Abstract

Background: In this study, we investigated the adequacy of radiation safety education for neurosurgical trainees and physicians, focusing on their perceptions and concerns.

Methods: A survey was distributed through the social media platforms LinkedIn, X (formerly Twitter), and Instagram, as well as through email to individuals listed on the “2023 Neurosurgery Residency Program Information and Interview Dates” document available on the Society of Neurological Surgeons website. Surveys were distributed on December 5, 2023, January 18, 2024, and February 8, 2024. The collection of responses ceased on February 26, 2024. Data collected encompassed respondent demographics, practice and training characteristics, radiation safety knowledge and practice, and radiation exposure concerns.

Results: Of the 48 total responses received, 25 (women, 22) received from neurosurgical residents, fellows, or attending physicians were analyzed. Concerns about health, fertility, and inadequate radiation safety education were evident. Notably, 68% expressed concerns about the impact of radiation exposure on fertility and 52% on pregnancy, with 60% reporting concerns about health risks of radiation exposure. In addition, 68% found radiation safety education provided throughout their neurosurgical career unsatisfactory, with 44% feeling inadequately informed. Considerable knowledge gaps were demonstrated on assessment.

Conclusion: This study reveals prevalent concerns and knowledge gaps in radiation safety education among a geographically diverse group of practicing and training neurosurgeons. Addressing these concerns requires targeted interventions to improve radiation safety education and alleviate apprehensions among neurosurgical trainees and physicians.

Keywords: Intraoperative imaging, Minimally invasive surgical procedures, Neurosurgery, Neurosurgical education, Radiation exposure

INTRODUCTION

Minimally invasive techniques have become the standard of care for many procedures in the field of neurosurgery, increasing the use of intraoperative imaging techniques. This increasing prevalence has been observed to directly impact radiation safety practices and workplace safety for both training and practicing neurosurgeons.[ 26 ] However, this observation is not isolated to the neurosurgical field as previous work in the field of orthopedic surgery has recognized the mounting exposure to ionizing radiation through the increased use of fluoroscopy-based surgical tools, such as C-arm and mini-C-arm imaging devices.[ 24 , 28 , 57 ] Unfortunately, the increased use of these tools, resulting in exposure to ionizing radiation, has not been met with increased knowledge regarding precautions to minimize the associated dangers.[ 16 , 21 , 59 ]

Recent surveys in the field of orthopedic surgery have highlighted an apparent deficit in both radiation safety knowledge and safety training, with trainees and attending physicians demonstrating consistently low levels of knowledge on survey assessments and only 20% of respondents reporting having received any form of training regarding radiation safety standards and practices.[ 1 , 10 , 20 , 22 , 25 , 27 , 31 , 38 , 39 , 45 - 47 , 53 , 56 - 58 ] Similar trends have been identified in the fields of vascular and urological surgery.[ 8 , 23 , 33 , 35 , 46 ] Interestingly, there is existing evidence that low demonstrated levels of knowledge on the subject, as well as low levels of reported training, are not directly related to the utilization of appropriate personal protective equipment (PPE) or confidence in the knowledge level of radiation risks and prevention.[ 45 , 57 ] However, recent studies have demonstrated that despite high levels of adherence to the use of PPE (i.e., thyroid shields, gloves, lead aprons, and glasses), both patients and surgeons across multiple fields of surgery continue to be exposed to higher levels of radiation than would be expected for those adhering to best radiation safety practices.[ 8 , 10 , 11 , 16 , 20 , 22 , 25 , 27 , 31 , 38 , 39 , 46 , 47 , 56 , 58 ] These practices include but are not limited to, efforts to maximize one’s distance from a radiation source, limit time of exposure, minimize fluoroscopy use and dose, appropriately manipulate fluoroscopic equipment, and avoid direct exposure of body parts.[ 10 , 20 , 22 , 25 , 27 , 31 , 38 , 39 , 46 , 47 , 50 , 56 , 58 ]

Although the impact of this over-exposure may not be seen for years, it is vital that surgeons and trainees recognize and mitigate the risks posed by exposure to intraoperative ionizing radiation. These risks are directly related to the degree and duration of exposure, with no threshold dose, and the probability of negative outcomes is proportional to the level of radiation dose.[ 12 , 24 , 31 , 38 , 57 ] Commonly recognized negative outcomes associated with exposure include increased risks of breast, testicular, and thyroid cancers, as well as cataracts, with the risk of these outcomes being directly proportional to the cumulative dose received.[ 19 , 24 , 31 , 39 , 57 ] In addition, exposure to ionizing radiation has long been known to pose significant threats to those who are pregnant or planning to become pregnant.[ 4 , 29 , 34 , 52 , 58 ] This fact, considered in the context of an increase in female trainees of child-bearing age in the neurosurgical field, leads to increasing relevance of ensuring consistent and thorough radiation safety practices throughout neurosurgical training and practice.[ 14 , 18 , 44 , 49 ]

In this study, we sought to characterize better the receipt of training regarding radiation safety and the utilization of suggested practices and PPE. We additionally sought to quantify and characterize the level of concern among neurosurgical trainees and physicians related to regular exposure to ionizing radiation. Although several factors are known to influence rates of cumulative exposure throughout a neurosurgical career, we sought to identify concerns and patterns relevant to most neurosurgical trainees and attending physicians despite differences in location of practice or experience level.

MATERIALS AND METHODS

Research ethics and data availability

In line with the policies set forth for use by Institutional Review Boards of the United States (US) starting January 20, 2019, the methods of this study meet the criteria to qualify for Exemption 45 CFR 46.104(d)(2).[ 43 ] As such, review or approval by our Local Institutional Review Board was not necessary for the conduction of this study. The data that support the findings of this study are available from the corresponding author upon reasonable request. The strengthening of the reporting of observational studies in epidemiology guidelines for use in cross-sectional studies was adhered to throughout study design, data collection, analysis, and reporting.

Data collection

Data were collected through the distribution of an anonymous survey using Google Forms. The survey was distributed through various mechanisms, including through email, to all contacts for 126 residency programs listed on the “2023 Neurosurgery Residency Program Information and Interview Dates” document (https://www.societyns.org/medical-students/interview-dates). Social media posts on the Instagram and LinkedIn accounts of one of the authors (totaling 377,000 followers at the time), the X (formerly Twitter) accounts of Neurosurgery Education and Research Virtual Experience Group (NERVE; @NERVE_research), and Brain and Spine Group (BSG, @BrainSpineGroup) with a combined total of 4,100. Additional Instagram and X posts were made on the accounts of Women in Neurosurgery (WINS; @WINSneurosurge1), which, at the time of survey distribution, had approximately 9,800 followers across both platforms. The survey was distributed on December 5, 2023, from the author’s social media accounts, on January 18, 2024, from the NERVE and BSG X accounts, and on February 8, 2024, from the WINS accounts. Response collection ended on February 26, 2024.

Data were collected on variables related to respondent demographics, practice and training characteristics, radiation safety practices and knowledge, and exposure concerns. Specific variables related to respondent demographics included current title, current practice or training location (country and state or territory, if applicable), age group, and number of years in and setting of practice or training. Nine multiple-choice questions were used to assess levels of respondents’ radiation safety knowledge [ Supplemental Appendix 1 ].

Data collected pertaining to respondents’ personal experiences and practice characteristics included questions regarding how many days per week respondents operate, the average number of operations performed per day, and the percentage of operations in which respondents use intraoperative X-ray radiography. Variables related to personal radiation safety practices included the following: how often and what kinds of specific radiation PPE are used, the source of the PPE, how often the provided PPE fit the respondents correctly if dosimeter badges were used during operations, location of dosimeter badge placement, respondents’ distance from the X-ray device during fluoroscopy use, and all safety guidelines routinely followed. For questions regarding safety guidelines routinely followed and forms of radiation PPE normally used, respondents were allowed to select as many answers as applied to their practice.

Questions involving respondents’ educational self-assessment included the following: feelings of adequate knowledge of radiation safety, provision of education about radiation exposure at any point throughout neurosurgical career, the primary format of radiation safety education, rating of satisfaction with radiation safety education received, and knowledge of the general dose of radiation received with standard anteroposterior imaging specific to their typically performed procedures. Finally, respondents’ concerns and health outcomes were assessed with questions regarding any worry about the risks of radiation to health, pregnancy, or fertility, history or diagnosis of any form of cancer, specifically breast, testicular, or thyroid cancers.

Statistical analysis

All data analyses were performed with Excel software (Microsoft Corporation, Redmond, Washington, USA). Data used for analyses were limited to those provided by respondents who identified themselves as neurosurgical residents, fellows, or attending physicians. For all questions, the number (n) and percentage of respondents who chose each response were calculated. Responses to the nine questions in the radiation safety knowledge assessment were evaluated for the percentage of respondents who answered the questions correctly. All percentages calculated in statistical analysis were adjusted for fluctuations in the number of respondents for each prompt.

RESULTS

A total of 48 survey responses were received; 25 respondents reported their job titles as neurosurgical trainees or attending physicians, and only these responses were included for further analysis. Geographically, responses were received from those practicing in 8 countries (the US, Morocco, Australia, Guam, Bahrain, Egypt, Germany, and China) and 18 states within the US. Most neurosurgical trainees and attendings who responded practiced in the US (n = 18 responses, 72%), with Georgia, Florida, and Illinois contributing the majority of participants.

Of the neurosurgical participants, 10 (40%) were between the ages of 30 and 39 years, 6 (24%) between 20 and 29 years, and 5 (20%) between 40 and 49 years. Most respondents reported practicing between 0 and 9 years and worked at academic-affiliated hospitals. Eleven (44%) respondents reported practicing 0–4 years, and 7 (28%) had practiced 5–9 years. Of the 25 neurosurgery respondents, 23 (92%) described their training setting as an academic-affiliated hospital [ Table 1 ].

Table 1:

Respondent-reported demographic information from 25 neurosurgical trainees or attending physicians.

The radiation safety knowledge assessment included nine questions, which gathered 14 responses from the 25 neurosurgical participants [ Table 2 ]. Considerable knowledge gaps were demonstrated, with fewer correct response rates garnered for questions regarding which part of the surgeon’s body has the greatest exposure to direct radiation (57.1% correct) and where the X-ray tube (42.9%) and surgeon (35.7%) should be positioned to reduce radiation exposure.

Table 2:

Knowledge assessment questions and responses (n=14).

In reported personal experiences and practice characteristics, 36% of respondents reported operating 5 days or more per week (n = 9), followed by 1 day at 20% (n = 5), 2 and 3 days at 16% each (n = 4), and 4 days at 12% (n = 3). Nearly half of respondents performed 1–2 operations per day (n = 13, 52%), followed by 3–4 daily operations performed (n = 10, 40%). Of respondents, 36% (n = 9) reported using intraoperative X-ray radiography in more than 50% of operations, with 28% (n = 7) using it in 25–50% of operations, and 20% (n = 5) using it in <25% of operations [ Table 3 ].

Table 3:

Reported personal experiences and practice characteristics of 25 neurosurgical trainees or attending physicians.

For personal radiation safety practices, most respondents reported using a lead apron (n = 22, 88%) or a thyroid shield (n = 18, 72%). A mobile radiation protection screen was only reported to be used by 36% (n = 9). In regards to the frequency of use of radiation PPE, 76% (n = 19) responded “always.” More than half of respondents, when provided with PPE, did not believe it fit correctly, with 20% reporting “never” and “sometimes” (n = 5 each). Dosimeter badges were reported as “not used” by 48% of respondents (n = 12). The response on wearing the dosimeter badge underneath lead aprons was selected by 24% of participants (n = 6). In response to safety guidelines routinely followed, 64% believed lead gowns and shields should be tested for cracks and defects annually (n = 16). Forty-four per cent also selected that fluoroscopy and all X-ray or ionizing radiation producing equipment should be calibrated annually, connections, cables, and support imaging equipment should be tested before each case, and each facility should have a radiation safety officer (n = 11) [ Table 4 ].

Table 4:

Reported personal radiation safety practices of 25 neurosurgical trainees or attending physicians.

Thirteen participants reported feeling that they had adequate radiation safety knowledge (52%), and 15 stated that they were provided education at some point while working in neurosurgery (60%). Although 44% selected “none” for the primary format of radiation exposure education received, 24% responded as having had in-person lectures or online training courses (n = 6 each). Eleven (44%) respondents reported feeling unsatisfied with the radiation safety education received, and only 2 (8%) reported feeling satisfied [ Table 5 ].

Table 5:

Respondent educational self-assessment of 25 neurosurgical trainees or attending physicians.

Health risks associated with radiation exposure concerned 60% (n = 15) of respondents, and risks of radiation exposure during pregnancy were a concern for 52% (n = 13). In addition, 68% affirmed that they worry about the impact of radiation on fertility. Of the 25 respondents, 16% (n = 4) reported having been diagnosed with cancer.

DISCUSSION

The concern for radiation safety among surgeons has gained traction over recent decades. Medical literature has primarily focused on determining radiation exposure risks to patients, staff, and surgeons during individual spine and endovascular procedures. Surgical subspecialties such as urology, vascular, and orthopedics have utilized survey data to assess radiation safety knowledge and practices.[ 7 , 9 , 23 , 28 , 42 , 48 ] Consistently, the findings demonstrate a lack of formal radiation safety education and a general concern for adverse outcomes associated with radiation exposure among providers and patients. In neurosurgery, efforts have been made to elucidate cumulative risks of radiation exposure to trainees throughout residency and offer suggestive strategies to mitigate this risk.[ 60 ] This study aims to characterize further the level of knowledge, practices, and perceptions regarding radiation safety among neurosurgical trainees and practitioners.

Gaps in education, knowledge, and understanding of radiation safety

Overall, knowledge of radiation safety principles among survey participants was moderate, with only a few key questions being answered correctly by a majority. For instance, 71.4% correctly identified that increasing the surgeon’s distance from the X-ray tube by 1 meter would reduce the radiation dose to a quarter, and 85.7% knew that keeping the image intensifier close to the patient reduces the patient’s radiation exposure. These findings are consistent with the existing literature, which stresses the importance of distance and positioning in reducing radiation dose exposure. However, only 42.9% knew that the X-ray tube should be positioned under the patient, and 35.7% understood that standing on the opposite side of the tube reduces exposure in lateral C-arm imaging. These low percentages indicate a lack of critical understanding of basic protective measures, echoing similar concerns raised in other surgical fields.[ 1 - 3 , 32 , 45 , 55 ] The low percentage of correct answers regarding the use of magnification (50%) and the effect of collimation (50%) underscores the need for more focused education on imaging techniques. These gaps in knowledge are notable, as improper use of magnification and collimation can increase exposure for both the surgeon and the patient.

Perhaps most notably, there was a relative lack of knowledge regarding the degree and location to which radiation exposure may have the most likely negative impact on practitioners, as only 57.1% of those who filled out the knowledge assessment were able to identify the hands as the area of the body at greatest risk to radiation exposure. In addition, only 65% of participants knew that the upper outer quadrant (UOQ) of the breast is the area of highest exposure to radiation, as well as the most common site for breast cancer, which is well documented.[ 54 ]

In support of the likely conclusion that educational deficits may be contributing to the overall problem, a significant portion of respondents (44%) reported that they had not received formal education regarding radiation safety, and the remaining rated the education they did receive as unsatisfactory (44%) or extremely unsatisfactory (24%). The primary modes of education – when offered – were in-person lectures (24%) and online courses (24%), but no respondents reported receiving written resources or detailed practical training. Notably, radiation safety training varies widely among institutions, states, and countries, even though hospitals are required to provide formal education, and substantial research suggests the educational benefits of a formal curriculum.[ 7 , 23 ] This is evidenced by the variation of responses given by the respondents of our study in the context of their reported practicing in several different regions of the US and the world. This lack of structured and comprehensive education likely contributes to the knowledge gaps observed in the study.

Radiation protection practices

The most important factor in the prevention of ionizing radiation is shielding. In our study, nearly all respondents used PPE most of the time, if not always, favoring either a lead apron or thyroid shield. Notably, fewer utilized other protective equipment such as lead glasses (20%) or gloves (8%) [ Table 3 ]. This discrepancy suggests that although basic protective gear has been widely adopted, more specialized protective measures are underutilized. It is well documented in the literature that the use of lead is necessary to protect susceptible areas of the body, particularly the thyroid, gonads, and breasts, for prevention of cancer and infertility from radiation exposure.[ 12 , 30 , 37 ]

Despite the unique vulnerability of the breast, a recent study demonstrated that even standard lead aprons do not adequately protect the UOQ from radiation – an issue that is undoubtedly worsened by the often ill-fitting hospital-provided lead aprons, as reported by nearly 50% of survey respondents.[ 54 ] Aside from this complicating factor with the aprons themselves, the use of aprons and thyroid shields does not equate to total protection, as the hands, eyes, head, arms, and legs are often still exposed.

Digging further into the issue, Zaidi et al.[ 60 ] found that, throughout residency, the projected radiation exposure of neurosurgery residents was 12.15 ± 13.50 millisevert (mSv), which equates to roughly six computed tomography scans of the head. This dose of radiation represents an estimate of areas not shielded by the typical lead devices. Although still a relatively safe exposure dose, it is a delivery of radiation that could otherwise be avoided. The International Commission on Radiological Protection suggests an exposure dose no greater than 20 mSV/year, averaged over 5 years, yet certain residents received above that dose in a single year.[ 26 , 40 , 60 ] This is likely worsened not only by the underutilization of recommended shielding equipment, as reported in this study’s survey, but also by the underuse and incorrect placement of measurement devices such as the dosimeter. Furthermore, the effects of these actions over years of training and practice are potentially cumulative and incredibly impactful.

In the case of our study population, less than half of respondents reported regular use of a dosimeter despite 80% reporting the use of intraoperative X-ray radiography in 25% or more of their operations [ Table 3 ]. Compounding the problem, our data demonstrate a lack of knowledge regarding the effective use of the device, with only 4% of participants reporting the correct position for dosimeter placement [ Table 3 ]. These data demonstrate that although radiation device monitoring has been shown to be effective at decreasing radiation exposure by providing real-time feedback to reinforce behavior modification, the devices do not appear to be used to their full effectiveness.[ 5 , 7 , 10 , 13 ]

The impact of unknown or ill-limited radiation exposure should not be taken lightly. Physicians exposed to 2–5 mSv/year have a 1 in 200 attributable risk of cancer diagnosis after 15 years.[ 7 , 17 ] Furthermore, it can be concluded that neurosurgical trainees are likely at an increased occupational risk of radiation relative to attending physicians, as supported by the findings in multiple studies that have demonstrated an inverse relationship between surgeon experience and fluoroscopy use. As such, trainees in the beginning stages of their training receive more radiation exposure.[ 36 ] This becomes more concerning upon consideration of the overlap in timing of career and family goals; residency is often the time in an aspiring neurosurgeon’s life in which they will likely be exposed to greater levels of radiation and also be in the process of family planning or building.[ 51 ] Consequently, the issue of radiation safety becomes of even greater importance.

Health and safety concerns

The importance of this study lies in the morbidity and mortality associated with radiation exposure. Deterministic effects of radiation occur in large doses, leading to cellular death and possibly resulting in hair loss, cataracts, or skin erythema. More subtle and relevant to trainees and physicians who are exposed to small doses is the cumulative cellular damage that can occur over a longer period from continued exposure, manifesting as malignancy or organ damage later in life.[ 23 , 37 , 41 ] Relevant to this concern, 16% of survey respondents did report having been diagnosed with some form of cancer in their lifetime [ Table 6 ]. For all physicians of reproductive age, but particularly female surgeons, the effects of radiation on fertility are of critical importance, especially considering that surgical training often occurs throughout the child-bearing years of resident and fellow physicians. Given this, it is unsurprising that associated health risks and impacts on fertility were of concern for 60% and 68% of overall respondents, respectively [ Table 6 ]. Fifty-two per cent of respondents noted specific concerns regarding the impact of radiation during pregnancy. Despite these concerns, our survey revealed that most respondents did not know the general radiation dose for anteroposterior imaging associated with their procedures. These two data points can be better understood in the framework proposed in previous work, suggesting that the lag time between dosimeter exposure to radiation and the accessibility of exposure data to surgical trainees and physicians limits understanding of and adherence to radiation safety best practices, despite true and continued concern among trainees and practicing surgeons.[ 21 , 59 ]

Table 6:

Reported concerns and health outcomes of 25 neurosurgical trainees or attending physicians.

Impact of Department and Program Education and Culture

This study provides unique insight into the current inadequacies of radiation safety training and practices for neurosurgical trainees and attendings despite high levels of concern among respondents of various levels of training and practice. Highlighting these inadequacies, our respondent data demonstrate that although 60% of respondents indicated that they had received some form of radiation safety education while working in neurosurgery, 68% of respondents remained unsatisfied with the training received.

Perhaps more impactful than satisfaction with educational efforts on the topic, only half of the participants believed that they had adequate radiation safety practices implemented in their workplace. These responses suggest not only inadequate efforts at trainee and physician education regarding radiation safety but also an underutilization of workplace culture and resources to promote and support safe practices in an effort to bridge any gaps remaining after providing education on the topic. It is apparent that increased emphasis and prioritization of well-fitted and utilized radiation safety equipment are necessary to address the overall issue effectively.

Study strengths and limitations

Strengths of the study include its comprehensive assessment of radiation safety knowledge, practices, and concerns among neurosurgical professionals. By distributing the survey through various channels, including social media platforms and residency program contacts, the study provides valuable insights into the landscape of radiation safety education within neurosurgery. However, it is essential to acknowledge the limitations inherent in survey-based research, such as potential respondent biases and the inability to capture longitudinal trends. Furthermore, the small sample size of the study introduces further potential bias and limitations in terms of considering the generalization of results to the wider neurosurgical field. It highlights the limitation of the survey’s distribution through social media and email. Despite the large number of potential respondents to whom the survey was distributed (i.e., 377,000 followers and 106 residency program email addresses), it is difficult to quantify the size of the audience that would have received the survey invitation. This audience was likely further narrowed by the diffusion of responsibility in the context of public calls for survey responses or action.[ 6 , 15 ] These factors may compound to impose a heavy limitation on the quality of survey responses. Despite these limitations, this study serves as a starting point for further research and initiatives aimed at enhancing radiation safety practices and mitigating risks for neurosurgical practitioners worldwide.

CONCLUSION

This study sheds light on the pressing issue of radiation safety education within the field of neurosurgery. The findings reveal concerns and knowledge gaps among neurosurgical trainees and physicians regarding radiation safety practices. Notably, a substantial portion of respondents expressed worries about health risks associated with radiation exposure, particularly regarding fertility and pregnancy. Furthermore, most participants found current radiation safety education in neurosurgery to be unsatisfactory. These results underscore the urgent need for targeted interventions aimed at improving radiation safety education and addressing apprehensions among neurosurgical practitioners. Radiation safety in neurosurgical education and practice is a multifaceted issue that requires multifactorial solutions; however, when the potential impact involves physician fertility and long-term health, it is of the utmost importance. Future studies are necessary to evaluate the impact of formalized radiation safety training as well as shifts in departmental and program culture on radiation safety practices and levels of exposure to trainees and physicians.

Ethical approval:

Institutional Review Board approval was not required as there are no patients in this study. The research/study complied with the Helsinki Declaration of 1964.The study is conducted in line with the policies set forth for use by Institutional Review Boards of the United States (US) starting January 20, 2019, the methods of this study meet the criteria to qualify for Exemption 45 CFR 46.104(d)(2).

Declaration of patient consent:

Patient’s consent was not required as there are no patients in this study.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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