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Recommendations for Medical Imaging Procedures Recommendations for medical imaging procedures Recommendation by the German Commission on Radiological Protection Adopted at the 300th SSK meeting on 27 June 2019 For many decades, diagnostic imaging has been an indispensable tool of ensure referral guidelines modern medicine to clarify diagnostic questions, thus allowing for the for medical imaging, taking planning of appropriate individual treatments. Some examination methods into account the radiation such as X-ray or nuclear medical diagnostics involve ionising radiation or doses, are available to the radioactive substances. In view of the radiological exposure involved in referrers. such procedures, physicians must consider carefully whether a different The Federal Environment diagnostic method with less or no radiation exposure, such as ultrasound Ministry, being responsible for radiological protection, has for many years or magnetic resonance procedures, might not be at least equally well advocated keeping the number of applications involving radiation suited for a specific patient. Therefore the Recommendations for medical exposure as low as possible. There is constant enhancement of imaging procedures address first of all physicians referring patients for diagnostic procedures and therefore these recommendations are further diagnostics. The goal is to avoid unnecessary radiation exposure reviewed and updated on a regular basis. while achieving the same level of diagnostic accuracy. I would like to thank the German Commission on Radiological Protection, the The recommendations list the most suitable imaging procedures for various medical associations involved and in particular the working group under various diagnostic questions. However, physicians must still provide in the chair of Professor Reinhard Loose for their work. each individual case the justifying indication for the selected examination method and document it. In view of the fast development of new examination methods, the German For the Federal Ministry for the Environment, Commission on Radiological Protection (SSK) has been regularly Nature Conservation and Nuclear Safety updating these recommendations since 2006. By doing so, it also meets the requirement to lay down basic safety standards for protection against Dr Wolfgang Cloosters the dangers arising from exposure to ionising radiation set out in Council Director-General Directive 2013/59/Euratom, which stipulates that member states shall Nuclear Safety, Radiation Protection Contents Preface to the 3rd edition (2019) 2 Introduction 4 TABLES Clinical/diagnostic problems and recommendations 26 A. Head (including ENT problems) 26 B. Neck 36 C. Spine 40 D. Musculoskeletal system 44 E. Cardiovascular system 52 F. Chest 60 G. Digestive system 66 H. Urological system, adrenal glands and urogenital tract 78 I. Gynaecology and obstetrics 85 J. Breast disease 90 K. Trauma 99 L. Oncology 116 M. Paediatrics 146 N. Interventional radiology 168 Abbreviations 177 References 180 2 Preface to the 3rd edition (2019) medical diagnostics and therapeutic procedures are evolving all the time, this catalogue requires regular updates to keep pace with the Technical progress in a constantly increasing spectrum of radiological state of the art in science. This third edition of the ‘recommendations and nuclear medicine investigations and therapeutic procedures has for medical imaging procedures’ offers physicians the latest medical led to a decrease in dose when performing various examinations, while developments to help them select suitable procedures for patients. The mean exposure to radiation for medical purposes continues to rise catalogue serves to avoid unnecessary exposures to radiation, while steadily among the German population due to such investigations optimising medical diagnostic processes. It does not, however, relieve being performed more frequently (BMUB 2017). physicians of their duty to provide and document the justification for Council Directive 97/43/Euratom requires Member States to provide the selected investigation and specific patient. ‘recommendations concerning medical exposure’. Section 58(c) of In the seven years since the 2nd edition was released, physicians, Council Directive 2013/59/Euratom added to this by mandating that scientific societies and working communities have supplied a number ‘referral guidelines for medical imaging, taking into account the of constructive suggestions for amendments and improvements. The radiation doses, are available to the referrers’ (Euratom 2014). SSK expert group evaluated these suggestions, the majority of which In 2006, the Federal Ministry for the Environment, Nature Conservation were added to this current version with minor modifications at most. In and Nuclear Safety (BMU) commissioned the German Commission on addition, the use of imaging procedures was revised for a number of Radiological Protection (SSK) to prepare the first catalogue providing medical questions and updated to reflect the state of the art in science. recommendations for the procedures suited to the wide variety of Changes were also made to the weighting of individual procedures, diagnostic and interventional questions. These recommendations with greater importance now attached to ultrasound and Magnetic garnered a great deal of interest within the medical community. As Resonance Imaging (MRI) when investigating certain problems. The range of indications for the use of positron emission tomography (PET) Prof. Dr. Dr. Prof. Dr. Prof. Dr. and PET-CT has also been extended. For the comprehensive breast Reinhard Loose Stefan Delorme Joachim Breckow cancer (mammography) screening programme in Germany, in addition Head of Chair of the Chair of the to the recommendations to screen asymptomatic women aged 50 to the working ‘Radiation German Commission on 69, the new S3 Guidelines breast cancer (AWMF 2018), and group protection in Radiological Protection recommendations on the use of breast tomosynthesis were added. medicine’ The SSK would like to thank the working group experts for their committee contributions, and for evaluating and collating the comments received. We would also like to thank the German Radiological Society (DRG) Members of the SSK working group and its working committees, the German Society of Nuclear Medicine Prof. Dr. W. Burchert Nuclear medicine (DGN), the German Society of Paediatric Radiology (GPR), the Prof. Dr. S. Delorme Radiology German Society of Neuroradiology (DGNR), the German Society of Prof. Dr. Dr. R. Loose Radiology Interventional Radiology (DGIR), and the working committee of the Prof. Dr. M. Müller-Schimpfle Radiology Association of the Scientific Medical Societies (AWMF) for many Prof. Dr. G. Staatz Paediatric radiology constructive comments. We are also grateful to the authors of Dr. M. Wucherer Medical physics corresponding publications in Austria and Great Britain whose valuable contributions have been included in these recommendations. Foreword 3 4 Introduction justification must also be provided if the request comes from a referring physician as it is always the performing physician who is Preliminary remarks ultimately responsible for the patient. These ‘recommendations’ are designed to serve as an aid to Such recommendations best serve their purpose if used in the referring physicians in hospitals as well as registered physicians dialogue between the referring physician and the radiologist/nuclear when selecting the appropriate radiological and nuclear medicine medicine specialist (performing physician). These recommend- investigations and therapeutic procedures for a given problem. dations evaluate the role of X-rays (XR), computed tomography They are designed to offer patients better care while reducing their (CT), nuclear medicine procedures (Nuc), as well as positron exposure to radiation to a level deemed medically reasonable. They emission tomography (PET and PET-CT), ultrasound (US), should also serve as a useful aid for teaching students and as part magnetic resonance imaging (MRI) and interventions for typical of a physician’s ongoing training. questions. The anatomy-based approach used in comparable referral criteria of other EU Member States has been retained. These criteria do not replace a physician’s duty to apply the necessary radiological protection expertise to provide the justify- This third edition of recommendations does not cover every cation as prescribed in Section 83(3) of the German Radiation conceivable clinical question; instead, questions were chosen Protection Act (StrlSchG 2017). The justification requires validation based on importance and incidence, although overall coverage of that the health benefit outweighs the radiation risk when performing clinical questions has grown compared to previous editions. Without such investigations and treatments. Other procedures of compa- doubt, some of the recommendations will prove controversial, but rable medical benefit involving no or only slight exposure to this is inevitable in all specialist fields of medicine undergoing such radiation must also be included in the decision-making process. The rapid development, and is actually a key factor contributing to their suspected diagnosis. A significant number of radiological swift advancement. investigations do not fulfil these criteria and may add unnecessary A general description is never a replacement for a decision tailored exposure to the patient.Anyone who deals with these important to a specific patient whose particular case may justify a deviation questions in advance
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