Article #4

CE Breakthroughs in Radiography:
Computed Radiography
John S. Mattoon, DVM, DACVR
The Ohio State University

Carin Smith, DVM*

Smith Veterinary Consulting
Peshastin, Washington

ABSTRACT:
Computed radiography (CR) is a digital imaging technology and digital x-ray image
management system that has been used in human and veterinary medicine since the
1980s. CR helps eliminate many of the disadvantages of traditional radiography. A storage
phosphor plate collects the pattern of x-ray attenuation that is extracted by a reader,
which converts the data into a digital signal. The image is stored like any computer file
and can be viewed on a computer screen, transmitted electronically, or printed out on
paper or transparent film, similar to x-ray film. Computer software allows manipulation
of the digital image to enhance viewing.

onventional filmintensifying screen which means that it cannot tolerate a wide

C radiography has been used for decades

and has served the medical profession
well. In an age of computers and digital data, it
range in radiation exposure without risking sat-
uration. In some studies, that latitude limitation
means some areas will be overexposed and some
is no surprise that digital diagnostic imaging has underexposed in the same film. In general, users
become the standard in human medicine. Intro- must choose between good contrast and good
duced in the 1980s by Fujifilm Medical Sys- latitude with traditional radiography1,2 (Figure 1).
tems, computed radiography (CR) was initially Another disadvantage with traditional radi-
limited to a few select veterinary colleges and ography is that the image cannot be adjusted
specialty private veterinary practices because of once taken. Although some errors, such as posi-
high cost. As technology has evolved, more and tioning problems or patient movement, reduce
more veterinary practices have replaced conven- image quality regardless of the technology,
tional filmscreen systems with CR. Further other errors have different remedies depending
development has led to veterinary-specific CR on the procedure used. With traditional radiog-
systems, making digital radiography more acces- raphy, the film is exposed and then processed
sible than ever before. This article considers the and viewed. At that time, any errors in the
basic principles of CR and how it may be used exposure cannot be remedied. Therefore, the
in modern veterinary imaging. image must be retaken, which increases radia-
tion exposure to the technician and patient,
LIMITATIONS OF TRADITIONAL increases the cost of the examination, inconven-
RADIOGRAPHY iences the animals owner, and uses additional
Email comments/questions to Silver halide film has several technician and veterinarian time.
compendium@medimedia.com, limitations. It has a limited In addition, traditional radiography requires
fax 800-556-3288, or log on to linear response to radiation, handling of film for viewing, archiving, and
www.VetLearn.com *While preparing this article, Dr. Smith received financial support from IDEXX Laboratories, Inc.

January 2004 1 COMPENDIUM

Reprinted with permission by Veterinary Learning Systems.
2 CE Breakthroughs in Radiography: Computed Radiography

Figure 1. Comparison of a conventional film-screen radiograph and a CR film. (Courtesy of Dr. Kip Berry, Maitland, FL)

Conventional pelvic radiograph of a dog with a total right-hip CR film of the same patient. Increased resolution of the fine bony
prosthesis. trabeculae and increased edge sharpness of the bony and soft tissue
structures are apparent. Note the resolution of the wire mesh of
the acetabular prosthesis compared with the image at the left.

transmission to others. If a pet owner, horse owner, or cialists (including veterinary dentistry), and in large pri-
another veterinarian wishes to view an image from a vate practices. As its use increases and prices drop, more
remote location, the image must be either copied and practices will use digital radiography.
sent via courier or scanned before electronic transmis-
sion. Films must be stored in a physical space that is TECHNOLOGY OF COMPUTED
large enough to access and sort films. This is usually a RADIOGRAPHY
separate area from the patients other records.2,3 CR is an indirect capture digital imaging technology,
which means that plates are used to capture the image
HISTORY OF DIGITAL RADIOGRAPHY before it is transferred to a computer. CR systems for
CR is a digital imaging technology introduced in human veterinary medicine use a hospitals current radiographic
medicine in the 1980s by Fujifilm Medical Systems. CR is generator. The image is created on reusable storage
a process, not a single product. It is an entire digital x-ray phosphor imaging plates rather than film.
image management system. Its use in veterinary medicine The storage phosphor plates are similar to intensify-
has increased over the last decade as smaller, more afford- ing screens. When exposed to x-rays, intensifying
able systems have become available. Mobile equine practi- screens emit light immediately, exposing the radio-
tioners have been the leaders in the use of CR technology graphic film. In contrast, when phosphor plates are
because of its advantages for mobile farm calls.1,2 exposed to x-rays, part of the radiation energy is
Digital radiography is used for both small and large absorbed by electrons, which store the image temporar-
animal imaging, in veterinary teaching hospitals, by spe- ily. The latent image is read by scanning the imaging

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 Breakthroughs in Radiography: Computed Radiography CE 3

Digital Imaging and Communications

in Medicine
The American College of Radiology and the National
Electrical Manufacturers Association formed a joint
committee to develop a global standard for Digital
Imaging and Communications in Medicine Figure 2. The two sizes of imaging plates available for
(DICOM). DICOM was intended to realize the the compact system are 8 10 inches and 8 12 inches.
interoperability between multiple devices
manufactured by different vendors (e.g., transmission
of images or information, displaying of an image). hospital or specialist. Many telemedicine services do
DICOMs scope is diagnostic imaging.18 not require hard-copy films and can support images in
multiple formats.
Currently available CR systems offer a range of imag-
plate with laser light. The electrons then return to their ing plate sizes, although the portable systems offer only
ground state by releasing visible light, which is detected a limited number of plate sizes (Figure 2). Plate mainte-
and converted to a digital image.1,2 nance includes regular cleaning by wiping with ethanol-
Exposure to a bright light (including sunlight) fully soaked gauze. The plates must be erased after each
de-excites the trapped electrons, erasing the stored exposure/read cycle to eliminate the residual energy
image. The imaging plates are reusable thousands of within the phosphors, which may produce ghost images.
times but are subject to physical wear and tear.2 The laser scanning process deactivates only about 50%
This article focuses on CR, which is the most tested of the stored energy, so the residual must be erased
digital radiographic technology to date. Direct digital before the plates are re-exposed. This can be done in
radiography (DDR; also called direct capture digital radi- conjunction with image reading in some systems. In
ography) uses a single unit, without a separate plate and addition, plates should be exposed to bright light at least
scanner. Both CR and DDR are used in human and once a week to remove any residual energy captured as
veterinary medicine.4 they sit unused.6
A CR system often has its own dedicated computer.
COMPONENTS OF COMPUTED Radiographs typically require one to 10 or more
RADIOGRAPHY SYSTEMS megabytes of space, which can be stored on the system
CR systems include hardware and software that fill hard drive or a network server and on portable media
several needs: radiation detection, radiographic display, such as CDs or DVDs (DVDs are now popular because
and storage or archiving. A complete CR hardware sys- of their increased storage capacity). An ideal CR system
tem includes imaging plates, a laser light scanner (plate would have the computer networked to other practice
reader), computer, and printer. Veterinarians may use the computers for data transfer to other applications, such
same radiographic generator that is used for traditional as practice management software. Veterinarians can use
radiography and the printer they normally use with their their own printer, in most cases, to print out hard copy
computer.5 There are studies from human medicine that (paper) images (Figure 3).
suggest soft copy diagnoses (on the monitor) are equal Mobile units are available that can be easily carried to a
to or better than hard copy diagnoses, although this farm or on a house call. One currently available compact
depends on the quality of the monitor. Paper images reader weighs 35 lb (16 kg). A laptop computer and
from laser or inkjet printers are primarily client commu- portable printer are part of the mobile system5 (Figure 4).
nication pieces in small animal medicine; in equine med- Veterinary dentists may also use digital radiography,
icine, when annotated appropriately using the on-screen often with human dental equipment.7
measurements, paper images can be used as a communi- Several veterinary teaching hospitals, specialist prac-
cation tool with veterinarians. tices, and large equine practices now use Fuji CR systems.
Several vendors offer high-quality film printers to use Although those systems are beyond the budget of a typi-
with CR systems. These printers produce diagnostic- cal private practice, other manufacturers are now provid-
quality films for on-site storage or to send to a referring ing CR and DDR technology. Because the technology is

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4 CE Breakthroughs in Radiography: Computed Radiography

Figure 3. Computer hardware: monitor, keyboard, and Figure 4. Mobile CR system: laptop and printer.
printer.

image for each radiographic view. Animal and human

new to veterinary medicine, there will likely be many new radiographic parameters differ sufficiently enough that
suppliers in the future. Some of them display their equip- software parameters developed for human medical use
ment in exhibit halls at major veterinary meetings. are not immediately adaptable for veterinary use. Veteri-
narians should ensure that their software is customized
IMAGE MANAGEMENT SOFTWARE for their specific use, whether equine or small animal
AND IMAGE PROCESSING imaging.
The term picture archiving and communication system Image software should ideally allow a user to include
(PACS) applies to the combined hardware and software information about the animal and client. Highlighting
used for digital imaging. In addition to PACS created for suspect areas and noting comments on the image can
human medical use, veterinary-specific PACS software make future readings easier. Image manipulation tools
has been developed. A PACS allows communication include brightness, contrast, magnification, inverting
between computers. Some users of CR do not use PACS black and white, edge enhancement, and cropping. Using
but instead simply use the image software provided by the image-management software, images that are too
the manufacturer to manipulate and view the data. light or dark can be adjusted and marginal images can be
Images are obtained using an available x-ray generator optimized. The long latitude allows brightening or dark-
and the digital imaging plates. 8 Veterinarians must ening of an image and potentially reveals areas that
develop new technique charts for their new CR system would not appear on the standard radiograph (Figure 5).
based on the manufacturers guidelines. Because digital Ideally, the PACS software would interplay with a
and screen-film have different characteristics, it cannot practices medical records system. Including digital
be assumed that the exposure techniques that work best images in patient records is one step closer to an inte-
for screen-film will be optimal for digital imaging.3 grated medical record system.9
After the plates image is transferred to the scanner,
the digital images are communicated electronically to a ADVANTAGES
computer. The images can be displayed on a computer The Images
screen, sent to others via email, or printed on transpar- Assuming a perfectly obtained exposure, on balance, a
ent film or photo-quality or plain paper. Because of the CR digital image is similar to that obtained with con-
high exposure latitude, an unprocessed digital image ventional radiography, with each having advantages and
usually does not look the same as a film/screen radio- disadvantages.1,1013 When using film, the veterinarian
graph. Most CR systems have built-in image processing must choose between good contrast and good latitude.
software to enhance the diagnostic information (e.g., This choice is not required when using CR. There is a
bone detail) in the displayed image. In the best systems, linear relationship in digital radiography that does not
these image-processing algorithms are preset by species exist with film. The number of electrons trapped by x-ray
and view and optimized for veterinary radiography. exposure is linearly related to the x-ray intensity. Images
Other systems offer the user a tool kit of algorithms to from the storage phosphor plates have more exposure
adjust the displayed image to pull out different degrees latitude (more shades of gray) than film images. High
of detail. gray-scale resolution is desirable because it allows detec-
Human medical CR software helps optimize the tion of very slight differences in radiation attenuation

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 Breakthroughs in Radiography: Computed Radiography CE 5

Figure 5. CR thoracic images of a medium-size dog. that may not be visible with film.1 Because x-ray film has
(Courtesy of Dr. Kip Berry, Maitland, FL) a limited linear response, a relatively small under- or
overexposure may result in an unacceptable image.14
The higher contrast resolution (or exposure latitude)
of CR has two consequences:

The need for retakes resulting from over- and under-

exposure is reduced. Images that are too light or dark
that would be discarded on film can be contrast-
adjusted with the image management software. Mar-
ginal images, which would normally be read or for-
warded to a specialist for a consultation, can now be
optimized, increasing their diagnostic utility.
It is possible to see both soft tissue and bone detail in
a single image, reducing the total number of images
Underexposure. that have to be taken. Although both can be seen in
some standard radiographs, CR offers an advantage
in larger patients. Some software packages offer spe-
cial energy subtraction tools, which make it possible
to view bone-only and soft tissueonly images from a
single exposure.15

In digital radiography, the x-ray beam is converted into

an electronic form that is digitized and numerically
encoded into discrete picture elements (pixels). The num-
ber of pixels per unit area determines the theoretical spa-
tial resolution of the digital image. Actual spatial resolu-
tion of the digital image is determined by the efficiency
of the imaging plate and the design of the plate reader.
The spatial resolution of CR images is lower than a
high-quality film image. However, much of the
Overexposure. increased film resolution is beyond the range detectable
by the human eye, and as technology advances, this dif-
ference is becoming negligible. Many studies conducted
in human medicine show that CR images are equal to
or better than traditional film for evaluating most body
parts. Perceived image quality and the ability to visual-
ize abnormalities depend more on software manipula-
tion and processing of the image after it is taken than
on spatial resolution. CR has been clinically validated
in human medicine for over 18 years in a variety of
applications, including mammography, suggesting that
its minimally lower spatial resolution is not a clinical
limitation.1,2,16,17
The ability of the viewer to appreciate the image qual-
ity obtained with CR partially depends on the quality of
Properly exposed image of the same dog after computer
the computer monitor. Likewise, the quality of paper
manipulation. used to print out CR images affects the quality of the
image that is visualized on paper.

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6 CE Breakthroughs in Radiography: Computed Radiography

CR software allows an image to be not only manipu- often be remedied through manipulation of the image
lated but also measured and drawn on. For instance, on the computer.
heart dimensions or hip angles in a dog or hoof angles in
a horse can be measured. These measurements and com- Image Storage and Transport
ments can be printed directly onto the image, and the Backup copies are easier to create and store. The user
original (clean) image can be retained as a separate file. can also usually export the image files in other formats
(e.g., jpg, bmp, tiff ) depending on the image manage-
Time Savings ment software. Like other computer files, these should
Use of CR can reduce the time it takes to see the be backed up on removable media to avoid loss or cor-
image. A veterinarian can obtain the imageand ruption of patient data.
potentially make the diagnosissooner, and a veteri- Digital storage allows quick access and viewing. With
narian and client can discuss the findings and proceed todays demand for fast information, having access to a
to the next step without delay.3 This is especially true digital file offers veterinarians a distinct advantage over
for clinics with manual processing or in mobile prac- retrieving and viewing a specific film.
tices. In busy practices in which images are not Digital storage allows easy transferability of images via
processed until the client has departed, obtaining an email and easy reproduction. Veterinarians can simply print
image quickly is preferable to the veterinarian calling out a copy of the images for clients to take home. Equine
the client on the phone and trying to convey the find- veterinarians may want to provide copies for both the client
ings or to the client returning to the clinic to view the and farrier when corrective shoeing may be necessary.
image. Clients may also be more willing to proceed to An image can be sent electronically to a specialist for fur-
the next step if they do not have to reschedule and pay ther evaluation. In emergency situations, this instant consul-
for an additional consultation. tation with a specialist could be lifesaving for the patient.

CR images can be manipulated with computer software

to enhance visualization.

Practices that currently use an automatic processor Large images may need to be sent off site via file transfer
may not realize the same time savings as those who are protocol (FTP) or custom teleradiology systems or be con-
using manual development. Additionally, practices that verted to compressed formats (e.g., jpg) for efficient trans-
have inefficient workflow patterns may still have those mission. Network PACS that allow access to the database
inefficiencies when they use CR. are found in larger practices or universities and can solve
some problems (e.g., veterinarians can access the larger sys-
Fewer Retakes tem from a remote location and view the radiographs with-
Retaking radiographs is common in veterinary medi- out downloading them onto their own computer).
cine. Patient motion, improper exposure, and position- A digital image can be emailed to allow the veterinar-
ing problems all contribute to the need to retake a radio- ian and client to view the image in follow-up calls.
graph. At the least, these retakes require additional use Likewise, images can be emailed to specialists, without
of veterinarian and technician time. Other disadvan- the extra work of making copies.
tages include additional client trips to the clinic, farm
visits, or house calls. The patient may have to be sedated Cost Savings
again, and the veterinary team is exposed to additional Although the overall cost of purchasing a CR system
radiation and developing chemicals.1,3 is higher than that of a film developer, there are some
Retakes are significantly reduced with digital radiog- cost savings associated with CR, including fewer
raphy. Some, but not all, problems that cause retakes can retakes. Redoing images entails the cost of equipment,
be remedied. Specifically, problems with exposure can supplies, time, and labor. In cases in which two tradi-

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 Breakthroughs in Radiography: Computed Radiography CE 7

tional images would be taken to visualize bone and then CR system must be weighed against the benefits of using
soft tissue (especially in large patients or body parts), less film and chemicals and the significant benefit of
one image may suffice with CR. Savings include less increased efficiency. The cost savings of using a CR sys-
labor and time of the veterinarian and technician as well tem grows over time as the number of retakes is reduced.
as less film, developing, and storage of multiple images. Some veterinarians charge more per image for CR
For high-volume practices, the monthly cost of film, than for traditional film radiographs. This reflects the
developer maintenance, and chemicals may be higher improved service, the reduced number of films that
than the monthly lease of a new CR system. must be taken, and client appreciation of the new tech-
nology. Both the initial costs and maintenance costs
Monitoring Changes affect the purchase analysis. Cost comparisons of con-
Animals with chronic or progressive disease often ventional and CR include initial capital and setup, train-
have sequential radiographs taken over time. Compari- ing, and operating.
son of these images, including disease progression or The cost of consumables in conventional radiography
response to treatment, is easier with CR than with tra- includes film, film jackets, fixer, developer, and disposal
ditional radiography. The images can be manipulated to of toxic chemicals. CR technology eliminates those
have the same contrast. Although differences associated costs, although the initial cost of the CR plates is more
with patient mobility, phase of respiration, or poor posi- than that of standard film cassettes.
tioning may still occur, the veterinarian can equalize the Digital images must be backed up just like other com-
contrast and monitor differences in the sequential puter files. If veterinarians want printed copies of each
images that may reflect actual changes in the patient image, their hard-copy storage space will not be reduced.
and not in the exposure technique. Mobile veterinarians Digital manipulation cannot make all images useful.
in the field can easily access prior images rather than Very poor exposure or patient movement cannot be over-
waiting to return to the clinic to make comparisons. come with image enhancement. Veterinarians must also
be careful not to overprocess an image and create arti-
DISADVANTAGES facts (e.g., apparent lesions) through software manipula-
Disadvantages of using CR include making the tion. Comparing the unprocessed image with the manip-
change to a new system, the need for training, and cost. ulated one is a way of detecting processing artifacts.
Because veterinary staff have to learn to use the new Optimal viewing of CR images requires a high-qual-

The cost savings of using a CR system grow over time

as the number of retakes is reduced.

software, ease of use should be an important purchase ity monitor and, if detailed print images are desired, a
criterion. Manipulation of images takes practice and can high-quality printer and laser film. Veterinarians must
be time-consuming at first, depending on a users com- become accustomed to viewing films in an area other
puter skills.2 Because CR systems allow use of the exist- than on a view box.
ing radiographic generator and cassette-based method- CR will not compensate for poor radiographic tech-
ology, staff will be comfortable with that familiar aspect niques or tools or poor staff training. For example, sloppy
of the new technology. measurements caused by broken or bent calipers or not
CR systems are costly, although their prices are falling using a grid for images of anatomic regions greater than
consistently and they are affordable and economical for 15 cm will have the same effect on CR images as on
some high-volume practices. Direct costs include the film/screen images. In addition, improper labeling or
computer hardware, software, and optional higher-qual- misidentification of patients will undermine the image
ity paper for printing (images may be viewed on the storage and retrieval functions. Investment in a new CR
monitor for reading fine detail). The initial cost of the system should include a renewed commitment to main-

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8 CE Breakthroughs in Radiography: Computed Radiography

taining a high level of radiography practice for all staff. 6. American Association of Physicists in Medicine: Acceptance Testing and Qual-
ity Control of Photo Stimulable Phosphor Imaging Systems: Report of Task Group
#10, American Association of Physicists in Medicine. Available at www.the
THE FUTURE OF RADIOGRAPHY capturedimage.com/pdf/aapm10v3.doc; accessed November 2003.
Digital imaging provides many intangible benefits that 7. All Pets Dental: Why Radiology? Available at http://www.dentalvet.com/
are hard to quantify. Justifications for its use include vets/basicdentistry/whywhenhow_radiology.htm; accessed November 2003.
increased veterinarian efficiency, better diagnostic analy- 8. Fujifilm: Basic CR Theory. Available at http://www.fujimed.com/
medical/cr_basics.html; accessed November 2003.
sis, and timely decisions about patient care. One major
9. IDEXX Laboratories: Benefit from Innovation in Image Enhancement and
intangible benefit of CR is that it can help staff recog-
Management. Available at http://www.idexx.com/AnimalHealth/
nize that radiography is not a product but a service that Digital/PACS/; accessed November 2003.
provides diagnostic information, including the image 10. Swee RG, Gray JE, Beabout JW, et al: Screen-film versus computed radiog-
and written report. Increasingly, veterinarians collect, raphy imaging of the hand: A direct comparison. Am J Roentgenol
168(2):539542, 1997.
store, and transmit medical information digitally, thus
providing added convenience to veterinarians and clients. 11. Don S, Hildebolt CF, Sharp TL, et al: Computed radiography versus screen-
film radiography: Detection of pulmonary edema in a rabbit model that stim-
Many practitioners will wait for costs to come down ulates neonatal pulmonary infiltrates. Radiology 213:455460, 1999.
before investing in digital imaging equipment. However, 12. Reiner B, Siegel E, McLaurin T, et al: Evaluation of soft-tissue foreign bod-
the integration of this technology into private veterinary ies: Comparing conventional plain film radiography, computed radiography
practice is certain. Veterinarians will need to learn about printed on film, and computed radiography displayed on a computer work-
station. Am J Roentgenol 167(1):141144, 1996.
digital radiography so that they are ready to use it when
13. Wegryn SA, Piraino DW, Richmond BJ, et al: Comparison of digital and
it comes to their hospital. conventional musculoskeletal radiography: An observer performance study.
Radiology 175(1):225228, 1990.
REFERENCES 14. Roberts G: Computed radiography: How it works and its advantages. The
1. Greene RE, Oestmann J: Computed Digital Radiography in Clinical Practice. AAEP 2000 Resort Symposium Lecture Workbook, February 46, 2000.
New York, Thieme Medical Publishers, 1992, pp 246. 15. Fujifilm: Advanced Processing Capabilities of FCR. Available at http://www.
2. Roberts G, Graham J: Computed radiography, in Kraft S, Roberts G (eds): fujimed.com/medical/cr_process5.html; accessed November 2003.
Vet Clin North Am Equine Pract: Modern Diagnostic Imaging. Philadelphia,
16. Murphey MD, Bramble JM, Cook LT, et al: Nondisplaced fractures: Spatial
WB Saunders, 2001, pp 4762.
resolution requirements for detection with digital skeletal imaging. Radiology
3. Launders J: Digital x-ray systems, Part 1: Health devices: An introduction to 174(3 Pt 1):865870, 1990.
DX technologies and an evaluation of cassette DX systems. Health Devices
30(8):273310, 2001. 17. Lund PJ, Krupinski EA, Pereles S, Mockbee B: Comparison of conventional
and computed radiography: Assessment of image quality and reader perfor-
4. Fujifilm: CR vs. DR. Available at http://www.fujimed.com/medical/
crvsdr.html; accessed November 2003. mance in skeletal extremity trauma. Acad Radiol 4(8):570576, 1997.

5. IDEXX Laboratories: Enhance Your Patients Image. Available at http:// 18. Ogoda M: DICOM 101: Understanding the Basics of DICOM. Insights &
www.idexx.com/AnimalHealth/Digital/index.cfm; accessed November Images: The Users Publication of Computed Radiography. Stamford, CT, Fuji-
2003. film Medical Systems, 2001, pp 2, 4.

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