 1977;
accepted
after
were detected in in table 2. Of the revision
March
our
interest population
in the amount is receiving.
Of
of
Kansas
Medial
Center
had
lumbar
spine
abnormalities. This high percentage of abnormal studies reflects both the active interest at this institution in such structural problems as scoliosis and congenital abnormalities, as well as the ease with which these entities can be suspected on an adequate physical examination. The observation of greatest interest was the relative contribution of the oblique films as compared to the anteroposterior and lateral films. In only four cases in this series was a diagnosis made on an oblique film that had not previously been established by the anteropostenor and/or lateral films together. The diagnosis in all four of these cases was unilateral spondylolysis without evidence of spondylolisthesis. (It was not the purpose of this study to evaluate the clinical significance of spondylolysis, but many authors feel that no therapy is required unless there is subsequent development of a significant spondylolisthesis [18-1 1]). Therefore, while the oblique films in this series increased our diagnostic accuracy by 5%, the findings are of doubtful clinical significance.
The
at one
that
‘ ‘
by two of us (F. F.
The anteroposterior
independently
is considerable
concern is the risk to younger members of our Overuse of radiologic studies, as well as inhealth care costs, has received widespread attention in both medical and lay press [5-7]. Since the genetically significant dose is high in lumbar spine examinations, it becomes worthwhile to determine whether reduction in the number of films for routine” study could be accomplished without loss of significant information. Although no attempt was made to analyze the radiographic abnormalities relative to the chief complaint, it is noteworthy that 48 of the 86 patients examined at the
Methods
data for a total of 125 patients.
in a double-blind
and P. A. S. Kishore).
were
similar reach where tween films.
additional
studied
exposure
particular society. creased
Complete lumbar spine series (anteroposterior, lateral, both obliques, and L5-S1 spot film) obtained on all patients under the age of 18 years from July 1974 to December 1975 at the University of Kansas Medical Center were reviewed. To these 86 cases, 39 examinations from Children’s Mercy Hospital were
added
there
of radiation
,
and
E. CUNNINGHAM1’4
Discussion
Radiologic examination of the lumbar spine represents a small percentage of the work in most radiology departments. However, estimates of the genetically significant dose of this examination range from 18% to 40%, as high as any study in radiology [1 2]. In most general hospitals the routine radiographic evaluation of both the adult and pediatric patient with low back difficulty includes frontal, lateral, and both oblique projections with an occasional L5-S1 spot film. Since each radiation exposure contributes significantly to the gonadal dose (table 1), it would be desirable, especially in the pediatric patient, to reduce the number of routine films obtained in this examination if there were no significant loss of diagnostic information. This study was undertaken to evaluate the diagnostic contribution of oblique films of the lumbar spine to the information obtainable from frontal and lateral films. Subjects
MARY
86 abnormalities 43 (50%) were detected on the anteroposterior and lateral films but not on the oblique films; 39 (45%) were detected on both the frontal-lateral examnation and the oblique study. In only four cases (5%) was a diagnosis made on the oblique study that had not previously been detected on the combined frontal and lateral examination; in all four cases unilateral spondylolysis was identified without associated changes of spondylolisthesis.
A series of 86 pediatric lumbar spine abnormalities was evaluated to determine the diagnostic benefit of radiography in oblique projection as compared to frontal-lateral projections alone. In only four patients was an abnormality apparent on the oblique view which had not already been demonstrated by the frontal-lateral series; each of these represented an isolated spondylolysis. Because the diagnostic yield was low at a patient cost of more than double the gonadal radiation dose,
it is recommended
AND
30, 1978.
‘Department of Diagnostic Radiology, University of Kansas Medical Center, College of Health Sciences and Hospital, Kansas City, Kansas 66103. 2Present address: Department of Radiology, St. Joseph Hospital, 1000 Carondelet Drive, Kansas City, Missouri 64114. Address reprint requests to F. F. Roberts. 3Present
address:
4Present address: Am J Ro.ntgenol C
1978 American
Department
of Radiology,
Medical
Department
of Radiology,
Clatterbridge
131:297-298,
Roentgen
August
Ray Society
1978
College
of Virginia,
Hospital,
Richmond,
Wirral, Cheshire, 297
23298. Great Britain.
Virginia
0361
-803X/78/08-0297
$00.00
298
ROBERTS TABLE
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/22/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
Gonadal
1
Dose from Lumbar
Technique Adult
technique
(100-120
Male Female Pediatric technique Age 10: Male Female Age 4: Male Female .
t
Dose obtained Doses
Internally estimated using
there remains very little indication for the continued use of oblique films for routine evaluation of the pediatric lumbar spine. At the very least, the anteroposterior and lateral films should be reviewed with adequate clinical information before obtaining the oblique views.
Spine Studies (mrad)
kVp)
(70-75
ET AL.
[3]*: 15
10
20
70
62
94
5 214
1 52
6 270
3 114
1 28
4 145
kVp)t:
from adult phantom. data from [4].
ACKNOWLEDGMENTS We thank Joan Herring for help in obtaining the lumbar spine studies from Children’s Mercy Hospital and Or. A. W. Templeton for
reviewing
Larimore the pediatric
the
manuscript.
and Steve
We
Fritz for their
are
also
radiation
grateful
to
Emory
dose estimates
in
patient.
REFERENCES 1.
International tection
of the
Commission Patient
on Radiological in X-ray
Diagnosis,
Protection: Publication
Pro-
16,
1969
TABLE Classification Diagnosis
Scoliosis Schmorl’s nodes Spondylolisthesis Spondylosis (isolated) Congenital defect Fracture Infection Total
2
of Abnormalities cases
19 17 10 6 21 10 3 86
2. Penfil AL, Brown ML: Genetically significant dose to the United States population for diagnostic medical roentgenology, 1964. Radiology 90 :209-216, 1968 3, Antoku S, Russell WJ: Dose to the active bone marrow, gonads and skin from roentgenography and fluoroscopy. Radiology 101 : 669-678, 1971 4. U.S. Department of Health, Education, and Welfare: Organ Doses in Diagnostic Radiology, Publication 76-8030, May 1976 5. Hall FM: Overutilization of radiological examinations. Radiology 1 20 :443-448, 1976 6. McClenahan JL: Wasted x-rays. Pa Med 72 : 107-108, 1969 7. Rigler LG: Is this radiograph really necessary? Radiology 120:449-450,
There is no question that the intervertebral foramina, the pars interarticularis, and the apophyseal joints are seen well only in the oblique projection [12]. However, incidence of abnormalities in these areas is very low in the pediatric patient. Since the diagnosis of uncomplicated spondylolysis is of questionable clinical significance and there were no other lesions detected on the oblique films in this study,
1976
8. Epstein BS: The Spine: A Radiological Text and Atlas, 4th ad. Philadelphia, Lea & Febiger, 1976 9. Fullenlove TM, Williams AJ: Comparative roentgen findings in symptomatic and asymptomatic backs. Radiology 68:522-524, 1957 10. Nachemson A, Wiltse L: Spondylolisthesis. Clin Orthop 117:2-3, 1976 1 1 Wiltse LL, Jackson OW: Treatment of spondylolisthesis and spondylolysis in children. Clin Orthop 117:92-100, 1976 12. Schmorl G, Junghanns H: The Human Spine in Health and Disease, 2d American ed. New York, Grune & Stratton, 1971 .
