425

REVIEW

Digital radiography. A comparison with modern

conventional imaging
G J Bansal
...............................................................................................................................

Postgrad Med J 2006;82:425–428. doi: 10.1136/pgmj.2005.038448

The development of computed radiography over the past Conventional radiography (also known as
SFR) is still used more widely than digital
two decades has transformed radiological imaging. The radiography but this dominance is fast dwind-
radiology departments in the 21st century will look very ling. The reasons behind the declining popularity
different from those in the preceding period. In this review, of SFR are—fixed dose latitude, fixed non-linear
grey scale response, and limited potential for
the development of digital radiography is presented with a reducing dose to the patient. All these para-
description of its various forms and a comparison with meters limit the information that can be cap-
screen film radiography. tured on film. The images cannot be changed in
contrast once they have been processed. Apart
........................................................................... from this, film is expensive, uses hazardous
materials for processing, is labour intensive, and

W
ilhelm Roentgen, professor of experi- long term storage and retrieval of film is difficult.
mental physics in Germany, discovered SFR is not compatible with the picture archiving
x rays in 1895 while working on and communication systems (PACS).
emissions from electric current in vacuum. He Digital radiography (DR) has further evolved
noticed a glow from a barium platinocyanide into different forms. In computed radiography
coated screen kept across the room whenever the (CR), a photostimulable phosphor plate is used
current was passed between the two electrodes for detection of x rays instead of the conventional
in a charged cathode tube. A few weeks of film screen. The exposed plate is scanned with
intense experimentation led to a report to the helium neon laser and the emitted light is
local medical society in Germany and deservedly, captured by photomultiplier tube and converted
the first Nobel Prize in Physics in 1901. Over the to analogue electrical system, which is then
years, many significant refinements were made digitised. Another form of DR is direct radio-
in the techniques and the equipment. Presently, graphy in which a semiconductor based sensor
radiological facilities are found in even the directly converts x ray energy into electrical
smallest hospital and emergency units involved signals, hence eliminating the middle step of
in health care. A hospital without radiography is latent image and image plate reader. Solid state
inconceivable. detectors (selenium drum) and flat panel detec-
Fluoroscopy was introduced shortly after tors (selenium and cesium iodide) are used as
Roentgen’s discovery of x rays. The most sig- scintillators, which convert x ray photon to light
and this is converted to electrons via amorphous
nificant use of fluoroscopy is intraoperative use
silica arranged as photoiodide transistor. Image
as in image intensification during orthopaedic,
intensification, which is used for real time
vascular, urological procedures. It is also used for
images, uses digital sensor linked to video
dynamic radiographic investigations.
monitors and this is extremely useful for screen-
The next important change came about with
ing during radiological, vascular, and orthopae-
the development and widespread use of compu-
dic procedures. It increases the brightness by up
ter technology. Application of computers to to 6000 times without increasing the radiation
radiography was inevitable. The idea of a filmless dose.
radiology department was fascinating to medical
professionals. Digital radiography was intro-
duced in the mid-1980s1 and, with a steady gain RADIOGRAPHIC IMAGING EQUIPMENT
in popularity, it is now competing with conven- x Rays are produced by bombarding a metal
tional screen film radiography (SFR) in all target by high energy electrons. In conventional
radiographic applications. radiography, x rays passed through the human
body are absorbed, which causes attenuation of
....................... the incident beam. The uniform x ray beam
CLINICAL APPLICATIONS AND emitted from the source is modulated as it passes
Correspondence to: DIAGNOSTIC ROLE through the human body and these changes are
Dr G J Bansal, 16 Cherry Radiographs are the starting point for diagnosis
Tree Avenue, recorded on the film.
Scarborough, North of a variety of clinical situations; the clear The contrast in an x ray image depends on
Yorkshire YO12 5DX, UK; advantages being their easy availability, low cost, differential attenuation of x rays as they pass
[email protected] non-invasive, familiarity to medical profes- through different body tissues. In the absence of
sionals, relative harmlessness, and fast imaging
Submitted 13 June 2005
Accepted
times. Combine this with excellent resolution Abbreviations: SFR, screen film radiography; PACS,
6 November 2005 and contrast; it is not difficult to understand the picture archiving and communications system; DR, digital
....................... key role of radiographs in the medical sift. radiography; CR, computed radiography

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426 Bansal

contrast media, the x ray contrast depends on Crompton The intensity transfer function (characteristic curve)
effect for soft tissue and a combination of the Crompton depicts the relation between the dose at detector entrance
effect and photoelectric effect for bone. Contrast can be to intensity of resultant image. The dynamic range of the
further improved in some areas by giving contrast media. The image plate is the ratio of maximum and minimum doses
photoelectric effect predominates for iodinated contrast that can be imaged. For film screen images, the curve is S
media because of its K edge at 33 KeV and Barium 37 KeV. shaped with a short dynamic range of 1:40. Digital detectors
Plain radiographs have one of the best spatial resolutions have a linear curve that permits further processing and the
(0.1 mm) of all the imaging modalities. The beam is received dynamic range is between 1:100 to 1:1000 or even more
on a silver bromide plate sensitive to the electromagnetic (fig 1). This is important in areas of body with high
radiation and it leads to production of black metallic silver contrast—as between bone and soft tissues or in areas where
from silver bromide. A comparatively small dose of x rays is there is an acute change in body thickness—as in the region
used to produce a subtle change in the plate, which is then of neck. In such situations, the use of phosphor plates allows
amplified by chemical development to become visually for a sharp image and lesser number of repeat examinations
identifiable. as the detector is able to adjust to the different dose of
The x ray equipment must be calibrated to accurately incident radiation coming through body parts of varying
produce the desired voltage, current, and exposure time. This thickness.3
has to be frequently checked to ensure correct radiation dose. The image plates can be either standard (ST-V) with a 230m
The film is composed of supercoat—protective layer of thick phosphor plate or high resolution (HR-V), which are
hardened gelatin; emulsion—radiosensitive silver halide higher resolution plates used in musculoskeletal radiography.
grains suspended in gelatin; adhesive layer and film base. The HR plates require two to three times higher radiation
The amount of silver bromide is directly proportional to the dose compared with ST-V but are useful in musculoskeletal
sensitivity of the film. radiography because of its better image quality.
In SFR, the film acts as the medium for acquisition,
display, and storage of images. On the other hand, the
RADIOGRAPHIC AND OPERATIONAL ASPECTS OF
production of image in CR can be considered over four
THE IMAGING SYSTEM
discrete broad heading—image acquisition, processing, sto-
The keystones on which the SFR survives in current
rage, and display. All these four processes are separate and
radiological practice are resolution and familiarity of the
the performance of each can be optimised individually for
medical profession. The high resolution makes it useful to
maximum efficiency.2 Phosphor plates containing a thin layer
diagnose undisplaced fractures and in other situations like
of fine grain crystals of Barium fluoro halide doped divalent
subperiosteal erosions in hyperparathyroidism.
Europium (Eu+) are used in CR instead of silver halide plates
One of the many advantages of CR is that all the
used in conventional radiography.3 Incident x ray photons are
constituent processes—image acquisition, processing, dis-
absorbed by the phosphor crystals producing high energy
play, and archiving—are individual and separate. This in turn
photo electrons. The electrons are trapped at Halide vacancies
leads to secondary advantages like, for example, a reusable
(colour centres) to form F centres. A helium neon 633 nm
image plates, a linear response over a wide dynamic range,
laser beam is used to scan the plate. The colour centres absorb
ability to process an image after acquisition, and sharing the
energy and electrons drop to low energy level with release of
images over a network electronically. It also makes storage of
energy in the form of light photons. These photons are
a large amount of images in a comparatively much smaller
converted to electric current by high sensitivity photo
space and quick access for later reference. Conventional film
multiplier tube. The analogue electrical signal is then
digitised to provide the image and this can either be printed is subject to loss through storage and the images may
from a laser printer or viewed on grey scale high resolution deteriorate with time, and this problem does not exist for
monitors. Images can be stored on PACS and easily retrieved digital images. The processing enables the technologist to
at a later date if required. Images can be accessed from any change the image optical density after image capture and
terminal and by multiple users. hence avoiding another exposure to the patient.

SPECIAL TECHNICAL FACILITIES AND PHYSICAL

PRINCIPLES
In digital imaging, the detector should ideally detect even
small amounts of incoming quanta and have a high dynamic
range so as to detect subtle findings without adding artefacts. SFR
Detector efficiency is the percentage of photons emanating
from the subject that lead to formation of image. Phosphor
plates are two to four times faster than film screens. A higher
efficiency implies a lesser dose of x rays in required. Signal Log grey Optical
scale value density
normalisation helps to get an optimal image and the quality
of image can be changed even after the exposure has been
made with a certain radiation dose.
The image quality in a digital system depends on the CR
quality of x ray equipment, applied dose, and additionally on
pixel size, pixel depth, signal to noise ratio, and dynamic
range. The Shannon Theorem states that if the pixel size is 10:1 (approx)
smaller than the smallest detail that has to be visualised, 1 10 100 1000 10 000
then there will not be any loss of information. A variety of Log input dose
measures exist to assess the image quality and these include
pixel size, intensity transfer function, modulation transfer Figure 1 Detector response of conventional radiography has a short
function, noise equivalent quanta, and detective quantum linear segment while the digital radiographic plates have a long linear
efficiency. relation.

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Digital radiography 427

study on imaging of hand showed the resolution of CR to be

at least as good as SFR.4 Another study of interpretation of
Laser 122 musculoskeletal radiographs by four readers showed a
CR
printer resolution of 2048 6 1680 6 12 bits to be sufficient to detect
subtle findings and this corresponds to 2.5 lines per mm.5 At
this resolution there was no difference in diagnostic yield
between digital and conventional radiographs. Magnification
techniques in CR may overcome the constraints imposed by
limited spatial resolution in CR.6 The edge enhancement filter
Work in DR enhances subtle findings on chest radiographs. Piraino
CT LAN
station compared selenium based DR with conventional SFR (100
speed) for hands and feet in 24 patients and the films were
evaluated by five experienced radiologists.7 Selenium based
radiography was found to be equivalent to conventional
radiography in showing bones, soft tissue, and trabecular
detail by all observers.
Archive
MR A resolution of over 2.88 line pairs per mm was considered
system
essential to maintain diagnostic accuracy in a receiver
operating characteristic analysis with regards to undisplaced
or minimally displaced fractures of the extremities.8 This
Figure 2 An example of a local area network connected to the digital resolution size corresponds to a pixel size of 0.16 mm and the
imaging modalities and providing output on a work station and a laser pixel size is directly related to spatial resolution. The
printer. It is connected to the archive for storage and access. CR,
computed radiography, CT, computed tomography; MRI, magnetic
resolution with SFR for skeletal images is typically 8 lines
resonance imaging. per mm.
Another feature is that the images may not be comparable
to actual anatomical size. This makes it difficult to template
IMAGING SYSTEM DESIGN TO ACHIEVE THE on the images for preoperative planning for surgery. For
OPTIMUM IMAGE instance, the template available for planning hip replacement
The ideal imaging system should permit a high quality image surgery are generally 15% to 20% magnified, which fits in
with minimal radiation exposure. DR has the potential to with the SFR. It is not possible to template on a digital image
achieve this and further advances will possibly lead to with a different magnification as the conventional templates
lowering the radiation dose and using higher sensitivity will not match the image. To overcome this limitation, some
plates to give good resolution and sharpness of images. implant manufacturing companies are coming up with digital
Portable radiography is another significant reason to adopt templating options.
DR. It is useful in patients with multiple trauma for imaging
the neck, pelvis, and chest as part of the ATLS protocol. The
COMPATIBILITY OF DIGITAL IMAGING AND PACS
long linear response permits adjustment for attenuation and
PACS refers to the electronic management of digital images.9
maintains the image quality.
This technology was developed at the same time as digital
radiography in the mid-1980s and has come a long way since.
LIMITATIONS IN CURRENT IMAGING SYSTEMS The popularity of CR has generated an expansion of PACS
Limitations of the SFR system are related to storage, cost, and services as the conventional SFR was incompatible with this
film distribution. Also, the dose to the patient cannot be system. Modern PACS require substantial infrastructure and
reduced and screen film has fixed non-linear grey scale aim to perform the entire range of functions (fig 2) including
response and fixed dose latitude. image acquisition, display of soft copies on monitors,
The shortcomings in CR images were believed to be limited transmission of the images on the local area network, storage
spatial resolution, which is typically 2.5 to 5 lines per mm of images for quick access, permit access to the radiology
(lpm) while the SFR provides 2.5 to 15 lpm resolution. There information service and the hospital information service, and
have been a multitude of studies investigating the spatial finally, generation of hard copies.10 More recently, with the
resolution of SFR compared with CR. One such comparative widening presence of teleradiology, wide area networks
require PACS at the transmitting and receiving ends. CAD
(computer aided digitisation) and CADx schemes are avail-
Key references able that can point out an abnormal area to the radiologist
but at present, these are of limited value in musculoskeletal
imaging.
N Artz DS. Computed radiography for the radiological The digital imaging and communications in medicine
technologist. Semin Radiol 1997;32:12–24. (DICOM 3.0 standard) was established through the colla-
N Murphey MD, Quale JL, Martin NL, et al. Computed boration of the American College of Radiology and National
radiography in musculoskeletal imaging: state of the Equipment Manufacturing Association.11 The current grey
art. AJR Am J Roentgenol 1992;158:19–27. scale display monitors for soft copy reporting have resolution
N Arenson RL, Seshadri S, Kundel HL. Clinical evaluation of 2K62.5K68/12 bit resolution.
of a medical image management system for chest The requirements for a good PACS are efficient grey scale
images. AJR Am J Roentgenol 1988;150:55–9. work station display protocols, fast interfaces, and scalability.
N Dwyer SJ. Imaging system architecture for picture To achieve good throughput rates, it is essential that all
components of the PACS work at comparable data transfer
archiving and communication systems. Radiol Clin
speeds so that the images can be transferred and viewed
North Am 1996;34:495–503.
without delay.
N Kamm KF. The future of digital imaging. Br J Radiol Reversible compression of images further increases the
1997;70:S145–52. storage capacity of the archival systems and the images can
be restored to original size and quality at a later date without

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428 Bansal

loss of information. Irreversible compression generally results SELF ASSESSMENT QUESTIONS (TRUE (T), FALSE (F);
in loss of information and should be avoided. ANSWERS AT THE END OF THE REFERENCES)
1. Phosphor plates are used in digital radiography.
REVIEW OF FUTURE TRENDS IN RADIOLOGICAL
IMAGING AND POTENTIAL CLINICAL 2. Computed radiography has a wider linear dynamic
range in the dose response curve compared with screen
IMPLICATIONS
film radiography.
The important advantage of digital imaging is cost and
access. The hospitals save money from lower film cost, 3. Templating is easier on digital radiography because the
reduced requirement for storage space, and lesser staff images are comparable to anatomical size.
required to run the services and archiving sections. The 4. Spatial resolution is better in digital radiography by an
images are instantly available for distribution to the clinical order of magnitude compared with screen film radio-
services without the time and physical effort needed to graphy.
retrieve film packets and reviewing previous imaging on a 5. Solid state flat panel detectors provide better quality
patient is much easier. with less radiation dose compared with screen film
Spatial resolution was limited in earlier versions of CR but radiography.
newer versions have overcome this problem. Flat panel CR is
another technological advancement. The yield of electrons is Funding: none.
five times as compared with CR and it gives a superior image
quality and dose efficiency.
Solid state flat panel DR provides better quality than CR or REFERENCES
1 Sonoda M, Takano M, Miyahara A, et al. Computed radiography utilizing
SFR and at the same time requires a lower radiation dose. scanning laser stimulated luminescence. Radiology 1983;148:833–8.
These are composed of x ray detector material superimposed 2 Artz DS. Computed radiography for the radiological technologist. Semin
on micro circuit array. The indirect version of this technology Radiol 1997;32:12–24.
exhibits a much better signal to noise ratio. A portable 3 Murphey MD, Quale JL, Martin NL, et al. Computed radiography in
musculoskeletal imaging: state of the art. AJR Am J Roentgenol
version has also been devised. The direct DR version, 1992;158:19–27.
amorphous selenium replaces the photo sensors. It is very 4 Swee RG, Gray JE, Beabout JW, et al. Screen film versus computed
useful for imaging of extremities and shows the trabecular radiography imaging of the hand: A direct comparison. AJR Am J Roentgenol
bone pattern very well. The clinical utility of these recent 1997;168:539–42.
5 Wegryn SA, Piraino DW, Richmond BJ, et al. Comparison of digital and
developments is still under evaluation but it is probable that conventional musculoskeletal radiography: an observer performance study.
the overwhelming advantages offered by these newer Radiology 1990;175:225–8.
modalities will lead to their widespread use. 6 Nakano Y, Himoka T, Togashi K. Direct radiographic magnification with
computer radiography. AJR Am J Roentgenol, 1987;148:569–73.
Standing where we are in digital imaging, it is not hard to
7 Piraino DW, Davros WJ, Lieber M, et al. Selenium based digital radiography
see that the future is digital. More and more hospitals are versus conventional screen film radiography of the hands and feet. A
likely to set up PACS in the UK like many other countries. As subjective comparison. AJR Am J Roentgenol 1999;172:177–84.
we embrace the filmless radiology departments, it is 8 Murphey MD, Bramble JM, Cook LT, et al. Nondisplaced fractures: spatial
resolution requirements for detection with digital skeletal imaging. Radiology
important to uphold evidence based medicine and at the 1990;174:865–70.
same time to provide a personalised medicine tailored to the 9 Arenson RL, Seshadri S, Kundel HL. Clinical evaluation of a medical image
history of an individual patient.12 Better detectors, faster management system for chest images. AJR Am J Roentgenol, 1988;150:55–9.
processing, more powerful computers, bigger and sharper 10 Dwyer SJ. Imaging system architecture for picture archiving and
communication systems. Radiol Clin North Am 1996;34:495–503.
displays, efficient archiving will once again transform the 11 Spilker C. The ACR-NEMA digital imaging and communications standard: a
way we look at medical imaging.13 The display of images that non technical description. J Digit Imaging 1989;2:127–31.
is on cathode ray tubes is being replaced by flat panel high 12 Hobbs WC. Taking digital imaging to the next level: challenges and
resolution LCD. Projection and virtual displays may also have opportunities. Radiol Management, 2004;Mar/Apr, 16–20.
13 Kamm KF. The future of digital imaging. Br J Radiol 1997;70:S145–52.
a role in future. The PACS will enable integration with the
radiology information system and electronic patient records
and will transform medical care and be a valuable help to ANSWERS
patient’s journey through the hospital. 1. T; 2. T; 3. F; 4. F; 5. T.

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