ABSTRACT
Introduction
The undeniable benefits of irradiating examinations such as computed tomography (CT) scans should not overshadow their potential harmful effects, particularly late risks. Hence, it is important to justify CT scans requested for patients. The aim of this study is to analyse the justification for CT scans in all health facilities with a functional medical scanner in Togo.
Methods
This was a prospective descriptive study of spinal CT scans performed between 1st June and 31st August 2021 and interpreted by a radiologist in seven functional CT units in Togo. The analysis of the justification was based in particular on the formulation of the clinical indication, the consistency of the clinical indication with the requested CT scan, and the compliance of the clinical indication with the Best Practice Guidelines of the Société Française de Radiologie (SFR) and the Société Française de Médecine Nucléaire (SFMN).
Results
The 355 spinal CT scans included were exclusively cervical, dorsal and lumbar in 15.5%, 3.1% and 68.2% of the patients, respectively. The mean age of the patients was 48.2 years, with a sex ratio of 1.1:1.0. Approximately 69% of patients had a spinal CT scan within 3 days or less. Specialist (70.2%) and general practitioner (22.3%) were the most frequent requesters; 92.1% of the patients requested a non‐radiating or less radiating imaging test before the CT scan. Non‐physician staff (paramedics) accounted for 2.5% of requesters. The formulation of the clinical indication was good in 89.9%, acceptable in 7.6% and wrong in 2.5% of the patients. These indications were consistent with the examination requested in 98.9% of the cases and complied with the SFR's best practice guidelines in 72.1% of the cases. Spinal CT scans were pathological in 91% of the patients. The more clearly the clinical indications were formulated, the more significantly the results were pathological. Overall, in 34.1% of the cases, the CT scans performed were deemed not to be justified.
Conclusion
A significant number of spinal CT scans performed in Togo were not justified. Efforts must be made by both requesters and providers of medical imaging examinations to ensure judicious medical use of irradiating examinations in Togo.
Keywords: justification, medical irradiation, radiation protection, spinal CT, Togo
The undeniable benefits of irradiating examinations such as CT scans should not overshadow their potential harmful effects, particularly late risks. Hence it is important to justify CT scans requested for patients. This study revealed that a significant number of spinal CT scans performed in developing countries such as Togo were not a priori justified, and constitute unnecessary medical irradiation and avoidable health expenses for patients.
1. Introduction
The usefulness of computed tomography (CT) in the medical and surgical management of patients, particularly those with spinal pathologies, is undeniable, but this usefulness should not obscure the fact that it is highly irradiative compared with conventional radiology [1, 2]. In fact, it is the most irradiating diagnostic imaging technique, delivering a dose approximately one hundred times greater than that delivered by conventional radiography [3]. Therefore, despite the valuable diagnostic benefits of CT, the risk of radiation‐induced cancer due to the X‐rays emitted by this technique remains the main concern for patients [4]. Faced with this risk of radiation‐induced cancer, it seems essential to implement measures to protect healthcare staff and patients from this ionising radiation, hence radiation protection. Radiation protection is defined as the set of rules, procedures, and means of prevention and monitoring designed to prevent or reduce the harmful effects of ionising radiation produced on people directly or indirectly, including damage to the environment [5].
Radiation protection is based on three principles (justification, optimisation and limitation), the first of which is the justification of activities involving a risk of exposure to ionising radiation. Justification is an analysis carried out prior to exposure to ionising radiation to ensure that such exposure offers sufficient direct benefit in relation to the risk it may present. Any exposure to ionising radiation must be justified; that is, the net benefit to the patient must outweigh the potential risk associated with the exposure, and any unjustified examination is prohibited [6]. This is particularly true for CT scans, which alone account for approximately 50% of ionising radiation (IR) exposure doses in medical practice [7]. Spinal CT scans are frequently requested in adult patients, who are often confronted with spinal pain, particularly in the lumbar region [8, 9], but few studies have focused on their justification, particularly in African countries. In this context, we undertook this study, the general aim of which was to evaluate the justification for spinal CT scans performed in Togo.
2. Materials and Methods
This was a prospective descriptive study analysing the justification for spinal CT examinations performed in seven functional CT units in Togo, namely, the Centre Hospitalier et Universitaire Campus (CHU‐Campus), the Clinique Autel d'Elie (CAE), the Polyclinique Internationale Saint Joseph, the Polyclinique WOSSINU & GBOGBO, the Clinique BIASA and the Hôpital Saint Jean de Dieu d'Afagnan. This study was conducted over a period of 3 months, from 01 June to 31 August 2021.
In this study, we included all spinal CT examination reports from patients of either sex or age interpreted by a radiologist during the abovementioned period. All spinal CT examinations that did not obtain patient consent to participate in the study, those performed and not interpreted by a radiologist, those whose reports did not include the identity of the requester, or those performed outside the study period were not included in this study. The sampling method was exhaustive and not purposeful. Prior approval was obtained from the heads of the health facilities concerned and from the radiation protection commission of the Togolese Ministry of Health.
Data were collected from CT scan request forms, patient interviews during CT scan performance, and CT scan reports. The data collection form was developed based on the recommendations of the Best Practice Guidelines of medical imaging examinations of the Société Française de Radiologie (SFR) and the Société française de Médecine Nucléaire (SFMN). This form was validated by a committee of three senior Togolese radiologists to ensure content validity. The justification was analysed on the basis of the requester's qualifications, the clinical and biological context of the request for spinal CT scans (conscious or unconscious patient, inpatient or outpatient, prior biological or other imaging tests, medical treatment in progress or not), the formulation of the clinical indication, the consistency of the clinical indication with the CT scan requested, and the compliance of the clinical indication with the Best Practice Guidelines of medical imaging examinations of the SFR and the SFMN.
The formulation of the indication was judged to be good, acceptable, or wrong. The clinical indication was judged to be good if it was formulated using an appropriate and well‐detailed medical lexicon. Example: acute febrile low back pain. The indication was judged acceptable if it was made in an appropriate medical lexicon but in an imprecise or vague manner. Example: low back pain. The indication was judged wrong if it used nonmedical vocabulary or lexicon. Example: kidney problems. The various assessments of the formulation of clinical indications were validated by a senior radiologist specialising in patient radiation protection.
The indication was deemed inconsistent with the CT scan requested if the topography of the lesion did not correspond to the anatomical region explored by the CT scan. For example, lumbar spinal CT image requested for headaches.
The indication was judged not to comply with the Best Practice Guidelines of the SFR and the SFMN if it did not comply with the latter's recommendations. The context of accessibility to medical imaging techniques in our French‐speaking sub‐Saharan African countries, marked by a scarcity of MRI services, was nevertheless taken into account in this justification analysis.
The CT examinations judged to be ‘a priori unjustified’ were CT examinations requested by a non‐physician practitioner (a paramedic), without indication, with an indication that did not comply with the SFR's best practice guidelines, or with an indication that was not consistent with the examination requested. This concept of ‘a priori unjustified’ examination has already been used to analyse the justification for chest and/or abdominopelvic and paediatric CT scans in previous studies [10, 11].
An inter‐rater consistency test was carried out on a sub‐sample of 20 patient files, independently assessed by two radiologists. The concordance rate of the justifications (κ = 0.81) shows excellent inter‐rater reliability. In addition, a random re‐reading of 10% of the files by a third radiologist confirmed the stability of the analysis criteria.
The data were analysed and processed via ‘Sphinx’ statistical software and Microsoft Word 2010. Graphs were produced via Microsoft Excel 2010. The results were tested via the ꭓ 2 test, and a significant result was obtained if p < 0.05.
3. Results
3.1. General Characteristics of Patients and CT Scans
A total of 355 spinal CT scans were included; in patients who were predominantly male, with a sex ratio of 1.1:1.0, adults were the most represented (Table 1). The extremes of age were 0 and 84 years. The mean age was 48.2 years. There were 282 patients (79.4%) who had no medical insurance.
TABLE 1.
Distribution of patients by age and sex.
| Female | Male | Total | ||||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Children (aged 6–18 years) | 7 | 2.0 | 9 | 2.5 | 16 | 4.5 |
| Adults (aged 18–65 years) | 133 | 37.5 | 148 | 41.6 | 281 | 79.1 |
| Seniors (> 65 years) | 29 | 8.2 | 29 | 8.2 | 58 | 16.4 |
| Total | 169 | 47.7 | 186 | 52.3 | 355 | 100 |
Lumbar spinal CT scans were the most common; CT scans were requested in 326 cases (91.8%) by doctors, with a predominance of specialist doctors (n = 247), that is, 69.6% of all requesters (Table 2). Nine CT scans (2.5%) were requested by nonphysicians (paramedics). The examinations were carried out (n = 244; 68.7%) between 0 and 3 days after their request, 65 examinations (18.3%) were carried out between 4 and 7 days, 25 examinations (7%) were carried out between 8 and 14 days, and 21 examinations (5.9%) were carried out 15 days after their request. Two hundred and twenty (n = 220) or 62% of the requests came from public health facilities.
TABLE 2.
Distribution of spinal CT scans according to the spinal levels explored and the qualifications of the requesters.
| n | % | |
|---|---|---|
| Spinal levels | 355 | 100 |
| Lumbar | 237 | 66.8 |
| Cervical | 55 | 15.5 |
| Dorsal | 11 | 3.1 |
| Dorso‐lumbar | 33 | 9.3 |
| Cervico‐lumbar | 9 | 2.5 |
| Cervico‐dorsal | 2 | 0.6 |
| Cervico‐dorso‐lumbar | 8 | 2.2 |
| Applicant's qualifications | 355 | 100 |
| Rheumatologist | 78 | 22 |
| Neurosurgeon | 71 | 20 |
| Neurologist | 55 | 15.5 |
| Traumatologist | 31 | 8.7 |
| General surgeon | 7 | 2 |
| Paediatrician | 5 | 1.4 |
| Paediatric surgeon | 2 | 0.6 |
| Internist | 1 | 0.3 |
| Other specialty (ENT) | 2 | 0.6 |
| General practitioner | 79 | 22.2 |
| Residents | 15 | 4.2 |
| Medical assistant | 8 | 2.2 |
| Physiotherapist | 1 | 0.3 |
3.2. The Clinical and Biological Context in Which CT Scans Were Requested and Performed
Spinal CT scans were performed in 339 outpatients (95.5%) and 354 conscious patients (99.7%). All patients had undergone a clinical consultation prior to requesting a spinal CT scan. Only 12 patients (3.4%) had undergone a biological examination prior to the spinal CT scan.
Spinal CT scans were preceded by a less radiation‐intensive imaging examination (standard spine X‐ray) in 326 patients (91.8%). MRI was performed before spinal CT in only one patient (0.3%). A total of 275 patients (77.5%) had received medical treatment prior to spinal CT.
3.3. Relevance of Clinical Indications
Assessment of the formulation of clinical indications for spinal CT scans was good in approximately 90% of cases (Table 3).
TABLE 3.
Assessment of the formulation of clinical indications for CT scans according to the spinal levels and the qualifications of the applicants.
| Good | Acceptable | Wrong | ||||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Spinal levels (n = 355) | 319 | 89.9 | 27 | 7.6 | 9 | 2.5 |
| Cervical (n = 55) | 45 | 81.8 | 9 | 16.4 | 1 | 1.8 |
| Dorsal (n = 11) | 10 | 90.9 | 1 | 9.1 | 0 | 0.0 |
| Lumbar (n = 237) | 215 | 90.7 | 14 | 5.9 | 8 | 3.4 |
| Cervico‐dorsal (n = 2) | 2 | 100.0 | 0 | 0.0 | 0 | 0.0 |
| Dorso‐lumbar (n = 33) | 33 | 100.0 | 0 | 0.0 | 0 | 0.0 |
| Cervico‐lumbar (n = 9) | 8 | 88.9 | 1 | 11.1 | 0 | 0.0 |
| Cervico‐dorso‐lumbar (n = 8) | 6 | 75.0 | 2 | 25.0 | 0 | 0.0 |
| Applicant's qualifications (n = 355) | 319 | 89.9 | 27 | 7.6 | 9 | 2.5 |
| Rheumatologist (n = 78) | 74 | 94.9 | 0 | 0.0 | 4 | 5.1 |
| Neurosurgeon (n = 71) | 67 | 94.4 | 3 | 4.2 | 1 | 1.4 |
| Neurologist (n = 55) | 45 | 81.8 | 8 | 14.6 | 2 | 3.6 |
| Traumatologist (n = 31) | 29 | 93.6 | 1 | 3.2 | 1 | 3.2 |
| General surgeon (n = 7) | 6 | 85.7 | 1 | 14.3 | 0 | 0.0 |
| Paediatrician (n = 5) | 5 | 100.0 | 0 | 0.0 | 0 | 0.0 |
| Other specialists (n = 5) | 4 | 80.0 | 1 | 20.0 | 0 | 0.0 |
| General practitioner (n = 79) | 68 | 86.0 | 10 | 12.7 | 1 | 1.3 |
| Residents (n = 15) | 14 | 93.3 | 1 | 6.7 | 0 | 0.0 |
| Medical assistant (n = 8) | 7 | 87.5 | 1 | 12.5 | 0 | 0.0 |
| Physiotherapy (n = 1) | 1 | 100.0 | 0 | 0.0 | 0 | 0.0 |
The consistency of the clinical indication with the CT scan was good for almost all requesters, and approximately 28% of requests did not comply with the SFR's best practice guidelines (Table 4).
TABLE 4.
Assessment of the consistency and compliance of the indications of the various CT scans with the best practice guidelines of French Society of Radiology (SFR).
| Consistency | Compliance | |||
|---|---|---|---|---|
| n | % | n | % | |
| Spinal levels (n = 355) | 351 | 98.9 | 256 | 72.1 |
| Cervical (n = 55) | 53 | 96.4 | 43 | 78.2 |
| Dorsal (n = 11) | 11 | 100.0 | 6 | 54.5 |
| Lumbar (n = 237) | 235 | 99.2 | 174 | 73.4 |
| Cervico‐lumbar (n = 9) | 9 | 100.0 | 6 | 66.7 |
| Cervico‐dorsal (n = 2) | 2 | 100.0 | 1 | 50.0 |
| Dorso‐lumbar (n = 33) | 33 | 100.0 | 20 | 60.6 |
| Cervico‐dorsal‐lumbar (n = 8) | 8 | 100.0 | 6 | 75.0 |
| Applicant's qualifications (n = 355) | 351 | 98.9 | 256 | 72.1 |
| Rheumatologist (n = 78) | 77 | 98.7 | 57 | 7.1 |
| Neurosurgeon (n = 71) | 70 | 98.6 | 44 | 62.0 |
| Neurologist (n = 55) | 54 | 98.2 | 41 | 74.6 |
| Traumatologist (n = 31) | 31 | 100 | 26 | 83.9 |
| General surgeon (n = 7) | 7 | 100 | 5 | 74.1 |
| Paediatrician (n = 5) | 5 | 100 | 4 | 80 |
| Other specialists (n = 5) | 5 | 100 | 3 | 66.7 |
| General practitioner (n = 79) | 78 | 98.7 | 60 | 76.0 |
| Residents (n = 15) | 15 | 100 | 10 | 66.7 |
| Medical assistant (n = 8) | 8 | 100 | 5 | 62.5 |
| Physiotherapist (n = 1) | 1 | 100 | 1 | 100 |
In 121 patients, that is, 34.1%, the spinal CT scans performed were considered to be unjustified CT scans in accordance with the criteria defined in the materials and methods (CT scans requested by a paramedic, formulation of clinical indication inconsistent with the examination requested or not compliant with the SFR's best practice guidelines, or with no clinical indication on the examination form).
3.4. Diagnostic Contribution of CT Scans
After interpretation by the radiologists, 323 spinal CT scans (91%) were pathological, of which 282, or 87.3% of the pathological CT scans, were related to clinical indications.
The more clearly the clinical indication was formulated, the more the results were pathological, with a statistically significant difference (p = 0.029); the more consistent the clinical indication was and the more closely it complied with the SFR's best practice guidelines, the more the results were pathological, but the difference was not statistically significant (p > 0.05) (Table 5).
TABLE 5.
Pathological results of CT scan interpretation according to the assessment of clinical indications.
| n | % | p | |
|---|---|---|---|
| Consistency with CT | |||
| Consistent (n = 351) | 320 | 91.2 | 0.316 |
| Not consistent (n = 4) | 3 | 75 | |
| Compliance with best practices guidelines | |||
| Compliant (n = 256) | 235 | 91.8 | 0.411 |
| Noncompliant (n = 99) | 88 | 88.8 | |
| Formulation of clinical indications | |||
| Good formulation (n = 319) | 294 | 92.2 | 0.029 |
| Acceptable formulation (n = 27) | 21 | 77.8 | |
| Poor formulation (n = 9) | 8 | 88.9 | |
4. Discussion
Justification is the first fundamental principle of radiation protection, aimed at ensuring that the patient derives a net benefit from the irradiating examination in comparison with the potential risks associated with exposure to ionising radiation. However, confirming that a CT scan is justified is a particularly complex analysis that involves validating and arguing the clinical indication, taking into account the technical resources available. To do this, each indication for an irradiating examination was analysed, and as a reference, we used the best practice guidelines of medical imaging examinations of the SFR and of the SFMN in the absence of validated best practice guidelines of medical imaging examinations in Togo or in French‐speaking Sub‐Saharan African countries. The best practice guidelines of medical imaging examinations are essential tools for putting the principle of justification into practice. They are intended for all healthcare professionals authorised to request and/or carry out medical imaging examinations [5].
The mean age of the patients was 48.2 years, confirming that spinal CT is much more common in adult patients over 35 years of age, who are often confronted with degenerative spinal pathologies. A previous study of adult CT dosimetry in Togo revealed that spinal CT accounted for 25.9% of CT scans performed on adult patients [8]. They are therefore frequently requested in Togo, accounting for approximately a quarter of all CT scans performed on adult patients in the country. Low back pain is an extremely common symptom and is thought to affect almost everyone at some point in their lives [9]. A Swedish study in 2012 revealed that approximately 4% of the population consulted a doctor each year because of this type of pain [12]. It is therefore not surprising that the large proportion of spinal CT scans in our study concerned the lumbar region.
Approximately 2.5% of the spinal CT scans were requested by paramedics (medical assistant and physiotherapist in our study). This situation is regrettable, as the request for an irradiating examination is a medical act and falls within the exclusive remit of a doctor. A request for an irradiating examination such as a CT scan from healthcare staff who are not authorised to do so is considered a priori to be an unjustified request. Requests for irradiating examinations in Lomé (Togo) by nonmedical professionals have already been reported in previous studies on the justification for chest and/or abdominopelvic CT scans and paediatric CT scans [10, 11]. This situation is not unique to Togo; in Cameroon, Moifo et al. [13] reported that, in 23% of cases, the requester did not have the qualifications required to request the medical imaging examination. However, it is reassuring to note that the majority of CT scans in our sample were requested by specialist physicians (rheumatologists, neurosurgeons and neurologists) who, because of their more in‐depth training, have sufficient expertise in the rules governing requests for the various techniques used to explore pathologies or organs within their specialties.
The rules governing the proper use of medical imaging examinations recommend that, wherever possible, nonirradiating or less‐irradiating examinations should be preferred to highly irradiating examinations such as CT in the management of patients. In view of its radiation dose, CT should, except in special circumstances, be used only as a second‐line treatment, given the limitations of first‐line examinations such as ultrasound (a nonirradiating examination) and standard X‐rays (less irradiating examinations) [5]. Accordingly, in our study, 91.8% of the CT examinations were preceded by a request for standard spine X‐rays (fewer irradiating examinations). The first‐line nonirradiating examination generally requested before a CT scan is ultrasound, but even though it is feasible and can explore various anatomical structures from the thoraco‐lumbar fascia at the surface to the posterior part of the vertebrae at depth, spinal ultrasound has limited diagnostic usefulness at present [14]. Its main interest at present remains in guiding infiltrative procedures [14]. It is therefore understandable that spinal ultrasound did not precede any of the spinal CT scans in our study. MRI, performed only once before CT in our study, is the most indicated nonirradiating examination, if not the reference, for the exploration of spinal pathologies, particularly non‐traumatic ones, but its poor accessibility, particularly in developing countries such as Togo [15], and its high cost for patients with limited financial resources and often without medical insurance, mean that it is often requested when spinal CT is limited in French‐speaking sub‐Saharan African countries.
All the patients had been consulted by a healthcare professional before a spinal CT scan was requested, and the vast majority (77.5%) had received medical treatment prior to the CT scan. This excellent finding is encouraging and shows that the request for a CT scan is part of the continuity of the clinical examination. In fact, the use of medical imaging in the management of spinal pain, particularly common lumbar pain without red flags (severe or progressive pain, numbness or weakness, loss of bowel or bladder control, fever or infection signs, and specific trauma‐related symptoms), is justified only after approximately 6 weeks of unsuccessful medical treatment [16]. Moreover, a medical imaging examination of any kind is only indicated after a clinical assessment that allows a decision to be made on the basis of precise medical documentation of the patient.
In contrast to the 2019 paediatric CT justification study, where approximately 0.6% of requisition slips had no clinical information [10], all of the CT requisition slips in our sample included the clinical indications. However, it is important to emphasise that it is not enough to simply state the clinical indication on the request form for a medical imaging examination for the request to be justified. This indication must be well formulated (as was the case in 89.9% of cases in our study) because the quality of the radiological diagnosis depends on it. The radiologist's interpretation is guided by the quality of the formulation of the clinical indication. If the clinical indication is poorly formulated, as was the case for approximately 2.5% of the CT scans in our study, the request for the examination will, a priori, be unjustified. Poor, incomplete, or even absent clinical indications were reported by Martins et al. [17], who noted that clinical indications were incomplete in 84.1% of cases and missing in 0.6% of cases in their study on the appropriateness of radiological examinations from emergency departments in Portugal in 2018. In addition to the quality of the formulation of the clinical indication, the justification of a medical imaging examination depends on the consistency of the clinical indication with the examination requested. The more consistent the clinical indication is with the CT scan, the more justified the request will be. We can therefore only be delighted that in our sample, the clinical indications were consistent with those of spinal CT in 98.9% of the patients. This high percentage of clinical indications consistent with the type of medical imaging examination requested was also noted by Moifo et al. in Cameroon, where 98.5% of imaging examinations were consistent with the clinical information provided by the applicant [13], and in our previous study on the justification for chest and/or abdominopelvic CT scans in Togo (96.6%) [11].
On the other hand, the clinical indications did not comply with our best practice guidelines for medical imaging examinations (SFR and SFMN) in 27.9% of the patients. Compliance of the clinical indication with the recommendations of Best Practice Guidelines is an important criterion in assessing the justification for a medical imaging examination, as emphasised by several other studies on the justification for medical imaging examinations [18, 19, 20]. The rate of indications not complying with the best practice guidelines in our sample (27.9%) is similar to the 31% reported in France by Léaute et al. in their study on the justification of CT scan requests in emergency departments [20]. The rate of noncompliance in the present study is very high if we compare it with that for chest and/or abdominopelvic CT scans, which was 17.3% in 2018 in Togo [11].
If we consider that the spinal CT scans requested by an unauthorised person (paramedic), with a clinical indication that is not consistent or does not comply with the best practice guidelines, or without any clinical indication on the examination form, are a priori unjustified, 34.1% of the spinal CT scans in our study were judged a priori to be unjustified. This proportion of unjustified spinal CT scans is very high but is lower than the 70% of unjustified lumbar spine CT scans reported in Finland in 2009 by Oikarinen et al. [21]. The justification of CT scans in patients is an issue in both Western and developing countries. For example, Ståhlbrandt et al. in Sweden in 2023 reported that 37% of CT scans and 24% of MRI scans were inappropriate [19]. A study by Vilar‐Palop et al. [22] in Spain in 2018 reported that 1/3 of radiological examinations were not justified. A previous study on the justification of chest and/or abdominopelvic CT scans performed in Togo revealed a lower rate (18.7%) [11], whereas a study on the justification of paediatric CT scans performed in Togo in 2019 revealed a much higher rate (53.1%) of examinations that were a priori not justified [10].
The CT scans performed in our study were pathological in 91% of the cases, which is comparable to the 84.4% of chest and/or abdominopelvic CT cases reported in 2018 [11].
We found that the better the clinical indication was formulated, the more consistent it was with the CT scan requested and the more closely it complied with the guidelines, the more pathological the results were, with a statistically significant difference for well‐formulated clinical indications. This finding only reinforces the close link between the quality of the radiologist's interpretation and the quality of the clinical information provided by the clinician. It is therefore clear that the justification for any procedure involving exposure to ionising radiation requires a prior exchange of written information between the applicant and those carrying out the procedure.
The significant number of apparently unjustified spinal CT scans in this study should call for greater efforts on the part of requesters, providers and health authorities to considerably reduce the number of unjustified radiological examinations in Togo. This situation can be explained by, among other things, abusive requests without consulting the best practice guidelines of medical imaging examinations. There are no best practice guidelines from African medical imaging societies, and the SFR's best practice guidelines, which have been provisionally adopted in French‐speaking sub‐Saharan African countries, have not been sufficiently disseminated to practitioners. In fact, 57.1% of those requesting medical imaging examinations in Togo in 2015 were unaware of the SFR's best practice guidelines for medical imaging examinations [23]. It is therefore essential to raise awareness among requesters for irradiating examinations of the importance of consulting Best Practice Guidelines, and this would make a significant contribution to better justification of medical irradiation in Togo, as was the case in Finland, where the implementation of Best Practice Guidelines and training for requesters in its use led to an increase in the rate of justification of spinal CT scans from 23% in 2005 to 81% in 2009 [24]. The high rate of unnecessary medical irradiation in Togo, as in many African countries, can also be partly explained by the scarcity of ongoing training in patient radiation protection, resulting in a mediocre level of knowledge of the principles of patient radiation protection, as is the case in Cameroon, where Moifo et al. [25] noted that 79.5% of practitioners were unaware of the justification principle.
The responsibility for justifying irradiating examinations also lies with medical imaging examination providers (radiologists and radiographers), who can help requesters to better specify the clinical indications and who must refuse to carry out irradiating examinations that are not justified in accordance with the principles of radiation protection. These examiners (radiologists and radiographers) must therefore receive regular ongoing medical training in patient radiation protection, which unfortunately is not common in African countries such as Togo. Given the increasing availability of CT scanners in health facilities in our countries in recent years, requests for CT scans from clinicians will increase, as is the case in Western countries [26]. It is therefore important that the health authorities in our African countries become more involved in the fight for better justification of CT scans in particular and of imaging examinations that are particularly irradiating in general, with a view to guaranteeing judicious medical irradiation for patients.
5. Conclusion
A significant number of spinal CT scans carried out in Togo were not justified and are therefore a source of unnecessary medical irradiation. This situation is worrying in view of the highly irradiating nature of CT scans. Open collaboration between those requesting and performing radiological procedures, as well as the organisation of periodic continuing medical training courses in patient radiation protection for doctors and radiographers, is highly desirable with a view to judicious medical irradiation in Togo in particular and French‐speaking sub‐Saharan Africa in general.
Ethics Statement
An approval from the thesis committee of the Faculty of Health Sciences at the University of Lomé, acting as its IRB (Institutional Review Board), had been obtained (N°: 015/RIM/21). The study did not involve the use of animals and had been performed in accordance with the Declaration of Helsinki.
Consent
The patients included in this study gave verbal informed consent to participate in this research.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgements
The authors have nothing to report.
Funding: The authors received no specific funding for this work.
Data Availability Statement
The data used and/or analysed during the current study are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used and/or analysed during the current study are available from the corresponding author on reasonable request.