| I O N I S I N G R A D I AT I O N |

X-rays:
benefit and risk
Impress

Federal Office for Radiation Protection

Postfach 10 01 49
D - 38201 Salzgitter
Telephone: + 49 (0) 30 18333 - 0
Fax: + 49 (0) 30 18333 - 1885
Website: www.bfs.de
Email: [email protected]

Usage rights: BfS, dpa picture alliance (cover photo)

State of November 2012

Printed on 100 per cent recycled paper.

Contents

What is X-radiation?..................................................................... 4

How X-radiation acts on health.................................................. 5

Benefits and risks of medical X-rays .........................................6

Medical X-rays during pregnancy.............................................. 9

Radiation dose from X-ray examinations................................ 10

Tips: How to keep your radiation exposure low.................... 13

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What is X-radiation?

X-rays belong to the so-called ionising radiation. When X-rays

pass through human tissue, the energy imparted can be so high
as to entrain genetic damage to the cells involved, subsequently
resulting in radiation damage.

Schematic diagram of an X-ray assembly used for diagnosis.

Different materials act to attenuate X-radiation to a varying

extent. A thin lead foil is already sufficient for almost complete
shielding of X-radiation occurring in medical diagnostics. Non-
metallic substances, such as organs or bone, provide less attenu-
ation of the radiation. This effect is utilised in X-ray examina-
tions: the radiation penetrating the body is rendered visible by a
film-screen system or a digital detector. Dense structures, such as
bone, come out pale and less dense tissues, such as fatty tissue,
dark.

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As soon as the X-ray machine is switched off, X-radiation will not
be produced any more. This is the difference between X-radiation
and nuclear radiation which emanates from radioactive substan-
ces and is emitted until all atoms have decayed.

How X-radiation acts on health

There is as yet no confirmed evidence as to the health effects

of radiation at doses such as those occurring in radiographic
procedures. It is, however, well known that ionising radiation in
the higher dose range can cause malignancies such as cancer or
damage to the unborn child in the womb. Indeed, these findings
have to be transferred to the lower dose range relying on appro-
priate presumptions and modelling.

An X-ray image gives information on the patient’s health.

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Estimates of radiation risk assume a steadily increasing relation-
ship between dose and cancer risk; that is, the higher the dose,
the higher the risk. This is a precautionary assumption in radia-
tion protection, implying that every medical examination using
radiation involves an additional, albeit low risk.

As a general rule, the probability of cancer development is not

equal for all people. There are individual differences such as
strong or weakened body’s defence against cancer cells or aging.
The tissue of elderly people is less susceptible to radiation effects
than that of younger people. Furthermore, cancer development
is associated with a latency period. This is one of the reasons
why elderly and seriously diseased people are less affected by the
radiation risks from diagnostic radiology. Their life expectancy is
often shorter than the time it takes to develop radiation-induced
cancer, i.e. several years or decades.

Benefits and risks of medical X-rays

In Germany, medical X-rays make the most important contribu-

tion to man-made radiation exposure. It is generally believed
that there is still a tendency towards taking too much X-rays in
Germany. Although X-ray examinations can be of great utility,
they also hold risks. The question of whether or not to take an X-
ray therefore requires thorough
consideration.

Medical X-rays are vital for

patients affected by conditions
such as bone fracture requiring
safe diagnosis and correct re-
alignment under visual control.
Misalignment could result in
malposition, entailing pain and
arthrosis later on.

Head injuries following an

accident may be clarified by
Broken bone after re-alignment. computed tomography (CT),

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Medical X-rays facilitate monitoring of the healing process.

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i.e. a special kind of medical X-rays. This procedure permits to
confirm or refute suspected bleeding within the skull, thus either
enabling timely surgery or avoiding unnecessary operation.
Breast cancer early detection, or the detection of narrowings of
the blood vessels are additional examples for the use of medical
X-rays.

The X-ray Ordinance (Röntgenverordnung, RöV) stipulates that

each and every X-ray examination shall be medically justified, i.e.
that the benefit and risk associated with that radiation applica-
tion shall be balanced thoroughly. This balancing is influenced
by the patient’s individual conditions. An X-ray examination is
only justified when the patient’s benefit from it outweighs the
radiation risk involved. This is the case when the examination
procedure is appropriate to answer the diagnostic question and
no alternative procedure is available.

CT examinations have increased during the last few years.

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Doctor using X-ray pictures to explain diagnostic findings.

X-ray examinations shall not be conducted

• as a routine procedure;
• until all other findings compiled before then have been
critically evaluated and the X-ray examination has been
ascertained to be the only procedure providing the lacking
information;
• exclusively as documentary evidence for reasons of liability
or pursuant to insurance law.

Medical X-rays during pregnancy

In the case of pregnancy, it is crucial to critically consider the

need for a radiological procedure. If possible the X-ray should be
refrained from and possibly replaced by alternative examination
procedures such as sonography, or postponed until after preg-
nancy where appropriate.

When balancing benefits and risks, the potential benefit for the
mother must be compared with the potential risk for the child.
In the case of special risks to the mother’s health and life, X-rays
are justified in order to rapidly establish safe diagnosis and begin
treatment.

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Ultrasound picture of an unborn baby’s head in week 20 of pregnancy.

In some cases women are not aware of being pregnant at the

time of radiation exposure. Such cases require retrospective
consulting. In order to give well-founded, case-related decision
support to both the woman concerned and the attending physici-
an, the medical staff is offered the opportunity to raise a written
request to the Federal Office for Radiation Protection (Bundesamt
für Strahlenschutz, BfS) on the individual risk of the unborn child.

Further information is provided in the brochure Strahlenthema

„Schwangerschaft und Strahlenschutz“ (http://www.bfs.de/de/bfs/
publikationen/broschueren/strahlenschutz).

Radiation dose from X-ray examinations

Diagnostic X-rays are subdivided into conventional radiography,

X-ray fluoroscopy and CT.

Conventional radiography, which is most frequently applied,

involves relatively low radiation doses. Some examinations
such as those of motional processes (swallowing, heart action

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Ranges of typical values of effective dose for frequent X-ray
examinations in millisievert (mSv)

Dental < 0,01

Extremities (limbs) < 0,01 – 0,1

Chest (thorax), 1 image 0,02 – 0,04

Skull 0,03 – 0,06

Cervical spine in 2 planes 0,1 – 0,2

Mammography, both breasts in 2 planes 0,2 – 0,4

Thoracic spine in 2 planes 0,2 – 0,5

Abdominal view 0,3 – 0,7

Pelvic view 0,3 – 0,7

Peripheral arteries phlebography (one leg) 0,3 – 0,7

Lumbar spine in 2 planes 0,6 – 1,1

CT braincase 1–3

Gall bladder, urinary tract 1–8

Urinary tract 2–5

CT chest (thorax) 4–7

Stomach 4–8

CT lumbar spine 4–9

Intestine (small intestine or contrast enema) 5 – 12

CT abdomen 8 – 20

Arteriography and interventions 10 – 30

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etc.) require additional X-ray fluoroscopy, where the radiation
dose to the patient is usually higher compared to conventio-
nal X-rays. CT is a tomography procedure of high diagnostic
significance which is, however, associated with a relatively high
radiation dose.

In order to evaluate and compare different radiation exposures

and the burden possibly involved, the concept of “effective dose”
has been introduced. Effective dose accounts for the different
susceptibility of organs and tissues in terms of radiation-induced
cancer development or genetic defect. The unit of effective dose
is the Sievert (Sv), low dose values are expressed in terms of milli-
sievert (mSv).

The lead apron protects from X-radiation.

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Due to the progress made in X-ray technology, doses from many
X-ray examinations have been reduced over the course of the last
three decades. Particularly the development of more sensitive
film-screen systems, advanced generator and image intensifier
technology and digital systems have added to the reduction of
radiation exposure. In spite of these technical advances, the
mean radiation exposure of the general public is increasing,
because X-ray examinations involving high doses, such as CT, are
carried out more and more frequently.

The dose levels for one and the same examination procedure
vary widely from case to case. This is due to individual diffe-
rences between patients in terms of constitution, weight, etc,
but also to technical, medical and diagnostic factors. A crucial
factor is the experience of the medical staff (physicians and
radiology assistants) as well as the quality of their advanced
training.

Ranges of typical values of effective dose from frequent X-ray

examinations are given in the table below in milisievert (mSv).
The average value of radiation exposure of the general public
from natural radiation sources may serve for comparison. This
latter, i.e. the mean effective dose, is about 2.1 mSv per year in
Germany.

Tips: How to keep your radiation exposure low

• Ask the medical staff to tell you why the planned X-ray exa-
mination is necessary.

• Your doctor is obliged to consider procedures involving less

or no radiation exposure for your examination (e.g. magne-
tic resonance tomography or sonography). Ask specifically
for alternative diagnostic procedures.

• Tell your doctor whether you have undergone similar exami-

nations recently.

• Bring along X-rays produced up to now or have them reques-

ted.

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• Prior to an X-ray examination, women should tell whether
they are, or suspect to be pregnant, because X-rays during
pregnancy should only be taken if there is good medical
reason.

• Make sure that shielding of the parts of the body not under
examination is considered (lead apron)

• Make use of the Röntgenpass (X-ray record card).

• Submit your Röntgenpass and have examinations entered.

Please find further information in the brochure “Medical

X-rays – harmful or useful?” (http://www.bfs.de/de/bfs/publikatio-
nen/broschueren) and on the BfS website under
www.bfs.de/roentgen.

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