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.

C
onventional film–intensifying screen which means that it cannot tolerate a wide
radiography has been used for decades range in radiation exposure without risking sat-
and has served the medical profession uration. In some studies, that latitude limitation
well. In an age of computers and digital data, it means some areas will be overexposed and some
is no surprise that digital diagnostic imaging underexposed in the same film. In general, users
has become the standard in human medicine. must choose between good contrast and good
Intro- duced in the 1980s by Fujifilm Medical latitude with traditional radiography1,2 (Figure 1).
Sys- tems, computed radiography (CR) was Another disadvantage with traditional radi-
initially limited to a few select veterinary ography is that the image cannot be adjusted
colleges and specialty private veterinary once taken. Although some errors, such as posi-
practices because of high cost. As technology has tioning problems or patient movement, reduce
evolved, more and more veterinary practices image quality regardless of the technology,
have replaced conven- tional film–screen other errors have different remedies depending
systems with CR. Further development has led on the procedure used. With traditional radiog-
to veterinary-specific CR systems, making digital raphy, the film is exposed and then processed
radiography more acces- sible than ever before. and viewed. At that time, any errors in the
This article considers the basic principles of CR exposure cannot be remedied. Therefore, the
and how it may be used in modern veterinary image must be retaken, which increases radia-
imaging. tion exposure to the technician and patient,
increases the cost of the examination, inconven-
LIMITATIONS OF TRADITIONAL iences the animal’s owner, and uses additional
RADIOGRAPHY
Email comments/questions to Silver halide film has several technician and veterinarian time.
[email protected], 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
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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 patient’s 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 veterinary medicine use a hospital’s current radiographic
human medicine in the 1980s by Fujifilm Medical generator. The image is created on reusable storage
Systems. CR is a process, not a single product. It is an phosphor imaging plates rather than film.
entire digital x-ray image management system. Its use in The storage phosphor plates are similar to intensify-
veterinary medicine has increased over the last decade as ing screens. When exposed to x-rays, intensifying
smaller, more afford- able systems have become available. screens emit light immediately, exposing the radio-
Mobile equine practi- tioners have been the leaders in graphic film. In contrast, when phosphor plates are
the use of CR technology because of its advantages for exposed to x-rays, part of the radiation energy is
mobile farm calls.1,2 absorbed by electrons, which store the image temporar-
Digital radiography is used for both small and large ily. The latent image is read by scanning the imaging
animal imaging, in veterinary teaching hospitals, by spe-

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Digital Imaging and Communications in Medicine

The American College of Radiology and the National Electrical Manufacturer’s Association formed a joint committee to develop
DICOM’s scope is diagnostic imaging.18

Figure 2. The two sizes of imaging plates available for

the compact system are 8  10 inches and 8  12 inches.

hospital or specialist. Many telemedicine services do

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 own printer, in most cases, to print out hard copy
their computer.5 There are studies from human medicine (paper) images (Figure 3).
that suggest “soft copy” diagnoses (on the monitor) are Mobile units are available that can be easily carried to
equal to or better than hard copy diagnoses, although a farm or on a house call. One currently available
this depends on the quality of the monitor. Paper images compact reader weighs 35 lb (16 kg). A laptop computer
from laser or inkjet printers are primarily client commu- and portable printer are part of the mobile system5
nication pieces in small animal medicine; in equine med- (Figure 4). Veterinary dentists may also use digital
icine, when annotated appropriately using the on-screen radiography,
measurements, paper images can be used as a often with human dental equipment.7
communi- cation tool with veterinarians. Several veterinary teaching hospitals, specialist prac-
Several vendors offer high-quality film printers to use tices, and large equine practices now use Fuji CR systems.
with CR systems. These printers produce diagnostic- Although those systems are beyond the budget of a typi-
quality films for on-site storage or to send to a referring cal private practice, other manufacturers are now provid-
ing CR and DDR technology. Because the technology
is

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

bone detail) in the displayed image. In the best systems,

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

ADVANTAGES
The Images
Assuming a perfectly obtained exposure, on balance,
a CR digital image is similar to that obtained with
con- ventional radiography, with each having
advantages and disadvantages.1,10–13 When using film,
the veterinarian must choose between good contrast
and good latitude. This choice is not required when
using CR. There is a linear relationship in digital
radiography that does not exist with film. The number of
electrons trapped by x-ray exposure is linearly related to
the x-ray intensity. Images from the storage phosphor
plates have more exposure latitude (more shades of
gray) than film images. High gray-scale resolution is
desirable because it allows detec- tion of very slight
differences in radiation attenuation

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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 tissue–only 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
the computer monitor. Likewise, the quality of paper
Properly exposed image of the same dog after computer
manipulation. used to print out CR images affects the quality of the
image that is visualized on paper.

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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 image—and ruption of patient data.
potentially make the diagnosis—sooner, and a veteri- Digital storage allows quick access and viewing. With
narian and client can discuss the findings and proceed today’s 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
ings or to the client returning to the clinic to view the client and farrier when corrective shoeing may be
image. Clients may also be more willing to proceed to necessary.
the next step if they do not have to reschedule and pay An image can be sent electronically to a specialist for fur-
for an additional consultation. ther evaluation. In emergency situations, this instant consul-
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
using manual development. Additionally, practices that con- verted to compressed formats (e.g., jpg) for efficient
have inefficient workflow patterns may still have those trans- mission. Network PACS that allow access to the
inefficiencies when they use CR. database are found in larger practices or universities and
can solve some problems (e.g., veterinarians can access the
Fewer Retakes larger sys- tem from a remote location and view the
Retaking radiographs is common in veterinary medi- radiographs with- out downloading them onto their own
cine. Patient motion, improper exposure, and position- computer).
ing problems all contribute to the need to retake a A digital image can be emailed to allow the veterinar-
radio- graph. At the least, these retakes require ian and client to view the image in follow-up calls.
additional use of veterinarian and technician time. Other Likewise, images can be emailed to specialists, without
disadvan- tages include additional client trips to the the extra work of making copies.
clinic, farm visits, or house calls. The patient may have to
be sedated again, and the veterinary team is exposed to Cost Savings
additional radiation and developing chemicals.1,3 Although the overall cost of purchasing a CR system
Retakes are significantly reduced with digital radiog- is higher than that of a film developer, there are some
raphy. Some, but not all, problems that cause retakes can cost savings associated with CR, including fewer
be remedied. Specifically, problems with exposure can retakes. Redoing images entails the cost of equipment,

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supplies, time, and labor. In cases in which two
tradi-

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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
waiting to return to the clinic to make comparisons. over- come with image enhancement. Veterinarians
must also be careful not to overprocess an image and
DISADVANTAGES create arti- facts (e.g., apparent lesions) through
Disadvantages of using CR include making the software manipula- tion. Comparing the unprocessed
change to a new system, the need for training, and cost. image with the manip-
Because veterinary staff have to learn to use the new ulated one is a way of detecting processing artifacts.
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 user’s 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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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/
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168(2):539–542, 1997.
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