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Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality - ERADIMAGING.COM: RT
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MENU & DETAILS :: Course Description And Objectives :: CE Information Release Date: 11/14/2008 Expiration Date: 11/30/2012

Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality
Tracy Herrmann, MEd, RT(R)
*Professor, Allied Health University of Cincinnati, Raymond Walters College, Blue Ash, Ohio.

Address correspondence to: Tracy Herrmann, MEd, RT(R), Professor, Allied Health University of Cincinnati, Raymond Walters College, 9555 Plainfield Road, Blue Ash, OH 45236. E-mail: Disclosure: Ms Herrmann reports having no significant financial or advisory relationships with corporate organizations related to this activity. ABSTRACT The medical imaging field has been considerably impacted in recent years by the emergence of digital imaging modalities, including computed radiography (CR) and digital radiography (DR), also known as direct digital radiography. Digital systems often allow for a streamlining of workflow and greater flexibility in staffing options, which may help offset the substantial costs associated with acquiring digital equipment. When comparing CR and DR, each type of system offers relative advantages, but DR may represent a better option for some facilities with a larger patient load due to the greater ease of use and elimination of cassette handling with DR. When considering a switch to CR or DR, facilities should anticipate the need for extensive staff training because medical imaging professionals require specialized knowledge in these systems to make the regular adjustments to image acquisition and processing that limit radiation dose while preserving image quality. This review addresses important similarities and differences between CR and DR technologies and explains technical practices that can help maximize the safety and diagnostic strength of these modalities.


he use of digital technology in diagnostic medical imaging is rapidly expanding. A census conducted in 2005 to 2006 by IMV Medical Information Division, Inc reported that of 4860 hospitals surveyed, 56% had installed digital computed radiography (CR) systems and 30% had installed direct digital radiography (DR) systems.1 As the benefits of digital technology continue to grow, it is becoming increasingly important for medical imaging professionals to understand the differences and similarities between CR and DR, as the similarity of the terms alone can

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be confusing. CR typically refers to cassette-based technology that uses a scanning/reader mechanism to extract information from the exposed cassette. Meanwhile, DR, sometimes referred to as cassetteless, typically refers to technology in which the latent image data are transferred directly from a flat-panel detector to a review monitor without the need for a reader. Some of the newer DR technology today, however, allows for DR plates to be used with mobile X-ray units or in bucky trays using wireless remote technology to transfer the image data. The similarities between CR and DR technology are primarily in the digital format of the resultant image. Both CR and DR image formats are compatible for storage in a digital picture archiving computer system (PACS) and the appearance of the digital images can be manipulated. The differences are much more numerous and involve the operation and image capture; workflow and cost; technique and dose; and image quality. This review discusses the relative advantages of CR and DR and outstanding limitations of digital modalities. Operation and Image Capture The most substantial differences between CR and DR radiography lie in the operation of the systems and processes by which images are captured. The overall differences between CR and DR in terms of steps required to complete an imaging study and image quality are summarized in the Table.



Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality - ERADIMAGING.COM: RT

Digital Imaging: Necessary Setup of Imaging and Patient Data Any imaging study begins with a brief patient consultation and preparation to ensure that the examination goes smoothly. Proper room preparation is also necessary in any imaging modality. In a digital environment, a PACS is most likely used to manage imaging data and streamline information transfer between relevant departments. For instance, under the direction of the PACS, the radiology information system (RIS) collects patient information from a central hospital information system. In digital modalities, users can confirm that the planned imaging procedure has been indeed ordered for the patient through the RIS. Also, digital systems allow technologists to track specific information on the imaging procedure, patient position, and orientation to ensure that images are accurately processed. General Steps in Digital Imaging All technologists are familiar with the routine steps needed in completing an imaging study. Once the technologist has reviewed the patient's data and confirmed that all of the required information is available, the patient is brought to the imaging room. In CR imaging, the technologist then loads the cassette, positions the patient, positions the tube, performs the exposure, transports the cassette, processes the cassette, performs a brief quality control (QC) review of the image, and then returns to the patient to complete the appointment. An advantage of CR when performing non-routine or trauma radiography is the allowance of unlimited manipulation and positioning of the image receptor for cross-table projections and those that require creative techniques due to patient condition. Meanwhile, most DR imaging eliminates the steps requiring the manipulation of a cassette, and the image is sent directly to the review station normally located near the X-ray control panel. The position of some DR detectors can be manipulated to allow for cross-table lateral and decubitus procedures.



Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality - ERADIMAGING.COM: RT
CR Image Capture In CR digital imaging, a photostimulable phosphor (PSP) plate within the imaging cassette is exposed during the study. Depending on the specific needs of the facility, vendors offer systems with phosphor plates that are either flexible and allow for more rapid image processing or rigid and ensure greater durability over time. The latent image is captured in the plate as electrons in the phosphor are excited when exposed to radiation. With time, this latent image eventually degrades due to spontaneous phosphorescence. For example, a typical image can be expected to lose approximately 25% of its stored energy within 8 hours of initial exposure. After exposure, the cassette is placed in a reader to capture and analyze the image data. A laser extracts information from the plate as an analog electrical signal, and an analog-to-digital converter translates this signal to digital binary code. Technologists may need to make note of the direction of the laser scan so that the source of artifacts or malfunctions can be located, if necessary, during the QC process. If a facility typically experiences a low volume of patients, a single reader, usually located in or near the imaging room, is sufficient. However, larger facilities with a greater patient volume often benefit from a centrally located multicassette reader. Once the analog image is converted to a digital image, the resulting digital image is sent to a review station and then to the PACS for processing. Before the next imaging study, the latent image is erased from the PSP through exposure to fluorescent light in the reader and then put back into the cassette. This step is necessary because the process of image capture in CR is relatively inefficient, and approximately 50% of the electrons that were excited during the initial radiation exposure are not released during the laser reading process. DR Image Capture Unlike CR imaging, DR systems use built-in image plates and no cassettes are required. This eliminates the manual steps required in manipulating the cassette and the time needed for PSP read-out and processing. A variety of image capture configurations are used in DR systems. These configurations can consist of either large-area, flat-panel detectors with integrated thin-film transistor (TFT) readout mechanisms, or integrated PSP plate scanning mechanisms. Alternatively, DR systems can house an optic lens that immediately translates the analog image to a digital image with a charge-coupled device (CCD) or complementary metal oxide semiconductor (CMOS) image sensor. Facilities should note that whereas CCD units can be serviced if problems arise, TFT mechanisms must be entirely replaced if they malfunction. In general, DR imaging processes result in an almost instant display of the desired diagnostic image on a monitor and can substantially reduce the amount of time needed for a successful imaging study. Flat-panel DR systems can either be characterized as providing a direct or indirect image capture. Indirect systems accomplish image capture through a process in which a scintillator turns X rays into light during exposure. A silicon photodiode then converts this light into an analog electrical charge. The TFT accomplishes the storage, digital translation, and readout of this electrical charge. Direct systems, meanwhile, house a selenium-based Xray photoconductor that turns X rays into an electrical charge, which can then be processed by the TFT. This eliminates the photodiode process and the step of converting X rays into light. Assessing Image Capture Efficiency Detective quantum efficiency (DQE) is a value used to describe a detector's efficiency in capturing images. This includes signal absorption efficiency, as well as conversion efficiency in indirect systems that require a scintillator for the translating of X rays to light. As DQE values increase, less radiation exposure is necessary to achieve a target signal-to-noise ratio. In general, modern digital CR systems achieve lower DQE values than DR flat-panel detectors. However, higher DQE in CR imaging can be achieved with systems that incorporate dual-side plate readers with cesium barium halide-structured phosphors. Other improvements, such as higher-efficiency crystals in the phosphor screens and lasers that are either smaller or thinner, can also be used to achieve better DQE in CR. Achieving better DQE is an important goal so that facilities can reduce the radiation doses needed to obtain quality diagnostic images, especially in pediatric populations.2 Workflow and Costs Compared with CR, the DR workflow is typically faster due to the removal of the cassette processing step. However, facilities considering a transition from CR to DR should carefully evaluate the potential for substantial costs in upgrading to DR. Initial evaluations of CR versus DR should weigh the advantages and drawbacks of a DR system in terms of workflow and relative costs, in the context of the facility's current patient load and projections for future growth. Workflow Advantages The ability to streamline workflow is a major advantage to DR systems, especially in facilities that regularly encounter a high patient volume. Even those imaging centers that do not currently have substantial scheduling constraints may see increased challenges in the future with the aging population and an anticipated dwindling of healthcare workers.3 Meanwhile, facilities could also be drawn to CR and DR systems as images are increasingly managed through PACS.3 While a CR image may take approximately 60 to 90 seconds to be processed and available for viewing, a DR image can be available for review within seconds. A DR system also frees medical imaging professionals from time-consuming tasks associated with cassette manipulation and image development, which opens up their schedule to other important tasks that can improve workflow.4 Also, transitioning to DR could resolve or prevent the repetitive motion injuries that have been reported with CR due to the constant need to handle cassettes.5 These factors could soon make DR upgrades more attractive to a wider range of facilities. Flexibility in Staffing Options The emergence of telemedicine may represent another changing aspect of radiology that favors DR and CR. A digital environment greatly improves a facility's ability to rapidly share images, either within different departments through an internal intranet or via the Internet to other facilities.6 This capability could substantially improve healthcare delivery, especially in emergency situations. Also, telemedicine applications are being developed that allow facilities to draw upon a larger pool of qualified healthcare personnel, especially in underserved geographic regions, by e-mailing lowerresolution digital images for review.6 Although the lower quality of digital images that can be e-mailed may be of concern, file compression technologies are improving and may increase the viability of this option to expand a facility's staffing pool.



Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality - ERADIMAGING.COM: RT
Space Constraints: Film Versus Digital Facilities considering an update to a digital imaging system should evaluate their short-term and long-term space and storage needs as an important component of the decision-making process. Currently available DR systems take up less space than CR units, which may be an important factor in facilities challenged by limited space. However, CR systems can offer clear advantages in the portability of the cassettes, especially if the facility regularly serves patients who are not easily moved.5 Although the physical space needed for storing films can be considerable, the electronic storage needed to store the digital images generated with DR and CR can be an important source of additional costs with a digital imaging upgrade. Digital image files are often very large, and the number of images obtained in one study has increased dramatically with the advent of digital modalities. Radiologists at Massachusetts General Hospital in Boston recently estimated that each digital imaging examination generates approximately 2 gigabytes (GB) of data, all of which needs to be stored on a series of hard drives. Facilities working with a PACS, regardless of CR or DR techniques, likewise experience an endless increase in digital storage needs.7 Fortunately, the costs of the large hard drives typically used for digital storage have decreased dramatically as new technologies have substantially increased the amount of data that can be stored.7 Lifecycle management software has also been introduced that can help facilities transition older files to cheaper storage devices. However, the legal implications of lifecycle management in terms of the integrity of medical data and the length of time that image files must be stored are still in the process of being clarified.7 Larger Cost Considerations Initial cost investment is the primary disadvantage of DR as compared to CR. CR can be easily integrated into an existing room structure whereas DR requires new radiographic equipment. Although an entire system overhaul to DR may offer greater streamlining of workflow, the costs of this upgrade could still be prohibitive to some facilities. In response to the high costs of upgrading the entire X-ray room or suite to DR, some vendors are offering DR tools that can be integrated into an existing CR platform. For instance, one vendor is planning to soon offer a DR detector that fits into a conventional cassette and bucky tray. A wireless transmission of images to the PACS allows facilities to take advantage of DR technology without upgrading the entire room.3 Direct digital radiography and CR may also offer some cost advantages to screen-film radiography in terms of acquisition and physical storage. As already mentioned, digital storage is becoming more affordable and physical space for film storage will always be at a premium. In the long run, facilities may find CR or DR more cost-effective as part of a larger plan to create an entirely digital environment.6 The cost of X-ray film is also considerable and may be an important consideration when weighing the relative operating expenses of CR and DR.6 In addition, the costs of repeat studies may also be factored into the decision to transition to a DR system; unlike CR, the digital images obtained with DR can be immediately viewed, enhanced, and manipulated.4,6 This decreases the amount of time between initial images and repeat images to improve workflow. The range of exposures (dynamic range) that will produce a diagnostic image is much larger for CR and DR than for film. This reduces the need for repeat studies due to technique; however, increase in technique and patient dose must be closely monitored. Therefore, facilities need to understand the need for advanced staff training and continuing system optimization to limit radiation exposure while obtaining adequate images. Technique and Patient Dose Radiation Exposure in Digital Modalities The decision to offer X-ray imaging based on CR or DR can also have a potential impact on the amount of radiation that a patient receives during the imaging study. Some concerns have been raised about increased radiation doses with CR or DR, compared with traditional screen-film radiography, due to the larger dynamic ranges with CR and DR.8 Furthermore, some digital imaging systems automatically adjust radiation exposure, which can reduce the number of images needed, but prevents operators from accurately assessing and adjusting radiation exposure when a repeat is necessary. Methods to estimate exposure in digital modalities have been developed to help resolve this issue.9 Optimizing Digital Techniques to Reduce Exposure In digital imaging there is a trade-off between image quality, most specifically noise, and patient dose for both CR and DR. Efforts to reduce radiation doses during imaging studies have been traditionally limited by a lower image quality, but the use of digital modalities and new optimization strategies may offer an opportunity to reduce exposure with images of adequate diagnostic quality. For instance, Wiltz et al reported that they reduced image noise, which is a substantial impediment to dose reduction in digital imaging, by reducing X-ray tube voltage from 69 to 53 in patients undergoing intravenous urography (IVU) with CR. Despite this reduction in tube voltage and radiation dose, the clinicians were able to obtain images of adequate quality with advanced digital processing techniques.10 Although a reduction in peak kilovoltage (kVp) to demonstrate iodinated contrast media in this study was shown to decrease patient dose, many institutions have taken a different approach and used an increase in kVp with a corresponding decrease in milliampere-seconds product (mAs). These technique adjustments increase the penetration of the beam to provide adequate radiation exposure to the image receptor while reducing the relative absorption in the patient and therefore reducing patient dose. Meanwhile, a retrospective analysis of radiation entrance surface dose (ESD) in patients undergoing posterior-anterior (PA) chest X ray or lateral (LAT) lumbar spine X ray at 2 Australian hospitals sought to determine the relationship between radiation dose delivered and exposure indices (EI) with CR to assess the hospitals' ability to perform imaging within the EI range recommended by equipment manufacturers. This analysis found that 30% of PA chest X rays and 38% of LAT lumbar spine X rays could be performed with an EI below levels recommended by manufacturers by optimizing the operation of the CR equipment. For example, operators were able to obtain adequate images and reduce ESD by 56% by varying X-ray potential and maintaining an EI of 1550 in a series of phantom studies. The authors cautioned that based on their analysis, radiology staff who encountered CR and DR systems likely require extensive training to properly optimize the equipment and limit radiation exposure to patients.11 Evidence exists to suggest that imaging protocols are likely to vary widely between departments and institutions, as is radiation exposure. One retrospective analysis of 40 000 CR examinations found that a wide degree of variability in protocols between departments and some techniques resulted in excessive radiation exposure. The investigators suggested that medical imaging professionals should clearly label imaging files with the



Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality - ERADIMAGING.COM: RT
resulted in excessive radiation exposure. The investigators suggested that medical imaging professionals should clearly label imaging files with the imaging technique and beam quality used to track and improve practices over time.12 Meanwhile, another analysis reported the risk of excessive radiation exposure with CR, mainly due to the fact that overexposure is more difficult to identify with digital modalities. This is a result of the design of the digital imaging system and the automatic adjustment of optimal brightness and contrast at a wide range of exposure. Optimization practices were able to reduce radiation exposure to acceptable levels, emphasizing the need for staff education when upgrading from screen-film radiography to CR or DR.13 Digital imaging with DR may further the potential to reduce radiation exposure due to better image quality with lower radiation exposure. One study by Gruber et al administered a series of 3 sequential chest radiographs in 50 patients, 1 with CR and 2 with DR (1 at full dose and 1 at 50% dose). The resulting images were read side-by-side by radiologists who were blinded to the source of each image. The clarity of most pulmonary structures was sufficient in all images based on the radiologists' evaluation, regardless of the technique used or the acquisition dose. Images obtained with full-dose DR resulted in lower scores for image noise and therefore, were superior in quality. The study's investigators concluded that dose reduction with DR was likely feasible in chest radiography without sacrificing image quality or diagnostic information.14 Another study followed radiation exposure during IVU in one Swedish facility during a transition from screen-film imaging to CR to DR. Radiation exposure is an important concern in IVU due to the fact that a large radiation field is needed and, consequently, organs that are most sensitive to radiation exposure are irradiated during the process.15 The facility first transitioned from screen-film to CR phosphor plates, and then to a flat-panel DR detector. Examination techniques were otherwise unchanged during the transition process. The investigators found that each transition was accompanied by a reduction in radiation exposure, and exposure was reduced more than 3-fold from screen-film (7.5 mSv) to flat-panel (2.2 mSv) techniques. The greatest reductions in exposure were achieved with DR at a speed of 400. The authors noted that the number of images considered necessary for an IVU study varies widely between hospitals, and that the number of images could be optimized with DR. They also emphasized that radiation exposure could be even further reduced with technique optimization practices.15 Other facilities have tracked radiation exposure as they transitioned from screen-film radiography to CR to DR techniques. A Canadian facility reported radiation exposure (as measured by surface dose) in common procedures, including PA chest, LAT chest, PA abdomen, and PA pelvis X rays. Radiation exposure during PA chest X rays varied widely by the technique used, with CR resulting in significantly higher radiation doses than either screen-film radiography (P <.01) or DR (P <.01). Doses for PA chest X rays with CR were 5 times more than those that occurred during screen-film techniques, but exposure was similar with screen-film radiography and DR. For PA abdomen X rays, DR resulted in significantly lower radiation doses than screen-film radiography (P <.05) or CR (P <.01). Imaging was optimized with DR to reduce noise by doubling the radiation dose (reducing the speed by half), but the authors noted that radiation exposure with DR was still within the recommended dose limits cited by various advisory groups.8 An Italian emergency department also conducted an analysis of entrance surface radiation dose and effective dose with screen-film radiography, CR, and DR modalities in a variety of clinical applications. In the CR and DR studies, the operators optimized the systems by using higher tube potentials and a lower mAs to limit radiation exposure. Although all modalities resulted in images of acceptable diagnostic quality, the use of DR resulted in an effective dose that was 29% lower than screen-film radiography and 43% lower than CR.16 Recognizing the Potential for Dose Increase In digital modalities, medical imaging professionals need to be wary of routine system adjustments that could result in radiation dose increase over time. Dose increase most commonly occurs as operators try to reduce image noise by gradually increasing radiation dose.17 Regular quality assurance (QA) and QC measures can prevent this problem but require vigilance on the part of system operators.18 Operator training is a critical issue when facilities upgrade to either CR or DR systems from a screen-film environment, due to the sophisticated knowledge and technique needed to optimize image capture and manage the potential for higher levels of patient radiation exposure. Digital modalities, especially DR, may nevertheless represent an opportunity to improve image quality while limiting radiation exposure. Relative Image Quality with CR and DR Image quality is an important issue in digital techniques, as signal-to-noise ratio can be higher with both CR and DR. However, optimization strategies have been used in digital modalities to reduce signal noise and improve image quality while keeping radiation doses within acceptable limits. Therefore, medical imaging professionals in facilities upgrading to CR or DR from screen-film should receive the advanced training necessary to recognize opportunities with digital systems to reduce radiation exposure while reducing image noise and improving overall image quality. As previously mentioned, Gruber et al compared CR with DR, including DR performed with a 50% radiation dose reduction, in patients undergoing chest radiography. Even though the CR used in the study was an up-to-date, dual readout system, blinded radiologists judged the images obtained with DR as equivalent or superior to the CR images. When equivalent radiation doses were used, the images obtained with DR were judged as superior in quality to those obtained with CR by 5 of the 8 readers. Image noise scores were significantly lower with DR compared with CR (1.01 vs 2.48, P <.001). Noise scores were also significantly lower with full-dose DR compared with 50% dose DR (1.01 vs 2.51, P <.001). However, noise scores between 50% DR and CR images were not significantly different (P = .334).14 Processes to Ensure Image Quality Radiographers can take the lead on a series of practices to optimize image quality and make the most of advanced digital modalities. First of all, technologists should work closely with their system's vendor to keep up-to-date on possible upgrades and receive guidance on optimization strategies. Adjustments of routine practice are typically needed when multiple exposures are taken on one image receptor with CR and when surgical and crosstable lateral projections are done with both CR and DR. As mentioned previously, QA/QC processes should also be in place, not only to monitor dose increases but to also ensure that image processing is optimal. Although specialized QA technologists or department supervisors may be initially responsible for QA/QC oversight, radiographers should expect that they will eventually be responsible for these duties and will require specialized training.18



Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality - ERADIMAGING.COM: RT
Rejected images are easier to track in a screen-film environment due to the presence of a physical film image that needs to be recycled. However, in a digital environment with CR or DR, the facility still needs to track image rejects to evaluate possible technique or workflow issues. Many digital systems provide software upgrades to assist with repeat monitoring. Several processes can be used to track rejects on a regular basis, such as setting up the PACS to automatically track rejected images. Regular system maintenance, including tracking of monitor quality, is also necessary to ensure image quality.18 Despite the additional processes and training that may be needed to ensure image quality, digital modalities, especially DR, represent an opportunity to improve image quality and streamline processing without the need for increases in radiation exposure. Accuracy of Diagnosis The digital environment may offer greater flexibility in imaging options and opportunities to reduce radiation doses with DR, but medical imaging professionals should understand that this flexibility could result in discrepant diagnostic results if the system and PACS are not appropriately calibrated. Multiple clinical reports have highlighted the possibilities for diagnostic ambiguity or inaccuracy with poorly calibrated digital equipment, and technologists should be familiar enough with the system, including its communication with the PACS, that these problems can be avoided. Also, although digital modalities have demonstrated the ability to provide sufficient diagnostic accuracy in most applications, there still exists room to improve CR and DR in specific detection capabilities. One retrospective analysis of patients who had undergone lumbar spine radiographs for the diagnosis of osteoporosis compared diagnostic accuracy with screen-film versus digital radiography. The study included 128 patients who received screen-film radiography and 158 patients who had received CR. Mineral loss was confirmed with dual-energy X-ray absorptiometry (DXA). The overall rate of diagnostic accuracy was not significantly different between screen-film radiography and CR (68% and 64%, respectively). Low rates of diagnostic specificity resulted with both screen-film radiography and CR (36% and 47%, respectively), but sensitivity rates were higher (86% with screen-film radiography and 72% with CR). Correct diagnoses as true positives increased with the degree of mineral loss as detected by DXA. Overall, images obtained with screen-film radiography resulted in a higher rate of true positives but a lower degree of specificity in diagnosing osteoporosis. Also, agreement between the participating readers was much lower with CR, with only 35% of all 4 readers agreeing on digital images and 73% of all 4 agreeing on screen-film images. The authors suspected that bone mineral loss could be more easily visible with screen-film imaging due to the fact that image contrast cannot be adjusted with this modality, whereas CR (and DR) images undergo digital post-processing techniques to maximize contrast. This could result in misleading results that confound diagnostic strength in osteoporosis.19 The relative diagnostic value of CR and screen-film mammography was also assessed in a prospective study. The investigators recruited 100 patients who were imaged with both 2-view screen-film mammography and CR mammography, which were obtained with double exposure that did not require decompression or repositioning of the breast between images. The primary end point of the study was overall diagnostic value, with a secondary end point of lesion conspicuity and the ability to image lesion details (in masses and microcalcifications); tissue visibility at the chest wall and skin line; axillary details; overall density and sharpness impression; and overall image noise. Secondary parameters were scored with a 7-point system. Three radiologists within the study's institution and 3 independent radiologists were recruited to assess the images. The diagnostic accuracy of both modalities was sufficient, with readers scoring images obtained with CR and screen-film mammography as having an overall diagnostic value of 100%. In the secondary analysis, the readers expressed significantly greater confidence in the CR images to detect lesion conspicuity of masses (P = .021), lesion detail of masses (P <.001), tissue visibility of skin line (P <.001), overall density impression (P = .003), and the composite of all of the secondary end point parameters studied (P <.001). However, screen-film images scored significantly better than CR for lesion detail of calcification (P <.001) and overall noise impression (P <.001). The authors concluded that both CR and screen-film mammography were clinically valuable in the diagnosis of breast cancer, but that additional improvements are necessary with CR to accurately detect and evaluate microcalcifications. They stressed that CR was found to be noninferior to screen-film mammography in this diagnostic setting and that these results could not be extrapolated to the setting of screening mammography.20 Another study assessed the ability of the PACS in digital imaging to accurately determine the correct length of intramedullary nails to set tibial shaft fractures. The investigators reported that the PACS measuring distance and measuring calibration tools resulted in consistently larger measurements, with the PACS obtaining measurements that averaged 20 mm longer than the actual known length of the tibial nail. However, when an object of known length was included in the image as a calibration reference, the measurements obtained with PACS were accurate, with values that were within 0.0 mm and 0.34 mm for anteroposterior and LAT studies, respectively. Digital imaging depending on accurate measurements may therefore benefit from calibrating the PACS with an object of known length that is captured in the image, according to the authors.21 Additional Factors Affecting Digital Image Quality Due to the digital nature of both CR and DR imaging, additional factors should be kept in mind that could influence image quality. The ultimate quality of an image resulting from a digital modality can be influenced by a variety of factors, including the system parameters used in capturing the image, the communication of the system hardware with the PACS, diagnostic workflow protocols, and image processing and visualization techniques.22 Unlike screen-film imaging, the digital environment provides clinicians with ongoing opportunities to improve image interpretation and diagnostic strength, particularly with modifications to image processing. For example, investigators have reported adjustments to the PACS with nonlinearity intensity transformation or anti-aliasing techniques that prevent the formation of Moir patterns, with resulting improvements in image contrast in CR chest and extremity studies. Both of these modifications were possible with intensity and resize transformations that did not require any changes to the original digital imaging and communications in medicine data.22 Clinicians should also recognize the impact that image compression techniques can have on image quality. The joint photographic experts group (JPEG) 2000 compression technique has been superior to JPEG in higher compression ratio levels, and one study confirmed that JPEG 2000 is also superior at low compression levels in CR, computed tomography of the head and body, digital mammography, and magnetic resonance T1 and T2 images. The investigators noted that image contrast and average gray level are important factors in the quality of compressed images at low



Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality - ERADIMAGING.COM: RT
images. The investigators noted that image contrast and average gray level are important factors in the quality of compressed images at low compression levels.23 Conclusions Digital radiography, including CR and DR, has reshaped the field of medical imaging and continues to evolve due to new image processing and manipulation techniques that are possible in a digital environment. Although there continues to be considerable interest in both CR and DR modalities, DR may offer improved workflow for routine procedures due to the elimination of cassette manipulation and processing, as well as a greater capacity to limit radiation exposure. CR continues to offer flexible position of the image receptor for procedures such as those done for trauma, surgical cases, and for non-routine positioning, such as urologic and cross-table lateral projections of the hip and spine. DR has been proven to offer comparable diagnostic accuracy in a variety of clinical applications, but there still exists room for improvement in some areas, often due to the automatic adjustments in image contrast that are made during digital image processing. Although some facilities have yet to switch to a digital modality, it is clear that medical imaging professionals will require a familiarity with digital imaging as these systems continue to demonstrate their benefit and centers increasingly decide to transition to a digital workplace. Additional Resources Professionals interested in additional information on CR and DR are encouraged to access the following resource: Digital radiography slowly, but surely, makes its mark References 1. IMV MarketStat #44: Percentage of US hospitals with DR or CR technology. Available at: Sec=sup&Sub=xra&Pag=dis&ItemId=72695. Accessed September 29, 2008. 2. Schaetzing R. Management of pediatric radiation dose using Agfa computed radiography. Pediatr Radiol. 2004;34(suppl 3):S207-S214. 3. Casey B. Carestream targets existing x-ray rooms with wireless DR. Available at: sec=sup=xra&pag=dis&ItemId=82282. Accessed September 29, 2008. 4. Lehrer R. Teaching technology to technologists. Radiol Technol. 2008;79:405-414. 5. Diiulio R. CR versus DR: which is the tech's choice? Med Imaging . May 2008. Available at: Accessed September 29, 2008. 6. Hatcher M. Database application of digital medical X-rays and labs: computerization, storage, retrieval, interpretation, and distribution. J Med Syst. 2005;29:317-325. 7. Joch A. Space jam: are digital imaging systems straining your storage resources? Hosp Health Netw. 2007;40-44. 8. Aldrich JE, Duran E, Dunlop P, Mayo JR. Optimization of dose and image quality for computed radiography and digital radiography. J Digit Imaging. 2006;19:126-131. 9. Ariga E, Ito S, Deji S, et al. Development of dosimetry using detectors of diagnostic digital radiograph systems. Med Phys. 2007;34:166-174. 10. Wiltz HJ, Petersen U, Axelsson B. Reduction of absorbed dose in storage phosphor urography by significant lowering of tube voltage and adjustment of image display parameters. Acta Radiol. 2005;46:391-395. 11. Warren-Forward H, Arthur L, Hobson L, et al. An assessment of exposure indices in computed radiography for the posterior-anterior chest and the lateral lumbar spine. Br J Radiol. 2007;80:26-31. 12. Stone K. Large CR study reveals wide variation in adult and pediatric protocols. Available at: Accessed September 29, 2008. 13. Skelding R. New studies examine CR, CT radiation dose. Available at: Sec=sup&Sub=xra&Pag=dis&ItemId=80366. Accessed September 29, 2008. 14. Gruber M, Uffmann M, Weber M, et al. Direct detector radiography versus dual reading computed radiography: feasibility of dose reduction in chest radiography. Eur Radiol. 2006;16:1544-1550. 15. Sjholm B, Geijer H, Persliden J. Impact of digital imaging on radiation doses to the patient during X-ray examination of the urinary tract. Acta Radiol. 2005;46:657-661. 16. Compagnone G, Baleni MC, Pagan L, et al. Comparison of radiation doses to patients undergoing standard radiographic examinations with conventional screen-film radiography, computed radiography and direct digital radiography. Br J Radiol. 2006;79:899-904. 17. Strauss J, Pitura K, Spahn G, et al. Strategies for reducing dose creep' in digital x-ray. Available at: Accessed September 29, 2008. 18. Oosterwijk H. CR/DR image quality: issues and concerns. Available at: Sec=sup&Sub=xra&Pag=dis&ItemId=75374. Accessed September 25, 2008. 19. Wagner S, Stbler A, Sittek H, et al. Diagnosis of osteoporosis: visual assessment on conventional versus digital radiographs. Osteoporos Int.




Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality - ERADIMAGING.COM: RT
2005;16:1815-1822. 20. Van Ongeval C, Bosmans H, Van Steen A, et al. Evaluation of the diagnostic value of a computed radiography system by comparison of digital hard copy images with screen-film mammography: results of a prospective clinical trial. Eur Radiol. 2006;16:1360-1366. 21. France MA, Koval KJ, Hiebert R, et al. Preoperative assessment of tibial nail length: accuracy using digital radiography. Orthopedics. 2006;29:623-627. 22. Bonciu C, Rezaee MR, Edwards W. Enhanced visualization methods for computed radiography images. J Digit Imaging. 2006;19:187-196. 23. Shiao YH, Chen TJ, Chuang KS, et al. Quality of compressed medical images. J Digit Imaging. 2007;20:149-159.

What did you think of this article? Computed Radiography and Digital Radiography: A Comparison of Technology, Functionality, Patient Dose, and Image Quality Comment From: KATHY very boring and would lke to read more articles about ct and anatomy and pathology findings on ct Posted on: 01/29/2009 12:48 PM

Comment From: gcshim Informative, I thought it met the objective

Posted on: 02/04/2009 11:28 AM

Comment From: Tonya Forrester informative

Posted on: 02/12/2009 9:01 AM

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