Transitioning to digital radiography

Objective – To describe the different forms of digital radiography (DR), image file formats, supporting equipment and services required for DR, storage of digital images, and teleradiology. Background – Purchasing a DR system is a major investment for a veterinary practice. Types of DR systems include computed radiography, charge coupled devices, and direct or indirect DR. Comparison of workflow for analog and DR is presented. Summary – On the surface, switching to DR involves the purchase of DR acquisition hardware. The X‐ray machine, table and grids used in analog radiography are the same for DR. Realistically, a considerable infrastructure supports the image acquisition hardware. This infrastructure includes monitors, computer workstations, a robust computer network and internet connection, a plan for storage and back up of images, and service contracts. Advantages of DR compared with analog radiography include improved image quality (when used properly), ease of use (more forgiving to the errors of radiographic technique), speed of making a complete study (important for critically ill patients), fewer repeat radiographs, less time looking for imaging studies, less physical storage space, and the ability to easily send images for consultation. Conclusions – With an understanding of the infrastructure requirements, capabilities and limitations of DR, an informed veterinary practice should be better able to make a sound decision about transitioning to DR.     

Comparison of computed radiography and conventional radiography in detection of small volume pneumoperitoneum

The role of digital imaging is increasing as these systems are becoming more affordable and accessible. Advantages of computed radiography compared with conventional film/screen combinations include improved contrast resolution and postprocessing capabilities. Computed radiography's spatial resolution is inferior to conventional radiography; however, this limitation is considered clinically insignificant. This study prospectively compared digital imaging and conventional radiography in detecting small volume pneumoperitoneum. Twenty cadaver dogs (15-30 kg) were injected with 0.25, 0.25, and 0.5 ml for 1 ml total of air intra-abdominally, and radiographed sequentially using computed and conventional radiographic technologies. Three radiologists independently evaluated the images, and receiver operating curve (ROC) analysis compared the two imaging modalities. There was no statistical difference between computed and conventional radiography in detecting free abdominal air, but overall computed radiography was relatively more sensitive based on ROC analysis. Computed radiographic images consistently and significantly demonstrated a minimal amount of 0.5 ml of free air based on ROC analysis. However, no minimal air amount was consistently or significantly detected with conventional film. Readers were more likely to detect free air on lateral computed images than the other projections, with no significant increased sensitivity between film/screen projections. Further studies are indicated to determine the differences or lack thereof between various digital imaging systems and conventional film/screen systems.     

Common artefacts and pitfalls in equine computed and digital radiography and how to avoid them

Radiographic technology has rapidly advanced over the last decade with the use of both computed radiography and digital radiography now being common in equine practice. Image quality is critical for optimal diagnostic accuracy, so identification of factors that negatively influence quality is vital. The most commonly encountered problems include positioning errors, exposure anomalies, movement artefacts, labelling errors and image processing faults. The aim of this review is to describe common radiographic faults that will allow the equine practitioner to recognise and learn how to prevent these issues, thus improving image quality. This will aid in improving diagnostic accuracy and will enhance radiation safety by reducing the number of repeat exposures required.     

A comparison of computed tomography, computed radiography, and film-screen radiography for the detection of canine pulmonary nodules

Computed tomography (CT) has become more widely available and computed radiography (CR) has replaced film-screen radiography for canine thoracic imaging in many veterinary practices. There are limited data comparing these modalities in a veterinary clinical setting to detect pulmonary nodules. We compared CT, CR, and film-screen radiography for detecting the presence, number, and characteristics of pulmonary nodules in dogs. Observer performance for a variety of experience levels was also evaluated. Twenty-one client-owned dogs with a primary neoplastic process underwent CT and CR; nine also received film-screen radiographs. Positive/negative classification by consensus agreed between the three modalities in 8/9 dogs and between CR and CT in the remaining 12. CT detected the greatest (P = 0.002) total number of nodules and no difference was seen between CR and films. The greatest number of nodules was seen in the right middle and both caudal regions, but only using CT (P < 0.0001). Significantly smaller nodules were detected with CT (P = 0.0007) and no difference in minimum size was detected between CR and films. Observer accuracy was high for all modalities; particularly for CT (90.5-100%) and for the senior radiologist (90.5-100%). CT was also characterized by the least interobserver variability. Although CT, CR, and film-screen performed similarly in determining the presence or absence of pulmonary nodules, a greater number of smaller nodules was detected with CT, and CT was associated with greater diagnostic confidence and observer accuracy and agreement.     

Comparison between radiography and computed tomography for diagnosis of equine skull fractures

The equine head is a complex structure prone to traumatic injuries. To determine the value and limitations of radiography and (CT) for the diagnosis of skull fracture, the differences between the two modalities were described. Two observers retrospectively reviewed the radiographic and CT images of 18 horses with a skull fracture. To allow direct comparison between the two modalities, a simplified fracture classification system was used. In 3/18 cases the evaluation of the radiographic examination concluded no injuries visible. In 2/15 cases soft tissue involvement was not detected and in 7/15 cases the extension of the fracture was underestimated with radiography. Radiography classified 4/10 multiple fractures incorrectly as single fracture and 5/15 comminuted fractures on CT were diagnosed as simple fracture with radiography. The number of fragments was underestimated with radiography in 14/15 cases. In conclusion, radiography is able to diagnose a skull fracture in most cases. Skull fractures however are not similarly classified after radiographic and CT evaluation, which causes a difference in interpretation and perception of the fractures. Therefore, CT should be the modality of choice for surgical planning and prognosis.     

The diagnosis of lameness associated with distal limbpathology in a horse: A comparison of radiography, computed tomography and magnetic resonance imaging

A cadaver limb from an eight-year-old horse with right forelimb lameness that was relieved with an intra-articular distal interphalangeal joint block was imaged with radiographs, spiral computed tomography (CT) and magnetic resonance imaging (MRI). Spiral CT demonstrated several lucencies within the deep digital flexor tendon immediately proximal to the navicular bone. On MRI these areas had increased signal and there was enlargement of the tendon at this site. Effusion in the proximal interphalangeal joint and navicular bursa and thinning of the fibrocartilage of the navicular bone were also observed on MRI images. These changes were not detected on radiographs. Histopathology confirmed that there were focal areas of collagen necrosis within the deep digital flexor tendon with thinning and degenerative changes in the fibrocartilage of the navicular bone.     

DIGITAL IMAGE PROCESSING

Image processing or digital image manipulation is one of the greatest advantages of digital radiography (DR). Preprocessing depends on the modality and corrects for system irregularities such as differential light detection efficiency, dead pixels, or dark noise. Processing is manipulation of the raw data just after acquisition. It is generally proprietary and specific to the DR vendor but encompasses manipulations such as unsharp mask filtering within two or more spatial frequency bands, histogram sliding and stretching, and gray scale rendition or lookup table application. These processing steps have a profound effect on the final appearance of the radiograph, but they can also lead to artifacts unique to digital systems. Postprocessing refers to manipulation of the final appearance of the radiograph by the end-user and does not involve alteration of the raw data.     

Cone beam computed tomography and intraoral radiography for diagnosis of dental abnormalities in dogs and cats

The development of veterinary dentistry has substantially improved the ability to diagnose canine and feline dental abnormalities. Consequently, examinations previously performed only on humans are now available for small animals, thus improving the diagnostic quality. This has increased the need for technical qualification of veterinary professionals and increased technological investments. This study evaluated the use of cone beam computed tomography and intraoral radiography as complementary exams for diagnosing dental abnormalities in dogs and cats. Cone beam computed tomography was provided faster image acquisition with high image quality, was associated with low ionizing radiation levels, enabled image editing, and reduced the exam duration. Our results showed that radiography was an effective method for dental radiographic examination with low cost and fast execution times, and can be performed during surgical procedures.     

Comparison between radiological and magnetic resonance imaging lesions in the distal border of the navicular bone with particular reference to distal border fragments and osseous cyst-like lesions

Reasons for performing study: There are no data concerning the accuracy of conventional and computed or digital radiography for evaluation of the equine foot. Objectives: To compare conventional film‐screen and computed radiography with magnetic resonance imaging (MRI) for detection of distal border fragments of the navicular bone; and to establish which type of fragment was more likely to be detected radiologically. Methods: Horses were included if forelimb lameness was localised to the foot and both radiography and high‐field MR images had been acquired. Horses were divided into 2 groups based on acquisition of conventional (Group A) or computed (Group B) radiographs. The presence of distal border fragments was recorded. From MR images, distal border fragments were graded based on their size and changes in signal intensity in the adjacent navicular bone. Sensitivity and specificity of conventional and computed radiography for detection of fragments were calculated using MRI as the gold standard. A Chi‐squared test was used to test for associations between specific radiological and MRI findings in the distal border of the navicular bone. Results: In Group A 46 and 18 fragments were identified on MR and radiographic images, respectively; in Group B 45 and 17 fragments were seen. There was no significant difference between computed and conventional radiography. Grades 4 and 5 fragments or large‐sized fragments were identified most frequently; low‐grade fragments were unlikely to be observed. There was a significant correlation between radiological and MRI abnormalities of the distal border of the navicular bone. Conclusions: Conventional and computed radiography had similar, rather low sensitivity for identification of distal border fragments of the navicular bone, but specificity was high. Large‐sized and high‐grade fragments were most likely to be identified radiologically. Potential relevance: Fragments observed radiologically are likely to be associated with other pathological abnormalities of the distal border of the navicular bone.     

DIGITAL RADIOGRAPHY ARTIFACTS

Radiographic artifacts may mimic a clinical feature, impair image quality, or obscure abnormalities. With the development of digital radiography (DR), a new set of artifacts is introduced. Regardless of the technology, the classic technical errors that occur with film screen radiography still occur using DR. Artifacts created using computed radiography, DR, and incorrect image processing are discussed. Methods for correction of the artifacts are presented.     

The use of intrathecal analgesia and contrast radiography as preoperative diagnostic methods for digital flexor tendon sheath pathology

Reasons for performing study: The sensitivity of ultrasonography for the diagnosis of manica flexoria (MF) tears within the digital flexor tendon sheath (DFTS) is lower than for diagnosis of marginal tears of the deep digital flexor tendon (DDFT). Additional diagnostic tools would assist in appropriate decision making for either conservative or surgical management. Objectives: To evaluate the improvement in lameness of horses with MF or DDFT tears following intrathecal analgesia and to assess the sensitivity and specificity of contrast radiography for the diagnosis of these tears. Methods: The case records of horses presented to a referral clinic over a 7‐year period that underwent intrathecal diagnostic analgesia, or intrathecal analgesia and contrast radiography, of the DFTS with subsequent tenoscopy were examined. Results: Fifty‐three limbs had intrathecal diagnostic analgesia performed and 23 contrast tenograms were assessed in horses undergoing DFTS tenoscopy. Horses with DDFT tears were significantly more likely to respond positively to intrathecal diagnostic analgesia than those with MF tears (P = 0.02). Using contrast radiography, tears of the MF were predicted with an overall sensitivity of 96% and specificity of 80%; marginal tears of the DDFT were predicted with an overall sensitivity of 57% and specificity of 84%. Conclusions: The results of intrathecal analgesia of the DFTS in combination with contrast radiography have a high sensitivity for predicting MF tears. The sensitivity of contrast radiography for predicting tears of the DDFT is lower but the specificity remains high. Potential relevance: Contrast radiography performed at the same time as intrathecal analgesia provides useful information regarding the presence of MF tears and DDFT tears, which can assist in the decision of whether to manage the lameness conservatively or with tenoscopic evaluation.     

Coxofemoral joint radiography in standing cattle

The objective of this study was to establish a technique for radiographic examination of the coxofemoral joint and adjacent bony structures in standing cattle. Left (or right) 30° dorsal-right (or left) ventral radiographic views of the coxofemoral joint region of standing cattle (n = 10) with hind limb lameness were evaluated retrospectively. In addition, an experimental study of oblique laterolateral views of the coxofemoral joint region of a bovine skeleton at angles of 15-45° was carried out to determine the optimal position for visualization of the hip region. In the 10 clinical patients, the bodies of the ilium and ischium, the acetabulum and proximal third of the femur could be assessed. Six of these cattle had fractures of the body of the ilium and body of the ischium, five with and one without involvement of the acetabulum, two had craniodorsal and one caudoventral luxation of the femur and one had a femoral neck fracture. The described laterodorsal-lateroventral radiographs of the hip region in standing cattle were suitable for assessing the coxofemoral joint, the proximal aspect of the femur and parts of the ischium, ilium and pubis. After testing the optimal angle on the skeleton, it was seen that distortion and superimposition were minimized by positioning the X-ray beam at an angle of 25° to the horizontal plane. It can be concluded that the described technique improves the evaluation of injuries of the coxofemoral region in cattle. With the appropriate angle, the technique can also be applied in recumbent cattle.     

ACQUISITION HARDWARE FOR DIGITAL IMAGING

Use of digital radiography is growing rapidly in veterinary medicine. Two basic digital imaging systems are available, computed radiography (CR) and direct digital radiography (DDR). Computed radiographic detectors use a two‐step process for image capture and processing. Image capture is by X‐ray sensitive phosphors in the image plate. The image plate reader transforms the latent phosphor image to light photons that are converted to an analog electrical signal. An analog to digital converter is used to digitize the electrical signal before computer analysis. Direct digital detectors provide digital data by direct readout after image capture—a reader unnecessary. Types of DDR detectors are flat panel detectors and charge coupled device (CCD) detectors. Flat panel detectors are composed of layers of semiconductors for image capture with transistor and microscopic circuitry embedded in a pixel array. Direct converting flat panel detectors convert incident X‐rays directly into electrical charges. Indirect detectors convert X‐rays to visible light, then to electrical charges. All flat panel detectors send a digitized electrical signal to a computer using a direct link. Charge coupled device detectors have a small chip similar to those used in digital cameras. A scintillator first converts X‐rays to a light signal that is minified by an optical system before reaching the chip. The chip sends a digital signal directly to a computer. Both CR and DDR provide quality diagnostic images. CR is a mature technology while DDR is an emerging technology.     

ACQUISITION HARDWARE FOR DIGITAL IMAGING

Use of digital radiography is growing rapidly in veterinary medicine. Two basic digital imaging systems are available, computed radiography (CR) and direct digital radiography (DDR). Computed radiographic detectors use a two-step process for image capture and processing. Image capture is by X-ray sensitive phosphors in the image plate. The image plate reader transforms the latent phosphor image to light photons that are converted to an analog electrical signal. An analog to digital converter is used to digitize the electrical signal before computer analysis. Direct digital detectors provide digital data by direct readout after image capture—a reader unnecessary. Types of DDR detectors are flat panel detectors and charge coupled device (CCD) detectors. Flat panel detectors are composed of layers of semiconductors for image capture with transistor and microscopic circuitry embedded in a pixel array. Direct converting flat panel detectors convert incident X-rays directly into electrical charges. Indirect detectors convert X-rays to visible light, then to electrical charges. All flat panel detectors send a digitized electrical signal to a computer using a direct link. Charge coupled device detectors have a small chip similar to those used in digital cameras. A scintillator first converts X-rays to a light signal that is minified by an optical system before reaching the chip. The chip sends a digital signal directly to a computer. Both CR and DDR provide quality diagnostic images. CR is a mature technology while DDR is an emerging technology.     

Differences in the morphology of distal border synovial invaginations of the distal sesamoid bone in the horse as evaluated by computed tomography compared with radiography

Reasons for performing study: Distal border synovial invaginations of the distal sesamoid bone are radiographically assessed during the selection process of horses admitted as breeding stallions or in purchase examinations. Nowadays, many moderately or some deeply penetrating proximally enlarged synovial invaginations are considered as moderate or severe radiographic findings. Objective: To measure the difference between and agreement of the morphology of distal border synovial invaginations on radiography vs. computed tomography (CT). It was hypothesised that the morphology of distal border synovial invaginations would be better evaluable on CT compared with radiography. Methods: Computed tomography scans and 3 dorsoproximal–palmarodistal oblique (DPr‐PaDiO) radiographs were obtained on 50 cadaver forefeet from 25 Warmblood horses. Computed tomography was assumed to be the gold standard. The number, shape and depth of penetration of distal border synovial invaginations into the distal sesamoid bone were evaluated with both methods, and the comparison of their measurements was statistically described. Results: A statistically significant mean difference for number of distal synovial invaginations between CT and all 3 DPr‐PaDiO projections was found and was approximately equal to 2, meaning that CT permits visualisation of an average of 2 more invaginations than radiography. In none of the cases did radiography have a higher number observed than CT. A large variation in the difference of measurements for depth of penetration against their mean difference between CT and the 3 radiographic projections was seen. Radiography underestimated the depth of invaginations, and more so when these were deeper. There was no statistically significant mean difference found between the techniques for depth. A moderate to good agreement between measurements on CT and the three DPr‐PaDiO projections for shape was seen, in which the D55°Pr‐PaDiO projection showed the best agreement. A high specificity (90–99%) and low sensitivity (65%) for all projections for shape were found. Conclusions and potential relevance: Radiography differs considerably from CT concerning the morphology of distal navicular border synovial invaginations. For the evaluation of the number, depth and shape of distal synovial invaginations in the distal sesamoid bone, radiography shows only partially the morphology seen on CT.     

The use of radiography for diagnosis of apical infection of equine cheek teeth

Despite recent developments in advanced imaging, radiography remains the most commonly employed imaging modality for investigating apical infection of cheek teeth in horses. Radiographic technique, knowledge of the normal anatomy and horse compliance are paramount for acquiring good quality dental radiographs. Interpretation of subtle pathology can be difficult for even the most experienced radiologist; however, in more chronic cases, identification of dental abnormalities is easier.     

Sensitivity and specificity of radiography for detection of elbow incongruity in clinical patients

Elbow incongruity is an important factor regarding the treatment and prognosis of elbow dysplasia. Our purpose was to determine the sensitivity and specificity for radiographic detection of elbow incongruity in clinical patients, to establish inter- and intraobserver variation for different parameters, and to evaluate the possibility of radiographic grading of incongruity. Standard radiographic projections were acquired from 29 incongruent and nine congruent elbows of dogs of various ages and breeds. Computed tomography (CT) was used to diagnose and grade the incongruity. All radiographs were evaluated by four observers for detection and grading of elbow incongruity. Sensitivity, specificity, inter- and intraobserver variability were calculated. The mean sensitivity for detection of incongruity was very good (88.8%) with a mean specificity of 91.7%. Correct grading of incongruity was difficult. The radioulnar step and the widening of the humeroulnar and humeroradial joint space were seen most frequently. Intraobserver and interobserver variability were fair to excellent (Kappa = 0.372-0.809), depending on the investigated parameters. Radiography is valuable to screen for elbow incongruity. In over 91% of the patients, a clear distinction could be made between a congruent and an incongruent joint grading was not possible.