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Advance Access publication 7 July 2011
doi:10.1093/rpd/ncr254
INTRODUCTION
Scoliosis is defined as a lateral curvature of the spine;
the deformity is more complicated as it is not limited
to one plane only. A lordosis rotates to one side, producing scoliosis as a secondary phenomenon; there
is, therefore, deformity in all three planes(1, 2).
Initial diagnosis of scoliosis is usually made by
physical examination using the forward bending or
Adamss test. Although, for a definitive diagnosis,
some doctors then use a scoliometer system to
measure the curvature if the child is thought to have
scoliosis, a radiographic examination is usually done,
which should include standing, frontal and lateral
views of the spine. Radiological imaging is necessary
to clarify the nature of scoliosis and the impact of
spine deformation on other systems(3). The frontal
projection is performed both in the anteroposterior
(AP) or posteroanterior (PA) position. This projection is crucial in determining the degree of distortion
and useful to measure the angle of curvature of the
spine according to Cobbs method. The lateral projection is very useful especially during the first investigation to reveal the kyphosis type of deformation(2).
The most observed scoliosis patients are children.
They constitute a population group with a high sensitivity to ionising radiation(4), and they undergo
many examinations during their control and treatment periods. Therefore, this group of patients was
chosen in order to carry out a detailed survey and to
compare the results of this study with those published from other countries.
As the received doses during this examination are
not at the level to induce deterministic effects, the
effective dose (E) has been assumed. E is an
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M. MOGAADI ET AL.
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Age (y)a
Weight (kg)
Height (cm)
AP thickness (cm)
,1 (n6)
1 4 (n21)
5 9 (n19)
10 15 (n40)
16 (n13)
Total number99
0.6 (0.250.8).
2.8 (1.1 4.6)
7.1 (59.7)
13.2 (10 15.7)
17.6 (16 22)
9.7 (0.2522)
8 (79)
12 (817)
22 (13 35)
38 (20 75)
48 (22 65)
29 (775)
69 (6274)
89 (71108)
120 (92141)
148 (110 173)
158 (125 182)
127 (62182)
14.4 (1415)
15.9 (1418)
19.2 (1423)
22.6 (1729)
24 (1827)
20.2 (1429)
Weight (kg)
EAK (mGy): frontal
EAK (mGy): lateral
E (mSv): frontal
E (mSv): lateral
0 1
1 4
5 9
10 15
16
8
479
796
229
169
12
589
967
299
227
22
830
1495
450
358
38
1275
2733
678
586
48
1495
3112
798
597
mA s, and for adult patients, the examination parameters ranged between 71 and 81 for peak kilovoltages and between 80 and 150 for mA s.
For the lateral view, for children the X-ray tube
potentials ranged between 58 and 97 kVpwith milliamperes per second values varying from 16 to 240
mA s, and for adult patients, the peak kilovoltage
ranged between 73 and 98 and the mA s between
120 and 240.
The beam area at the patient surface varied significantly (10 times) for the whole patient sample
(from 291 cm2 to 3114 cm2). The mean dimensions
of the entrance X-ray beam was (2358 cm2) either
for the lateral or the frontal views. A poor collimation was undertaken by the radiographers, which
tend to cover the full spine, exceeding sometimes the
cassette size, especially if the direction of deformation was unknown.
Patient doses
An overview of the EAK measurements for full
spine frontal and lateral examinations is presented in
Table 2. Values for lateral projection are higher than
those for frontal projection in all age groups.
The average values of effective doses for frontal
and lateral views are also presented in Table 2 for
each age group. According to the results in this
table, the effective dose to patients in 10 15 y of age
was three and four times higher than the infant
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n, number of patients.
a
First figure is the mean and the range is given in parentheses.
M. MOGAADI ET AL.
Figure 3. Effective dose E against patient weight for frontal and lateral views.
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Figure 2. Effective dose E against patient age for frontal and lateral views.
7 kg , W , 75kg
99
11
0.67
0.64
W . 20 kg
W . 30 kg
36
3.75
42
2.5
0.27
0.27
DISCUSSION
The X-ray output (mGy mA s21) depicted in
Figure 1 is three times higher than that presented by
Chamberlain et al. (11) because a wedge-shaped aluminium filter is not used in this study and the total
filtration is thin (2.5 mm Al). The filtration of the
primary X-ray beam reduces the total number of
X-ray photons in the beam but, more importantly, it
selectively removes a greater portion of the lowenergy photons that do not contribute to the
production of a radiograph. For the same reasons,
EAK values summarised in Table 2 are higher than
those found in the literature(11, 13).
Generally, effective dose tends to increase with the
patient age, but the dispersion depicted in Figure 2
which is due to the large variation of patient size
confirms the age distribution recommended by
NRPB. By considering the scatter regions observed
in this figure, the International Commission of
Radiation Protection age groups (3 months, 1, 27,
7 12, 12 17 y) seem to be more adapted.
Contrary to what is expected with the results of the
good correlation between effective dose and patient
weight, a limited dependence on the patient size is
observed especially for a weight of .30 kg which corresponds to child age of nearly .10 y having a slow
growth compared with children having an age of ,10
y. On average, effective dose tends to increase with
patient weight, but the contribution at the same time
of other factors such as the patients age and size do
not permit any definitive conclusions to be reached.
The question however still remains with regard to
the reservation on the use of the PCXMC program
for this special case of patients. To investigate the
body mass index (BMI weight/height2), which
define the body fatness in medicine was derived for
the sample in whom 35 % of them fall outside of the
normal expectations of size. While the remaining
patients are generally underweight, it is seen in
Table 3 that the coefficient of determination between
effective dose and patient weight remains unchanged
65
10
0.68
0.67
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0.16
0.18
BMI selection
M. MOGAADI ET AL.
Table 4. Effective dose E in scoliosis radiography for ulterior studies.
Study
E: mean
(minimum maximum)
Speed class
600
800
600
Gerjer et al.(14)
This study
400
Gradual speed
(100400)
54 (27 95)
33.9 (18 50)
39.9 (25 50)
40
69.6 (16 180)
116.9 (16 320)
108.7 (80 150)
184.7 (120240)
ACKNOWLEDGEMENTS
The authors would like to acknowledge the statistical advice from Dr. Mossadok Ben Attia at the
University of Bizerte and the assistance of the staff
of National Center of Radiation Protection of Tunis
and the staff of radiological service of Childrens
Hospital of Tunis.
FUNDING
This work has received funding from the Research
Unit of the National Center of Radiation Protection
of Tunis.
REFERENCES
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7 (925 y)
Hallen et al.(13)
Chamberlain et al.(11) 61 (9 55 y)
54 (4 17 y)
Chih-l et al.(12)
mA s: mean
(minimum maximum)
11.
12.
13.
14.
15.
16.
17.
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