The Price We Pay for Precision: The Silent Hazard of Radiation Exposure

With the increasing popularity of minimally invasive procedures and neurointerventional procedures, radiation exposure among neurosurgeons and interventionalists has increased exponentially in the recent years. While the benefits and advantages of MIS and interventional techniques remain undeniable, the potential for collateral harm from radiation exposure to operating theater personnel is often overlooked. Safety guidelines, if strictly adhered to, can markedly reduce these risks—yet compliance in everyday practice remains disappointingly low. Although patients receive the highest dose from the primary beam, surgeons and operating room staff are also exposed to significant scatter radiation. An occasional exposure does not pose any risk, yet the cumulative exposure over years is a major concern. Since the harmful effects of radiation exposure are not immediate, safety guidelines are often neglected with an attitude of denial and carelessness. Ted Diethrich, one of the early architects of the endovascular revolution, once commented, “I felt invincible to the effects of radiation until I was diagnosed with bilateral radiation-induced cataracts, premature left carotid artery atherosclerosis and a left brain oligodendroglioma.”1 Dr. Lindsay Machan, co-founder of the drug-eluting coronary stent who later developed bilateral radiation-induced cataracts, echoes the same feeling and has since become a prominent advocate for radiation safety, cautioning that there may be no completely safe level of occupational radiation exposure.1 The biological effects of chronic radiation exposure are broadly classified into deterministic and stochastic effects. Deterministic effects occur once a threshold dose is exceeded and include conditions such as radiation-induced cataracts, radiation dermatitis, and hair loss in exposed areas. In contrast, stochastic effects occur without a clearly defined threshold and include malignancies such as brain tumors, thyroid cancer, leukemia, and other cancers. Although current evidence does not conclusively demonstrate that high-dose medical imaging has directly increased cancer incidence, the linear no-threshold (LNT) model used in radioprotection assumes that no radiation dose is entirely safe: All exposures are cumulative, and the risk of cancer increases proportionally with increasing radiation dose. The International Commission on Radiological Protection (ICRP) has recommended an occupational exposure limit of 20 mSv per year averaged over 5 years, with a maximum of 50 mSv in any single year.1,2 The body parts most susceptible to exposure include the surgeon’s dominant hands, neck, chest, and gonads, followed by the eyes and thyroid. A prospective study by Harstall et al.3 demonstrated that radiation doses to the thyroid, left hand, right hand, and left arm of a surgeon performing vertebroplasty while wearing only a lead apron could readily exceed the recommended annual limits. In high-volume neurointervention centers, annual occupational exposure may range from 2 to 10 mSv, and over a 30-year career, cumulative exposure may approach levels associated with a measurable stochastic risk. Despite these concerns, surgeons can be accused of negligence in terms of inconsistent use of dosimeters, poor adherence to lead protection, and improper techniques while using C-arms. Lack of awareness among junior doctors and limited institutional radiation safety education compound the problem. Sheth et al.2 recently conducted a questionnaire-based survey among orthopedic surgeons to judge their awareness regarding safety practises to be ensured during radiation exposure. The findings were shocking: Nearly 15% of respondents were unaware of the risks associated with radiation exposure in routine orthopedic surgery, 82% did not know the recommended annual exposure limits, 30% were unfamiliar with the correct positioning of the C-arm, and 45% were uncertain about the appropriate thickness of lead aprons. Furthermore, 83% reported never using a thyroid shield, and none of the respondents used leaded protective eyewear. Only 11% used dosimeter badges to document radiation exposure. A similar study conducted among American Association of Neurological Surgeons members revealed that that most neurosurgeons (27%) performed 2–4 surgeries per week necessitating radiation (27%), did not use a dosimeter (59%), and wore a lead apron (89%) and a thyroid shield (75%). Only 3% of respondents could correctly identify the safety limit for occupational radiation, and only 59% respondents correctly identified the relationship between distance and radiation dose reduction. Although no significant association was found between occupational radiation exposure and the rate of cataracts, combined cancer, and skin cancer, multivariate logistic regression adjusting for age and cancer history found that the likelihood of developing leukemia (P = 0.02) and nonmalignant thyroid nodular disease (P = 0.01) is positively associated with increased total occupational radiation exposure.4 Although a similar study among neurosurgeons and interventional neuroradiologists from India is yet to be reported, it would not be surprising if the findings were along similar lines. Radiation safety must become a core competency in neurosurgical and neuroradiology training with emphasis on time reduction, distance optimization, mandatory shielding with lead aprons (0.5 mm), thyroid shields, leaded eyewear, and so on. Neurosurgeons and interventionalists should adopt the ALARA (as low as reasonably achievable) principle – meaning using the least amount of radiation necessary to get an image for the best outcome. Cost should not be a constraint while acquiring newer generation of fluoroscopy machines which reduce the risk of radiation considerably. All precautions should be taken to keep all members of the operation room safe from radiation exposure and safeguard patients too. While ignorance and lack of awareness can be overcome with training, a wilful reluctance to adhere to safety norms on the rather flimsy grounds puts the entire operating team to considerable risk. “A good surgeon or interventionalist cannot be afraid of life-saving radiation, but must be afraid of radiation unawareness and negligence”5 Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.