Computed Radiology

Robert H. Wrigley, BVSc, MS, DVR, MRCVS, Dipl ACVR, ECVDI

Computed radiography (CR) is a digital x-ray imaging technology that has been used in human and veterinary medicine since the 1980s. A reusable imaging storage plate is used to record the x-ray exposure and replace x-ray lm. The CR storage plate is scanned by a reader to create a digital radiographic image. The image is then processed to optimize its quality and then stored like any computer le. The digital radiographic image can then be viewed on a computer screen, transmitted electronically or printed on photographic paper or transparent lm. In the last ve years, CR devices have become portable and affordable for veterinarians. Many are now in use for equine eld radiology. Clin Tech Equine Pract 3:341-351 2004 Elsevier Inc. All rights reserved. KEYWORDS computed radiography, horses, diagnostic x-ray imaging

omputed radiology (CR) is the generic term for a large area digital x-ray detector system using photostimulable phosphor plates and a computer-controlled optical/mechanical scanner. CR was rst developed by the Fuji Medical Corporation and produced for human radiography in the early 1980s. Initially, the high cost and the large size of the device limited the application of this new digital imaging technology. In the late 1980s, more compact Fuji CR systems were developed, which physician radiologists accepted as replacements for lm-screen radiographs (FSR). In 1989, at Colorado State University, Department of Radiological Health Sciences, clinical evaluations of the Fuji CR imaging technology showed promise for imaging animal patients. Colorado State University (Fig. 1) and a few other veterinary colleges around the world have been using CR successfully for more than a decade.1-4 During the 1990s, the combination of reduced costs for computer systems and competition from other manufacturers resulted in smaller equipment, improved image quality, and lower cost. Now, portable CR equipment (Fig. 2) operated by a laptop computer is available at less then one-tenth of the cost of CR equipment in the early 1990s.5 Economics has made CR imaging affordable for veterinarians and veterinary supply companies are scrambling to develop veterinary-specic CR imaging systems.5 In the last 2 to 3 years, hundreds of CR systems have been delivered to private veterinary practices.5 The portability of CR allowing radiographs to be obtained quickly on site is especially useful for mobile equine practitioners.2

Technology of Computed Radiography

CR is an indirect x-ray recording system utilizing a photostimulable storage phosphor plate to record and store the radiographic image.6,7 Although plates can be manufactured in any size, the typical sizes match those of standard radiographic lm cassettes. The active component of the storage phosphor plate is a 100- to 150- m layer of europium-doped barium uorohalide in an organic binder adhered to a exible plastic plate. When exposed to x-rays, the europium releases electrons that are trapped in the uoride centers. So, like FSR, the storage phosphor plates record the absorbed x-rays as a latent image (Fig. 3). To capture the latent information, the plate is scanned with a red or near-infrared laser beam that releases electrons and returns the europium to a neutral state (Fig. 3). When electrons return to a ground state, low intensity blue-green/ultraviolet light (luminescence) is emitted from the storage phosphor.8 The intensity of the photostimulated luminescence emission is linearly proportional to the x-rays absorbed by the storage phosphor plate.9 The latent image is stable for a prolonged time though slowly decreases with approximately 25% of the light emission lost after 8 hours.10 Photostimulated emission also occurs when the phosphor plate is exposed to white light, so exposed phosphor plates are kept in light-tight cassettes before scanning with a laser. For this reason and the need to protect the expensive plates from damage and liquids, the phosphor plates are routinely protected by metal or plastic cassettes. CR cassettes look like regular lm-screen cassettes and personnel experienced with these immediately know how to use CR cassettes. Changes in radiographic procedures are not needed when converting from FSR to computed radiography. The CR cassettes are used just as if one was examining the horse with lm-screen cassettes. After x-ray ex341

Department of Radiological Health Sciences, Veterinary Teaching Hospital, Colorado State University, Fort Collins, CO. Address reprint requests to Robert H. Wrigley, BVSc, MS, DVR, MRCVS, Dipl ACVR, ECVDI, Department of Radiological Health Sciences, Veterinary Teaching Hospital, Colorado State University, Fort Collins, CO 80523. E-mail: rwrigley@lamar.colostate.edu.

1534-7516/04/$-see front matter 2004 Elsevier Inc. All rights reserved. doi:10.1053/j.ctep.2005.02.012

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printed on transparency lms by high quality medical laser printers. The network technology for distribution of the CR images had not been developed. Subsequently, with the maturation of medical Picture Archive and Communication Systems (PACS), CR image les now can be distributed and displayed on specially congured diagnostic workstations. Copying the images to permanent storage media such as CDROM, DVD, or digital tapes can create electronic archives. These systems allow for cost-effective permanent archives without the costs associated with printing and ling lm. In addition, the electronic images can be copied for the owner or referring veterinarians, or compressed and distributed via the Internet for telemedicine and consultation services.

Figure 1 High capacity CR plate reader with an image display and workstation. From here the digital CR images are routed to the hospitals Internet-based PACS system. CR images are then available on any of the hospitals computers. Also images may be transferred to portable storage media (oppy disks, CDs, and so on), e-mailed, or printed.

Advantages Over Film-Screen Radiology

When a CR system is combined with PACS to enable electronic display and storage of images, no radiographic lm needs to be purchased, as the imaging plates are reusable (Fig. 3). Also, as there is no need for wet-chemical lm processing, the darkroom and associated expense can be eliminated. In fact, with economical CR equipment now available, some veterinary practices have found that the cost of leasing a CR & PACS system is less expensive than their annual cost of radiographic lm, darkroom supplies, and maintenance.5 With conventional lm-screen systems, the intensifying screen and lm records, displays, and stores the image. With CR imaging, these functions are separated into three processes. The phosphor storage plate captures the latent image, the plate reader transforms the latent images into an electronic image le, and image display is on high-resolution computer workstations. Films have to be labeled, jacketed, led, and retrieved manually in dedicated le storage. CR images are stored on servers like any other computer les. The separation of each function allows optimization of each of these steps without the compromises inherent to lmscreen radiographic imaging. The phosphor imaging plates have a much greater range (104:1 for CR versus 102:1 for FS radiography) over which x-ray intensity can be stored as compared with conventional lm-screen radiography.12 Clinically diagnostic CR images can be acquired from the CR plate exposures that on FSR would be unacceptably underexposed (white) (Fig. 4A and B) or overexposed (black) (Fig. 4C and D). This expanded

posure, the cassette is taken to a plate reader rather than to a photographic darkroom. Manufacturers produce readers with varying technological sophistication, ranging from less expensive manual systems to more expensive automatic cassette unloading/loading systems.11 The cassettes from one manufacturer cannot be read in the plate reader of another. The most sophisticated machines with the highest plate throughput allow stacks of cassettes to be inserted and processed automatically allowing the radiographic technician to continue with other activities. The scanner process uses a precision laser that stimulates luminescence as the laser spot transverses the plate in a raster pattern. The luminescence is sampled in a rectangular matrix of picture elements (pixels) typically ranging from 5 to 10 pixels per square millimeter of the plate. The light emitted from the imaging plate is detected by an optical system coupled to a photomultiplier tube. This generates an electrical signal that is variably amplied and sent to an analog-to-digital converter to establish the value of each pixel. Pixel values may range between 0 and 1023 for a 10-bit scanner or between 0 and 4095 for a 12-bit scanner. This process is under computer control and the position and value of each pixel is stored and assembled by the computer into an imaging le. At the end of the laser scanning process the plate is exposed to high intensity uorescent light to completely erase the remaining latent image and the plate is returned to the cassette ready to record another radiographic image (Fig. 3). The manufacturer guarantees at least 10,000 x-ray exposures per plate.11 The cycle time for a plate through the CR plate reader is variable, ranging from 30 to 180 seconds depending on the plate size and the equipment design.11 Generally, less expensive CR systems have longer cycle times than the higher capacity more expensive systems. Reader technology is evolving with decreased scan times in the more sophisticated higher capacity systems. A recently released model can scan plates in 10 seconds.11 CR systems are routinely combined with a computer congured with large amounts of memory (RAM) and hard-drive storage. High capacity hard drives are required because CR images may be 20 MB each. Early on, most CR images were

Figure 2 Portable CR system that can be easily moved to where a horse is to be radiographed. Image display, manipulation, and storage can be performed on the laptop computer (courtesy of IDEXX Laboratories, Inc.).

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Figure 3 Schematic drawing illustrating the recycling of the same CR plate through the radiograph exposure, laser scanning and erasure process. Image plate manufacturer may guarantee that a plate can be recycled to obtain more than 10,000 images.

x-ray recording latitude with CR imaging allows for display of the thinnest soft tissues surrounding the horses limb as well as penetration of the adjacent thick bone by the same x-ray exposure. During radiography of the equine hoof, the outer borders of the hoof tissue, the thinner portion of the edges of the distal phalanx, the cofn joint, and navicular bone can all be displayed by one radiographic exposure (Fig. 5). Also, this increased x- ray exposure latitude allows for reoptimization and recovery of images that on FSR would be either overexposed (Fig. 4C) or underexposed (Fig. 4A). CR imaging leads to reduced need for repeating suboptimal x-ray exposures. Anatomical detail on CR images is dependent on the quality of the CR imaging plates, pixel size, x-ray exposure level, and the laser spot size. There has been a steady improvement since the mid 1980s in the detail recordable by the imaging plate with later generations of imaging plates giving improved detail to the CR images. The combination of plate size, pixel matrix number, and diameter of the laser point all interact to determine the detail resolution on CR images. Specications from manufacturers all meet or exceed the minimum requirement of the American College of Radiologys requirement to resolve 2.5 line pairs per millimeter.11 Use of a smaller plate size and high-resolution operating parameters of the plate reader can double this resolution to the

order of 5 line pairs per millimeter with optimized x-ray exposure. The resolution from CR imaging is less than that achievable with optimized FSR, as lm radiographs can have line pair resolutions up to 12 line pairs per millimeter.12 However, the reduced measured resolution of CR images has been shown to have no clinical signicance.3,13-17 Image postprocessing with edge enhancement algorithms adds clarity and resolves the ne detail edges on the images that improve detection of bone structures on CR images (Fig. 6A) when compared with regular lm radiographs (Fig. 6B).3,12 Intensifying screen/lm used for equine radiography typically has speed indexes of 100 to 800. The CR imaging plates are not speed indexed, as the wide latitude of the imaging plates allows recording of a very wide range of x-ray exposures (Fig. 7A and B). Satisfactory image optical density is achieved by an appropriate adjustment to the amplication circuit between the photo multiplier tube and the analog-todigital converter relative to the x-ray exposure. The quantum absorption efciency of CR plates is slightly lower than highspeed FS radiography and the luminosity from CR imaging plates becomes more mottled with low radiation exposure (Fig. 7B).7 Increased electronic gain within the reader system needed in the low x-ray exposures tends to increase the degree of random variation (noise) of the system (Fig. 7B). To

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Figure 4 (A) Film-screen radiograph made at 80 KV, 1 mAs with 100-speed radiograph intensifying screens. The lm image is very underexposed. (B) CR image made with 80 KV, 1 mAs by a Fuji CR system operating in automatic mode. The CR image displays the bones at optimum radiopacity. (C) Film-screen radiograph made at 80 KV, 8 mAs with 100-speed radiograph intensifying screens. The lm image is overexposed. (D) CR image made with 80 KV, 8 mAs by a Fuji CR system operating in automatic mode. The CR image displays the bones at optimum radiopacity.

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Figure 5 Dual CR image display from one radiograph exposure of the D60Pr-PDi oblique projection of P3. The left image has been optimized to display the distal sesamoid (navicular) bone. The right image has been optimized to display the peripheral border of the 3rd phalanx where fractures (arrows) were present.

maintain acceptable image detail, the x-ray exposure of CR plates needs to be somewhat higher than used for 400-speed lm-screen radiography.12 The newest generation of Fuji imaging plates now has a transparent-based plastic material coated on both sides by the photostimulable phosphor. This increases the amount of radiation absorbed due to a double coating of the phosphor and allows a reduction in x-ray exposure while still maintaining image quality. These plates have to be scanned in a special plate reader with two light guides in the reader.11

Radiographic Technique
CR images are produced using the same x- ray tube and generator system as for regular FSR. The CR cassettes are used in exactly the same manner as a FSR cassette. Just as with FSR it is important to optimize the radiographic technique for the body part being imaged. Proper patient positioning and beam centering are just as critical to obtain diagnostic quality images. Control of scattered radiation is just as important with CR imaging. Incorporation of an x-ray scatter grid is necessary to image thicker parts and most Bucky grids are compatible with CR imaging. However, stationary (handheld) grids aligned parallel to the scanning axis may result in an artifact of exaggerated grid lines due to creation of a moir pattern of lines on the image. If stationary grids are used, the CR vendor will either recommend replacement or provide high-line grids that perform satisfactorily with that particular model of plate reader. In comparing x-ray exposures for FSR and CR, thought has to be given to the speed index of FSR. Even though CR has wide latitude to x-ray exposure, the increased noise and reduced detail in the images made at very low x-ray exposures make such images less satisfactory. Radiograph exposures

satisfactory for a 400-speed FSR have less image detail than clinically desirable.12 Whereas CR images made with the same exposure as a 250-speed FSR are interpreted by clinical radiologists to have more than adequate image detail.12 In FSR, the type of lm-screen and the kVp setting controls image contrast. However, since image contrast in CR imaging is a function of image processing software, KVp selection becomes less critical. A setting between 80 and 100 kVp for equine extremity imaging is a good compromise between x-ray exposure generator efciency and CR imaging plate x-ray absorption.3 CR imaging systems are available to work with either a xed or automated photomultiplier gain. The user interface requires selection from preset menus of the body part imaged at the time the plate is inserted into the plate reader. Simpler, less expensive systems only use xed photo multiplier gain settings, so constant x-ray focus to detector distance and an x-ray technique chart is necessary.11 Such technique charts need to be provided by the CR vendor to establish the optimal match between the output of the x-ray generator, the body part, the response of the imaging plate, and the settings of the CR scanner. When using this type equipment, it is important that an accurate x-ray technique chart be maintained and followed. Even though the imaging plates have more latitude to exposure error than lm-screen radiography, there are still limits to satisfactory exposure of the CR plates. Underexposure results in a whiteout of the thickest parts of the body region and overexposure results in a blacked-out appearance to the thinnest part. The more sophisticated and expensive CR systems incorporate an automatic read mode that provides feedback adjustment to the photomultiplier gain by centering the output level using histogram analysis. This technology optimizes image blackness irrespective of x-ray exposure levels11 (Figs. 4B and C, and 7A and B). Such automatic image leveling

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Figure 6 (A) Lateral CR image made of the same left metacarpus shows increased conspicuousness of the 2 stress ssure fractures (arrows) of the dorsal cortex of the 3rd metacarpus. Improved visualization of the fracture lines is the result of edge enhancement image manipulation available with digital images. (B) Lateral lm-screen radiograph of the metacarpus of a 2-year-old racing Quarter Horse. Lameness and pain was localized to the mid portion of the left metacarpus. A smooth slight thickening was seen to the mid diaphyseal portion of the dorsal cortex of the third metacarpus. Two faint (arrows) incomplete vertically orientated radiolucent lines suggestive of stress fractures were observed.

simplies x-ray technique charts, as only a few x-ray settings are needed for horse limbs. Also, with portable examinations the accuracy of x-ray tube to CR plate imaging distance is no longer critical. The variable x-ray dose due to different distance is automatically compensated for by the CR system. Also, such automated systems reduce the amount of manual image postprocessing needed to compensate for variations in limb thickness resulting from breed variation and disease.

Image Processing
The extreme latitude of radiation exposure recorded by the phosphor plate results in an initial CR image with an extremely long gray scale (Fig. 8), which is not as pleasing to the human eye compared with the higher image contrast present on FSR. Typically, contrast enhancement is performed by making a nonlinear transformation to the gray scale. Look-up tables (algorithms) are used to construct a gradation curve to transform and shorten the gray scale of CR images7 (Fig. 8). It is important that multiple enhancement algorithms are available so that the image contrast for different regions can be

chosen and that the algorithms have been optimized for veterinary radiographic imaging.7 The second stage of CR image processing is spatial frequency processing that enhances resolution of edges in the image (Fig. 8). This is especially useful to bring out the ne detail of bones. Image smoothing is frequently rst applied to reduce the grandularity/noise of low exposure regions.7 In these low dose regions of the image, relevant clinical information may be present but applying a smoothing routine can minimize distraction to the viewer caused by the noise pattern. Spatial domain smoothing uses the average or median value of each pixel and compares it to the surrounding pixels and replaces the pixel value with either an averaged or median value. This has the effect of reducing gray scale variations on a pixel-by-pixel basis. This smoothing process is especially useful in noisy images made with low radiation exposures but may degrade the ne detail of images made with adequate or higher exposure levels.7 This smoothing process needs to be programmable based on the exposure level and the body part examined. Unsharp mask ltering is the most common spatial do-

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Figure 7 (A) CR Image of a normal equine carpus exposed at 80 kVp and 16 mAs using a Fuji CR system operated in automatic exposure mode. (B) Repeat CR image exposed at 80 kVp and 0.16 mAs. This CR image was also processed by the same Fuji CR system operated in automatic mode. The optical density of both images has been normalized even though the mAs used ranged from 16 to 1.6 mAs. Observe that the greatly improved ne bone detail is more visible in Fig 8A than in Fig 8B. Quanta mottle limits and excessively high photomultiplier gain required to compensate for the extreme underexposure results in reduced visualization of ne detail in bones.

main ltering technique that enhances the edges of objects at high contrast boundaries. This sharpening effect is most useful when examining bones, as it enhances detail to the bone edges (Figs. 6A and 8).7 First, an unsharp copy of the original image is subtracted from the original image to produce the edge image. The spatial frequencies of the edge image need to be selectable, as this determines the size of the objects that will be preferably enhanced. In the second step of unsharp mask subtraction, the edge image is added back to the original image after it has been modied by an enhancement that determines the degree of edge enhancement in the nal image.7 Because unsharp masking increases the noise (granularity) in the image, if the averaged area is suboptimally small or the enhancement factor is too high, then mottle will appear in uniform areas, creating an artifact in the cortex of bones and soft tissues.7 Likewise, if the averaged area is large and the enhancement factor to high, then articial black zones will appear along high contrast borders such as the surface of cortical bones and metallic implants (Fig. 9A and B). This articial black zone around metallic implants has been mistaken for loosening of surgical implants and is described as halation, over-shoot, or the uberschwinger artifact18 (Fig. 9A). Therefore, it is important that selection of the mask size and enhancement factor be optimized for the region of interest. Customization of the unsharp masking process is needed to optimize veterinary CR images as the parameters needed dif-

fer between cats, dogs, and horses. If artifacts appear on the enhanced images, it is important to be able to access the unprocessed CR image to decide whether the unusual appearance is as a result of postprocessing or a real lesion (Fig. 8). A limitation of unsharp mask enhancement is that objects of only a limited range of sizes can be enhanced on one image. This limitation can be overcome by reprocessing the image to provide enhancement of either larger or smaller objects as desirable to create a set of multiple images. An alternate approach is multi-scale image contrast enhancement (MUSICA), an advanced imaging processing algorithm using a local contrast enhancement technique based on the principal of detail amplitude and the notion that image features can be striking or subtle, large or small in size.19,20 Processing is independent of the size of the object that will be enhanced. This image processing technique results in diminished differences in contrast between features regardless of size so that all image features become more visible.19,20 The rst CR systems produced by Fuji Medical Systems generated three images each with different levels of gradient curving, smoothing, and unsharp mask subtraction based on the body part examined. This allowed the radiologist to view various postprocessed images and even display multiple variants simultaneously so that on one image soft tissue information could be optimally seen and on a second image other structures such as high contrast bone detail information was

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Figure 8 Dual display of a DP raw (unprocessed) CR image (A) of a normal equine tarsus. Spatial frequency processing has been performed on image B to provide an edge-enhanced display of the bones. Observe how the ne trabecular bone appearance and visualization of the joint spaces has been improved by the unsharp mask processing algorithm applied to this CR image.

displayed. Such paired sets of postprocessed images are desirable as this allows the radiologist to quickly view and then select the image most desirable for the region and diseases of concern (Fig. 5). It has been the experience of the author that many algorithms for human CR images are suboptimal for veterinary patients. The veterinary CR vendor needs to supply image postprocessing algorithms that have been optimized for animal anatomy. Such systems have a veterinary anatomical menu interface so that the CR plate will be scanned optimally and optimized image processing will be applied dependent on the animal species and body part imaged onto the CR plate.

Image Review: Soft Versus Hard Copy

As CR images are generated and processed by a computer, it seems logical to evaluate the images on a computer monitor (soft copy). However, in the 1980s and early 1990s, the limitations of resolution of monitors capable of displaying a 14 17 full-sized image at 2.5 line pairs per millimeter combined with the limited development of PACs systems for distribution of images led CR equipment manufacturers to provide printed lm images (hard copy). Initial review on a low-resolution computer monitor was available to the radiological technologist to quality control patient position, image quality, and print selection of single or multiple combinations of the various postprocessed image sets. Sometimes it was desirable for the radiologist to have prints of an image

enhanced for soft tissue detail beside a reprocessed image optimized for high bone detail. The printed digital images were read and archived as routine radiographs. Obviously, the cost associated with lm purchase, a high quality laser lm printer, and the associated lm development negated potential cost savings from the reusable phosphor plates. By the 1990s PACS systems became available for distribution, display, and archiving of digital medical images, reducing the need for lm printing. In addition, the reduced costs of personal computers and high-resolution CRT/LCD monitors have allowed for a migration from printed lm images to interactive computer workstations. For optimal display of CR images, a monochrome high brightness computer monitor is optimal. The American College of Radiology species that digital radiographic images should have a minimum resolution of 2.5 line pairs per millimeter and recommends workstation gray scale monitors with at least 50 foot-lamberts brightness.21 This degree of luminance is signicantly less than from a radiographic view box. High brightness computer monitors with luminosity of at least 150 foot-lamberts or greater are more desirable, as the image now more closely simulates the dynamic range of hard copy CR lms and radiographs. Diagnostic workstations need to be equipped with CR image manipulation software. At a minimum, image manipulation tools needed include21:

Rotation/realignment of images to conventional viewing alignments.

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Figure 9 (A) D6OPr-PDi oblique CR image made to recheck the prior surgically stabilized fracture of the 3rd phalanx. Note: The black radiolucency surrounding the edges of both the implanted screw and horseshoe. This black radiolucency is as a result of spatial processing using the unsharp mask edge enhancement algorithm. An articial black zone (halation, over shoot, uberschwinger artifact) surrounds the areas of high radiopacity. The black zone surrounding the screw simulates loosening or bone lysis, which is artifactual in nature as it is not present on the accompanying FSR. Likewise, a black halo surrounds the horse shoe as a result of this halation, over shoot, uberschwinger artifact resulting from edge enhancement by unsharp mask image ltering. (B) Comparison D6OPr-PDi oblique lm-screen radiograph of 3rd phalanx. The fracture has healed and a normal appearance is seen to the bone surrounding the screw.

Brightness and contrast adjustments to optimize the image. Image magnication to help evaluate smaller details. This is especially helpful for larger images (14 17 inch) displayed on low-resolution monitors ( 5 megapixels). Portions of the image can be expanded. Once magnied, a pan tool is needed to move the image around to evaluate all regions. Image inversion to display bone as black on white. Occasionally, nondisplaced fractures may be easier to detect in the inverted display format. Electronic calipers to accurately measure lesions and structures. Angle measurement tools are useful to quantify angular limb deformities and other lesions (rotational laminitis). Measurements should be permanently stored with the image le so that comparisons can be made at recheck examination.

After postprocessing, both the raw le and the optimized images should be archived. Due to the large le size of CR images (10-12 megabytes), compression algorithms are used to make the image le smaller. Compression algorithms (wavelet compression or high quality JPEG compression) can reduce image le size to approximately one-tenth of the original with no observable loss of diagnostic information from optimized CR images. Compression algorithms (medium quality JPEG compression) can further reduce image size with some visible loss of image quality. These smaller (compressed) les can be written to inexpensive digital media such as oppy disks/CD-ROM or transmitted to owners and consulting veterinarians as e-mail attachments.

A plan for a permanent archive of digital images is necessary to comply with legal requirements of maintaining medical images, for comparison with future images, for teaching les, and for research capability. This plan should be part of the process of obtaining CR equipment. Currently, the most practical approach is to use high capacity hard drives combined with regular backup procedures. Older les can be archived on DVD, digital tape, or through offsite, archive storage vendors. Most CR systems still allow printing hard copy images on high quality, medical laser printers and these lm images can also be a long-term archive. However, this plan does not offer cost savings, as the purchase price of the printers is substantial and can exceed the cost of the latest low cost CR systems. An alternate, less expensive plan is a photographic quality ink-jet printer using photo quality paper. The image quality of these paper prints is often satisfactory when printed after image optimization at the workstation. Paper prints may be a less expensive way to provide images to the owner and can be helpful when annotated at the workstation.

Advantages of Computed Radiology

The technology for CR imaging is mature since it has been used longer than any other digital acquisition technologies. Many renements have been made over the years to optimize CR performance and image quality. CR is clinically versatile. The cassettes are the same dimensions and used in exactly the same manner as FSR cassettes.

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Figure 10 Lateral CR image of the dorsal spinous processes of the thoracic spine (withers). The long scale of exposure latitude combined with optimized nonlinear contrast enhancement enables display of the skin surface and a considerable length of each bone.

CR imaging has broad exposure latitude (Fig. 10) and the image can be adjusted to optimize the evaluation of both soft-tissue and bone. When using FSR imaging, the veterinarian must choose an x-ray technique that creates a good balance between contrast, exposure, and latitude. These compromises are not required when using CR, as the response to the x-rays is linear and there is a much greater range of recordable x-ray intensities. CR imaging offers variable resolution, as the CR imaging plates do not consist of individual pixels but are scanned. Adjustable laser spot size and scan rate produces either highresolution or standard resolution images. In addition, higher resolution can be achieved with the combination of higher x-ray exposure and reduced photomultiplier amplication (Fig. 7A). Plus, the same imaging plates can be used to achieve high detail resolution images or lower resolution images with reduced x-ray exposures as clinically indicated (Fig. 7B). Work efciency can be increased with portable CR equipment that can be taken to the farm (Fig. 2). The images are processed on site and reviewed on a laptop computer. The radiographic diagnosis can be made at the farm and travel time for retake examinations eliminated. Using high capacity CR scanners, further efciency is achievable when compared with processing lms in a routine darkroom. Cost savings are achievable when images are viewed and stored electronically, as there is no need to purchase radiographic lm, radiographic processing chemicals, operating a lm processor, and the costs associated with x-ray lm jackets and ling procedures. Digital storage enables rapid retrieval and review of prior images and allows the transfer of images over computer networks and via e-mail. Fewer retake radiographs are needed with computed radiography, as misjudgments in exposure technique are less critical. With equipment operated in automatic mode/histo-

gram analysis, the CR system automatically normalizes the exposure density on the image (Fig. 4B and D). In systems with xed photomultiplier gain operation, mild degrees of over- and underexposure can be corrected manually at the CR display monitor. Radiation exposure to patient and personnel is decreased with fewer retakes. Cost savingsAlthough the cost of a CR system is more than buying a lm-screen radiographic facility with a darkroom and automatic processor, there are potential cost savings when images are displayed and evaluated on a computer monitor. The savings from eliminating radiographic lm, dark room supplies, processor maintenance, lm jackets, and the physical space of a darkroom and an x-ray lm le room can be substantial. In addition, there are work efciency gains from reduced repeat radiographs and wide latitude images. In high volume practices, the monthly cost for lm, developer, maintenance, and processing chemistry, and so on may be higher than the lease cost of a CR system.

Disadvantages of CR Imaging
X-ray absorption with CR imaging is less efcient at the same level of image detail when compared with FSR of speed indexes 400 and faster. It may be necessary to increase x-ray exposure if the facility had been using a very fast FSR system. This limitation has been overcome in the latest generation of CR equipment utilizing imaging plates with a clear base material and two layers of phosphor.11 However, these scanners are more expensive than current models using single-layer imaging plates. CR systems are moderately costly although prices are falling and can be affordable for the high volume veterinary practice. The cost savings accrue as lm and other disposables no longer have to be purchased and less retake images are made. A training period and experience using the equipment is

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needed to make the transition from FSR to CR imaging. This requires time during the startup phase to learn new processes and computer software. An understanding of image processing is important so that images are not overly processed, which can introduce artifacts. CR imaging plates are delicate when removed from their protective cassettes. CR plates will collect dirt, dust, and hair, which can be carried into the reader. A regular cleaning processs, as recommended by the vendor, needs to be performed. Also, CR plates need to be protected from exposure to liquids such as blood and urine. The time from x-ray exposure to image production with CR is dependent on the location of the CR reader and the capacity and throughput of the CR reader. The latest generation of CR reader can scan plates in as short as 10 seconds (nearly as fast as direct radiography systems), many systems take 30 to 85 seconds, but the least expensive equipment may take up to 3 minutes to generate an image. The slower plate cycle time with less expensive CR systems may be a disadvantage during examinations requiring a large number of exposures batched together such as equine purchase examinations. None of these systems take longer than hand processing lm with wet chemistry, but the least expensive take longer than most automatic lm processors.

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5. IDEXX Labs: Digital imaging, IDEXXCR compact system; available at http://www.idexx.com/animalhealth/digital/compact September 2004 6. Sonoda M, Takano M, Miyahara J, et al: Computed radiography utilizing scanning laser stimulated luminescence. Radiology 148:833-838, 1983 7. Greene RE, Oestmann J: Computed Digital Radiography in Clinical Practice. New York, NY, Thieme Medical Publishers, 1992 8. Kato H: Photostimulable phosphor radiography design considerations, in Specications, Acceptance Testing and Quality Control of Diagnostic X-Ray Imaging Equipment Seibert JA, Barnes GT, Gould RG (eds.). Medical Physics Publishing, Madison, WI, 1991, pp 860 898 9. Eastman Kodak: Digital Radiography Using Storage Phosphors. Kodak Health Sciences Technical and Scientic Monograph. Rochester, NY, Eastman Kodak, 1992 10. Miyahara J: Imaging plate, in Tateno Y, Iinuma T, Takano M(eds): Computed Radiology. Tokyo, Springer, 1998 11. Reilly JF: Product comparisonComputed radiography/digital radiography systems. Imaging Technol News 4:46-49, 2004 12. Cowen AR: Physical aspects of photostimulable phosphor computed radiography. Br J Radiol 66:332-345, 1993 13. Buckley KM, Schaefer CM, Green R, et al: Detection of bullous lung disease: Conventional radiography vs digital storage phosphor radiography. Am J Roentgenol 156:467-470, 1991 14. Kottamasu SR: Pediatric musculoskeletal computed radiography. Pediatr Radiol 27:563-575, 1997 15. Murphey MD: Computed radiography in musculoskeletal imaging. Semin Roentgenol 32:64-76, 1997 16. Swee RG, Gray JE, Beabout JW, et al: Screen-lm versus computed radiography of the hand: A direct comparison. Am J Roentgenol 168: 539-542, 1997 17. Wegryn SA, Piraino DW, Richmond BJ, et al: Comparison of digital and conventional musculoskeletal radiography: An observer performance study. Radiology 175:225-228, 1990 18. Tan THL: Uperschwinger: Artifact in computer radiographs. Br J Radiol 70:431, 1997 (letter) 19. Agfa. The highest productivity in computer radiography.Afga-Gavaert N.V. Report. Belgium, The Netherlands, Agfa-Gaveart, 1994 20. Vuylsteke P: Optimizing radiography imaging performance. Proc Am Assoc Phys Med Summer School American College of Radiology 107151, 1997 21. American College of Radiology: Standard for Teleradiology. Reston, VA, 1999

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