Ultrasonography in Pain Medicine SIG

Reduce Radiation Exposure Through Improved Education, Prevention, and Monitoring

Nov 1, 2021

Samuel A. Florentino, BA; David A. Provenzano, MD; and Jason S. Kilgore, PhD

Cite as: Florentino SA, Provenzano DA, Kilgore JS Reduce radiation exposure through improved education, prevention, and monitoring. ASRA News 2021;46. https://doi.org/10.52211/asra110121.066 

In its early history, x-ray fluoroscopy was performed almost entirely in the radiology department by radiologists to visualize internal anatomy and contrast movement. As medical imaging evolved and use of fluoroscopy increased, radiologists and specialists began working together to perform the procedures. However, in contemporary medicine, nonradiologists (eg, interventional pain physicians, cardiologists, orthopedic surgeons) are using the technique outside of the radiology department, with insufficient, if any, radiation safety education or training in medical school, residency, or fellowship.1–5

Radiation safety is a priority for most patients, physicians (including > 90% of interventional pain physicians), and medical staff, which adds to the concern that many users of fluoroscopy have inadequate training on radiation safety.1–3 Specifically, a global survey of 708 interventional pain physicians reported that 63% had ever received any radiation safety training or education and only 30% received more than two hours of training following medical school. The radiation safety education deficit exists not just among attending physicians but also in fellows from multiple specialties, including pain management, cardiology, orthopedics, radiology, and urology, who have reported significantly limited comprehension of radiation safety practices and principles.1,3–5

As pain management procedures increase in complexity and frequency, exposure to ionizing radiation and its associated health effects also increase. Radiation health effects are classified as stochastic or nonstochastic. Stochastic effects are probabilistic, occurring independently of a threshold radiation dose, and include malignancy and genetic effects. Nonstochastic health effects, also called deterministic effects, are dose dependent and have a threshold for occurrence (eg, erythema, tissue burns, blood disorders, reduced fertility, cataracts). Interventional pain physicians and medical staff are typically exposed to low-dose scatter radiation for many years, and the stochastic effects of that exposure may not be seen for decades.

Issues Surrounding Radiation Safety for Fluoroscopy

Fluoroscopy is frequently used in many specialties, including interventional cardiology, gastroenterology, interventional pain, obstetrics and gynecology, orthopedic surgery, urology, and vascular surgery. Contemporary techniques in surgical and interventional specialties are less invasive, and although they have reduced recovery time, surgical incision size, and pain, they often require more fluoroscopic guidance and thus greater exposure to ionizing radiation.

Despite the increase in its use, training to minimize fluoroscopy’s negative effects lags. International guidelines recommend that interventionists receive 20–30 hours of radiologic protection training, yet 90% of interventional pain physicians reported receiving less than or equal to six hours of radiation safety education or training.1,6 Specifically, the National Council on Radiation Protection and Measurements (NCRP) recommends that interventionalists who perform procedures with fluoroscopy need didactic training, hands-on training, and clinical operation under a preceptor physician.7 NCRP’s formal training is a minimum of one day and involves successful completion of a written examination, yet most surveyed interventional pain physicians and fellows did not meet those requirements.1

Both stochastic and nonstochastic effects have been documented in interventionists and surgeons. In a cohort of interventional cardiologists who developed brain and neck malignancies, 85% were found on the left side (ie, the side closest to the source of radiation).8-11 In addition, radiation-associated cataracts are increasingly observed in interventional cardiologists,12 and hair loss has been reported in interventional radiologists and cardiologists.2 Orthopedic surgeons in one hospital system with poor and discontinuous radiation protection measures had a fivefold increase in lifetime cancer rates compared to other personnel exposed to radiation.13 To further complicate the issue, reliable data on radiation doses to health care workers are lacking because many professionals do not consistently and correctly use their dosimeters.2 Less than 50% of interventional pain physicians reported proper use in an international survey.1

Best Practices for Fluoroscopy Safety

Patients, physicians, and medical staff can take several precautions to substantially reduce their radiation exposure and its risk for stochastic and nonstochastic effects.

  1. Proper shielding should be worn. The lead apron is essential and must be worn by all who are present. Additional necessary shielding includes thyroid protector, eye protection, hand protection, mounted shielding, and ceiling-suspended shielding. Shielding with a lead equivalence of 0.5 mm or more can reduce radiation exposure by more than 90%.2 Radiation safety glasses can reduce the exposure to the eyes by 70%–98%.14,15 In addition, a thyroid shield can reduce exposure to the thyroid by a factor of 12.16 To reduce cracking, radiation protection garments should not be folded and should be annually inspected with x-rays for deterioration.

    Note: Heavy aprons may cause discomfort for some workers, especially when wearing them for extended periods of time. Some newer aprons are lighter-weight alternatives with lead equivalence, or two-piece skirt aprons may offer a more comfortable weight distribution.

  2. Maximize the distance from the source of radiation. Scatter radiation is the primary source of radiation to surgeons and interventionalists. Doubling the distance from the source of radiation reduces exposure by a factor of 4 (ie, inverse square law).17

  3. Limit the radiation time. The duration of exposure to ionizing radiation should be as low as reasonably achievable (ALARA).

  4. Employ pulsed fluoroscopy when possible. Use of optimized pulsed versus continuous fluoroscopy can reduce effective radiation dose by 80%–90%.17

  5. Maximize the collimation to the target zone.  Reduce the ionizing radiation beam to the minimally necessary field of view.

  6. Maximize the distance between the x-ray tube and patient without sacrificing image quality.

  7. Minimize the distance between the image receptor and patient without sacrificing image quality.

  8. Monthly monitoring of radiation exposure to raise awareness and improve practice. A dosimeter/radiation badge should always be worn when potentially exposed to ionizing radiation and be evaluated monthly to ensure compliance with annual dose limits. Fluoroscopy time should also be recorded. Knowledge of radiation exposure with appropriate educational coaching reduces radiation exposure by as much as 50%.18

  9. Optimize position in relationship to the fluoroscopy machine. Stay on the side of the image receptor rather than on the side of the x-ray tube when performing imaging in the lateral orientation.

  10. Pre-procedure planning of required images to eliminate unnecessary and/or redundant radiation exposure.

Additional safety measures and details are described in the International Commission on Radiological Protection and National Council on Radiation Protection and Measurements guidelines on radiation safety.2,6,19–21


Solutions and Future Opportunities

The goal of radiation safety is to minimize radiation exposure and thus its harmful effects. As the medical community improves its understanding of how to improve patient safety and enhance target accuracy during medical imaging procedures, knowledge of radiation safety best practices can protect patients, physicians, and the health care team. Formal radiation safety education and training must be implemented by institutions and fellowship programs.

Educational radiation safety sessions can reduce radiation exposure by as much as 50%.22 As educators, physicians must be acutely aware of the influence that their attitudes regarding radiation safety have on their trainees; they have an essential responsibility to protect patients and personnel. Applying a quality assurance program can ensure that those who use x-ray fluoroscopy have appropriate levels of radiation exposure,23 and incorporating optimal radiation safety practices when planning for clinically necessary images will keep radiation exposure ALARA.

The medical community should promote appropriate radiation safety training and employ evidence-based radiation safety practices to minimize the risks of radiation exposure to practitioners and patients as an essential component of high-quality patient care.

Acknowledgment: We would like to acknowledge Heather Hoover, radiation technologist at the Western Pennsylvania Surgical Center, for reviewing this article.


Samuel A. Florentino

Samuel A. Florentino, BA, is a medical student at the University of Rochester School of Medicine and Dentistry in Rochester, NY.

Dr. David Provenzano

David A. Provenzano, MD, is a pain medicine specialist at Pain Diagnostics and Interventional Care in Sewickley, PA.

Dr. Jason Kilgore

Jason Kilgore, PhD, is an associate professor of biology at Washington and Jefferson College in Washington, PA.


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  2. Rehani MM, Ciraj-Bjelac O, Vañó E, et al. ICRP publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department. Ann ICRP 2010;40(6):1–102. https://doi.org/10.1016/j.icrp.2012.03.001 
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  16. Marshall NW, Faulkner K, Clarke P. An investigation into the effect of protective devices on the dose to radiosensitive organs in the head and neck. Br J Radiol 1992;65(777):799–802. https://doi.org/10.1259/0007-1285-65-777-799 
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