Improving adequacy of orthopaedics lumbosacral Spine X-rays and minimizing re-exposure rates: A study in a tertiary hospital
1. Suman Basel, KIST Medical College and Teaching Hospital, Lecturer, Nepal
2. Pramod Bhandari, KIST Medical College and Teaching Hospital, Student, Nepal
3. Gaurav Bajracharya, KIST Medical College and Teaching Hospital, Student, Nepal
4. Shriraj Shrestha, KIST Medical College and Teaching Hospital, Professor, Nepal
Background
Lumbosacral spine (LS) X-rays are essential diagnostic tools in orthopaedic and spinal practice, aiding in the evaluation of conditions such as trauma, degenerative diseases, infections, and deformities. However, inadequate imaging can lead to diagnostic uncertainty, repeat radiographs, increased radiation exposure, delayed clinical decision-making, and unnecessary healthcare costs. This audit aimed to assess the adequacy of LS spine X-rays ordered by the Orthopaedics Department in a tertiary hospital, identify factors contributing to poor-quality imaging, and implement interventions to reduce re-exposure rates.
Aim
This study aimed to improve adequacy rates of Orthopaedic lumbosacral spine X-rays and decrease re-exposure rates.
Methods
This was a three-phase observational audit conducted over 1 year at a tertiary hospital, evaluating all lumbosacral spine X-rays ordered by the Orthopaedics Department. Each phase lasted three months, followed by stakeholder meetings to review findings and implement interventions. Image adequacy was assessed using predefined radiographic criteria based on international guidelines. Interventions included radiographer training, standardized imaging protocols, and a quality control checklist. The primary outcome was the proportion of adequate X-rays, while the secondary outcome was the re-exposure rate. Data were analysed using descriptive statistics (percentage change) to assess improvements across phases.
Results
The adequacy of image improved significantly from 82.5% at the first phase to 95.1% in the final phase, and re-exposure rates dropped from 3.125% to 0%.
Keywords: Lumbosacral spine, Radiograph adequacy, Clinical audit, Re-exposure, Quality improvement
Lumbosacral spine Radiograph adequacy Quality improvement Clinical audit Re-exposure
This audit validates that methodical interventions in radiographic technique and quality assurance can enhance image adequacy while minimizing patient radiation risk. The progression from 82.5% to 95.1% adequacy and elimination of re-exposures illustrates a successful quality improvement model. Insights from contemporary literature—including dose audits, collimation studies, and EU regulatory standards—support continued refinement of radiographic practices in alignment with international safety protocols.
In summary, this audit illustrates that systematic, collaborative efforts can meaningfully improve the quality of LS-spine radiographs. By focusing on simple interventions, continuous feedback, and adherence to established standards, we were able to enhance both image adequacy and patient safety within a relatively short timeframe. We recommend ongoing periodic audits and refresher training sessions to maintain these improvements.
1. 1. A. ESPELAND, G. ALBREKTSEN and J. L. LARSEN: PLAIN RADIOGRAPHY OF THE LUMBOSACRAL SPINE An audit of referrals from general practitioners. Acta Radiologica. 1999, 40:52-9. 10.1080/02841859909174403 2. J G Scavone, R F Latshaw, W A Weidner: Anteroposterior and Lateral Radiographs: An Adequate Lumbar Spine Examination . AJR Am J Roentgenol. . 1981, Apr;136(4):715-7: 10.2214/ajr.136.4.715 3. Jarvik JG, Deyo RA: Diagnostic evaluation of low back pain with emphasis on imaging . Ann Intern Med. 2002, Oct 1;137(7):586-97. 10.7326/0003-4819-137-7-200210010-00010 4. Patel ND, Broderick DF, Burns J et. al.: ACR Appropriateness Criteria Low Back Pain . Journal of the American College of Radiology. 2016, Sep;13(9):1069-78. 10.1016/j.jacr.2016.06.008 5. Doktor K, Vilholm ML, Hardardóttir A, Christensen HW, Lauritsen J: European guidelines on quality criteria for diagnostic radiographic images of the lumbar spine - An intra- and inter-observer reproducibility study. Chiropr Man Therap. 2019, May 1;27:20:10.1186/s12998-019-0241-3 6. Pazanin A, Skrk D, O'Driscoll JC, McEntee MF, Mekis N: Optimal collimation significantly improves lumbar spine radiography. Radiat Prot Dosimetry. 2020, 189:420-7. 10.1093/rpd/ncaa057. 7. Zetterberg LG, Espeland A: Lumbar spine radiography--poor collimation practices after implementation of digital technology. Br J Radiol. 2011, 84:566-9. 10.1259/bjr/74571469 8. Ching W, Robinson J, McEntee M: Patient-based radiographic exposure factor selection: a systematic review . J Med Radiat Sci. 2014, 61:176-90. 10.1002/jmrs.66 9. L González, E Vañó, S Oliete: Report of an image quality and dose audit according to directive 97/43/Euratom at Spanish private radiodiagnostics facilities. British Journal of Radiology. 1999, 72 (854):186-192. 10.1259/bjr.72.854.10365071 10. Teunen D: The European Directive on health protection of individuals against the dangers of ionising radiation in relation to medical exposures (97/43/EURATOM). J Radiol Prot. 1998, 18:133-7. 10.1088/0952- 4746/18/2/009 11. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103.AnnICRP.2007,37:1-332. 10.1016/j.icrp.2007.10.003 . 12. Nol J, Isouard G, Mirecki J: Uncovering the causes of unnecessary repeated medical imaging examinations, or part of, in two hospital departments. Journal of Medical Radiation Sciences. 2005, Dec 1;52(3):26-31. 10.1002/j.2051-3909.2005.tb00038.x 13. Wettasinghe MC, Rosairo S, Wickramasinghe ND: Data quality of request forms for lumbar spine X-rays: A clinical audit form a tertiary care hospital in Sri Lanka. Sri Lanka Journal of Radiology. 2023, 31:27-31. 10.4038/sljr.v9i1.118 14. Simpson AK, Whang PG, Jonisch A, Haims A, Grauer JN: The radiation exposure associated with cervical and lumbar spine radiographs. J Spinal Disord Tech. 2008, Aug;21(6):409-12. 10.1097/BSD.0b013e3181568656 15. Alshamrani KM, Alkenawi AA, Alghamdi BN et.al: Patient-Based Dose Audit for Common Radiographic Examinations With Digital Radiology Systems: A Retrospective Cross-Sectional Study. Cureus. 2021, May 13; 13(5):10.7759/cureus.15005 16. Luechabhun C, Prasertdumrongchai S, Pukleeb B, Suwanpradit P, Apipunyasopon L: Optimization of exposure techniques for lumbosacral spine radiographic examination: a phantom studyThe Thai Journal of Radiological Technology. The Thai Journal of Radiological Technology. 2024, 49(1):103-109.
Suman K. Basel: Conceptualization and design, Acquisition and analysis of data, Manuscript drafting and review Pramod Bhandari: Acquisition and analysis of data, Manuscript drafting and review Gaurav Bir Bajracharya: Acquisition and analysis of data, Manuscript drafting and review Shriraj Shrestha: Conceptualization and design, Supervision
No funding was received for this audit.
SPSS v16.
None declared.
We would like to express our sincere gratitude to the Department of Radiology for their valuable cooperation and support throughout this audit. Their commitment to quality improvement and active participation in training, protocol development, and feedback discussions were instrumental in achieving the outcomes of this study.
Data available on reasonable request from the corresponding author.