Projectional radiography | |
---|---|
ICD-10-PCS | B?0 |
ICD-9-CM | 87 |
OPS-301 code | 3-10...3-13 |
Projectional radiography, also known as conventional radiography, [1] is a form of radiography and medical imaging that produces two-dimensional images by X-ray radiation. The image acquisition is generally performed by radiographers, and the images are often examined by radiologists. Both the procedure and any resultant images are often simply called 'X-ray'. Plain radiography or roentgenography generally refers to projectional radiography (without the use of more advanced techniques such as computed tomography that can generate 3D-images). Plain radiography can also refer to radiography without a radiocontrast agent or radiography that generates single static images, as contrasted to fluoroscopy, which are technically also projectional.
Projectional radiographs generally use X-rays created by X-ray generators, which generate X-rays from X-ray tubes.
An anti-scatter grid may be placed between the patient and the detector to reduce the quantity of scattered x-rays that reach the detector. This improves the contrast resolution of the image, but also increases radiation exposure for the patient.
Detectors can be divided into two major categories: imaging detectors (such as photographic plates and X-ray film (photographic film), now mostly replaced by various digitizing devices like image plates or flat panel detectors) and dose measurement devices (such as ionization chambers, Geiger counters, and dosimeters used to measure the local radiation exposure, dose, and/or dose rate, for example, for verifying that radiation protection equipment and procedures are effective on an ongoing basis).
Lead is the main material used by radiography personnel for shielding against scattered X-rays.
Projectional radiography relies on the characteristics of X-ray radiation (quantity and quality of the beam) and knowledge of how it interacts with human tissue to create diagnostic images. X-rays are a form of ionizing radiation, meaning it has sufficient energy to potentially remove electrons from an atom, thus giving it a charge and making it an ion.
When an exposure is made, X-ray radiation exits the tube as what is known as the primary beam. When the primary beam passes through the body, some of the radiation is absorbed in a process known as attenuation. Anatomy that is denser has a higher rate of attenuation than anatomy that is less dense, so bone will absorb more X-rays than soft tissue. What remains of the primary beam after attenuation is known as the remnant beam. The remnant beam is responsible for exposing the image receptor. Areas on the image receptor that receive the most radiation (portions of the remnant beam experiencing the least attenuation) will be more heavily exposed, and therefore will be processed as being darker. Conversely, areas on the image receptor that receive the least radiation (portions of the remnant beam experience the most attenuation) will be less exposed and will be processed as being lighter. This is why bone, which is very dense, process as being 'white' on radio graphs, and the lungs, which contain mostly air and is the least dense, shows up as 'black'.
Radiographic density is the measure of overall darkening of the image. Density is a logarithmic unit that describes the ratio between light hitting the film and light being transmitted through the film. A higher radiographic density represents more opaque areas of the film, and lower density more transparent areas of the film.
With digital imaging, however, density may be referred to as brightness. The brightness of the radiograph in digital imaging is determined by computer software and the monitor on which the image is being viewed.
Contrast is defined as the difference in radiographic density between adjacent portions of the image. The range between black and white on the final radiograph. High contrast, or short-scale contrast, means there is little gray on the radiograph, and there are fewer gray shades between black and white. Low contrast, or long-scale contrast, means there is much gray on the radiograph, and there are many gray shades between black and white.
Closely related to radiographic contrast is the concept of exposure latitude. Exposure latitude is the range of exposures over which the recording medium (image receptor) will respond with a diagnostically useful density; in other words, this is the "flexibility" or "leeway" that a radiographer has when setting his/her exposure factors. Images having a short-scale of contrast will have narrow exposure latitude. Images having long-scale contrast will have a wide exposure latitude; that is, the radiographer will be able to utilize a broader range of technical factors to produce a diagnostic-quality image.
Contrast is determined by the kilovoltage (kV; energy/quality/penetrability) of the x-ray beam and the tissue composition of the body part being radiographed. Selection of look-up tables (LUT) in digital imaging also affects contrast.
Generally speaking, high contrast is necessary for body parts in which bony anatomy is of clinical interest (extremities, bony thorax, etc.). When soft tissue is of interest (ex. abdomen or chest), lower contrast is preferable in order to accurately demonstrate all of the soft tissue tones in these areas.
Geometric magnification results from the detector being farther away from the X-ray source than the object. In this regard, the source-detector distance or SDD [3] is a measurement of the distance between the generator and the detector. Alternative names are source [4] /focus to detector/image-receptor [4] /film (latter used when using X-ray film) distance (SID, [4] FID or FRD).
The estimated radiographic magnification factor (ERMF) is the ratio of the source-detector distance (SDD) over the source-object distance (SOD). [5] The size of the object is given as:
,
where Sizeprojection is the size of the projection that the object forms on the detector. On lumbar and chest radiographs, it is anticipated that ERMF is between 1.05 and 1.40. [6] Because of the uncertainty of the true size of objects seen on projectional radiography, their sizes are often compared to other structures within the body, such as dimensions of the vertebrae, or empirically by clinical experience. [7]
The source-detector distance (SDD) is roughly related to the source-object distance (SOD) [8] and the object-detector distance (ODD) by the equation SOD + ODD = SDD.
Geometric unsharpness is caused by the X-ray generator not creating X-rays from a single point but rather from an area, as can be measured as the focal spot size. Geometric unsharpness increases proportionally to the focal spot size, as well as the estimated radiographic magnification factor (ERMF).
Organs will have different relative distances to the detector depending on which direction the X-rays come from. For example, chest radiographs are preferably taken with X-rays coming from behind (called a "posteroanterior" or "PA" radiograph). However, in case the patient cannot stand, the radiograph often needs to be taken with the patient lying in a supine position (called a "bedside" radiograph) with the X-rays coming from above ("anteroposterior" or "AP"), and geometric magnification will then cause for example the heart to appear larger than it actually is because it is further away from the detector. [9]
In addition to using an anti-scatter grid, increasing the ODD alone can improve image contrast by decreasing the amount of scattered radiation that reaches the receptor. However, this needs to be weighted against increased geometric unsharpness if the SDD is not also proportionally increased. [10]
Projection radiography uses X-rays in different amounts and strengths depending on what body part is being imaged:
NOTE: The simplified word 'view' is often used to describe a radiographic projection.
Plain radiography generally refers to projectional radiography (without the use of more advanced techniques such as computed tomography). Plain radiography can also refer to radiography without a radiocontrast agent or radiography that generates single static images, as contrasted to fluoroscopy.
Projectional radiography of the breasts is called mammography. This has been used mostly on women to screen for breast cancer, but is also used to view male breasts, and used in conjunction with a radiologist or a surgeon to localise suspicious tissues before a biopsy or a lumpectomy. Breast implants designed to enlarge the breasts reduce the viewing ability of mammography, and require more time for imaging as more views need to be taken. This is because the material used in the implant is very dense compared to breast tissue, and looks white (clear) on the film. The radiation used for mammography tends to be softer (has a lower photon energy) than that used for the harder tissues. Often a tube with a molybdenum anode is used with about 30 000 volts (30 kV), giving a range of X-ray energies of about 15-30 keV. Many of these photons are "characteristic radiation" of a specific energy determined by the atomic structure of the target material (Mo-K radiation).
Chest radiographs are used to diagnose many conditions involving the chest wall, including its bones, and also structures contained within the thoracic cavity including the lungs, heart, and great vessels. Conditions commonly identified by chest radiography include pneumonia, pneumothorax, interstitial lung disease, heart failure, bone fracture and hiatal hernia. Typically an erect postero-anterior (PA) projection is the preferred projection. Chest radiographs are also used to screen for job-related lung disease in industries such as mining where workers are exposed to dust. [12]
For some conditions of the chest, radiography is good for screening but poor for diagnosis. When a condition is suspected based on chest radiography, additional imaging of the chest can be obtained to definitively diagnose the condition or to provide evidence in favor of the diagnosis suggested by initial chest radiography. Unless a fractured rib is suspected of being displaced, and therefore likely to cause damage to the lungs and other tissue structures, an X-ray of the chest is not necessary as it will not alter patient management.
In children, abdominal radiography is indicated in the acute setting in suspected bowel obstruction, gastrointestinal perforation, foreign body in the alimentary tract, suspected abdominal mass and intussusception (latter as part of the differential diagnosis). [13] Yet, CT scan is the best alternative for diagnosing intra-abdominal injury in children. [13] For acute abdominal pain in adults, an abdominal X-ray has a low sensitivity and accuracy in general. Computed tomography provides an overall better surgical strategy planning, and possibly less unnecessary laparotomies. Abdominal X-ray is therefore not recommended for adults presenting in the emergency department with acute abdominal pain. [14]
The standard abdominal X-ray protocol is usually a single anteroposterior projection in supine position. [15] A Kidneys, Ureters, and Bladder projection (KUB) is an anteroposterior abdominal projection that covers the levels of the urinary system, but does not necessarily include the diaphragm.
In case of trauma, the standard UK protocol is to have a CT scan of the skull instead of projectional radiography. [15] A skeletal survey including the skull can be indicated in for example multiple myeloma. [15]
These include:
The body has to be rotated about 30 to 45 degrees towards the shoulder to be imaged, and the standing or sitting patient lets the arm hang. This method reveals the joint gap and the vertical alignment towards the socket. [17]
The arm should be abducted 80 to 100 degrees. This method reveals: [17]
The lateral contour of the shoulder should be positioned in front of the film in a way that the longitudinal axis of the scapula continues parallel to the path of the rays. This method reveals: [17]
This projection has a low tolerance for errors and accordingly needs proper execution. [17] The Y-projection can be traced back to Wijnblath's 1933 published cavitas-en-face projection. [18]
In the UK, the standard projections of the shoulder are AP and Lateral Scapula or Axillary Projection. [15]
A projectional radiograph of an extremity confers an effective dose of approximately 0.001 mSv, comparable to a background radiation equivalent time of 3 hours. [16]
The standard projection protocols in the UK are: [15]
Certain suspected conditions require specific projections. For example, skeletal signs of rickets are seen predominantly at sites of rapid growth, including the proximal humerus, distal radius, distal femur and both the proximal and the distal tibia. Therefore, a skeletal survey for rickets can be accomplished with anteroposterior radiographs of the knees, wrists, and ankles. [20]
Radiological disease mimics are visual artifacts, normal anatomic structures or harmless variants that may simulate diseases or abnormalities. In projectional radiography, general disease mimics include jewelry, clothes and skin folds. [21] In general medicine a disease mimic shows symptoms and/or signs like those of another. [22]
X-ray radiation, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 nanometers to 10 picometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz (3×1016 Hz to 3×1019 Hz) and energies in the range 124 keV to 145 eV, respectively. X-ray wavelengths are shorter than those of UV rays and typically longer than those of gamma rays. In many languages, X-radiation is referred to as Röntgen radiation, after the German scientist Wilhelm Conrad Röntgen, who discovered it on November 8, 1895. He named it X-radiation to signify an unknown type of radiation. Spellings of X-ray(s) in English include the variants x-ray(s), xray(s), and X ray(s).
A computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or radiology technologists.
Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography and industrial radiography. Similar techniques are used in airport security. To create an image in conventional radiography, a beam of X-rays is produced by an X-ray generator and is projected toward the object. A certain amount of the X-rays or other radiation is absorbed by the object, dependent on the object's density and structural composition. The X-rays that pass through the object are captured behind the object by a detector. The generation of flat two dimensional images by this technique is called projectional radiography. In computed tomography an X-ray source and its associated detectors rotate around the subject which itself moves through the conical X-ray beam produced. Any given point within the subject is crossed from many directions by many different beams at different times. Information regarding attenuation of these beams is collated and subjected to computation to generate two dimensional images in three planes which can be further processed to produce a three dimensional image.
Radiology is the medical discipline that uses medical imaging to diagnose diseases and guide their treatment, within the bodies of humans and other animals. It began with radiography, but today it includes all imaging modalities, including those that use no electromagnetic radiation, as well as others that do, such as computed tomography (CT), fluoroscopy, and nuclear medicine including positron emission tomography (PET). Interventional radiology is the performance of usually minimally invasive medical procedures with the guidance of imaging technologies such as those mentioned above.
Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to reveal internal structures hidden by the skin and bones, as well as to diagnose and treat disease. Medical imaging also establishes a database of normal anatomy and physiology to make it possible to identify abnormalities. Although imaging of removed organs and tissues can be performed for medical reasons, such procedures are usually considered part of pathology instead of medical imaging.
A lower gastrointestinal series is a medical procedure used to examine and diagnose problems with the human colon of the large intestine. Radiographs are taken while barium sulfate, a radiocontrast agent, fills the colon via an enema through the rectum.
A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in medicine.
Digital radiography is a form of radiography that uses x-ray–sensitive plates to directly capture data during the patient examination, immediately transferring it to a computer system without the use of an intermediate cassette. Advantages include time efficiency through bypassing chemical processing and the ability to digitally transfer and enhance images. Also, less radiation can be used to produce an image of similar contrast to conventional radiography.
Radiographers, also known as radiologic technologists, diagnostic radiographers and medical radiation technologists are healthcare professionals who specialise in the imaging of human anatomy for the diagnosis and treatment of pathology. Radiographers are infrequently, and almost always erroneously, known as x-ray technicians. In countries that use the title radiologic technologist they are often informally referred to as techs in the clinical environment; this phrase has emerged in popular culture such as television programmes. The term radiographer can also refer to a therapeutic radiographer, also known as a radiation therapist.
Industrial radiography is a modality of non-destructive testing that uses ionizing radiation to inspect materials and components with the objective of locating and quantifying defects and degradation in material properties that would lead to the failure of engineering structures. It plays an important role in the science and technology needed to ensure product quality and reliability. In Australia, industrial radiographic non-destructive testing is colloquially referred to as "bombing" a component with a "bomb".
Dental radiographs, commonly known as X-rays, are radiographs used to diagnose hidden dental structures, malignant or benign masses, bone loss, and cavities.
Image-guided radiation therapy is the process of frequent imaging, during a course of radiation treatment, used to direct the treatment, position the patient, and compare to the pre-therapy imaging from the treatment plan. Immediately prior to, or during, a treatment fraction, the patient is localized in the treatment room in the same position as planned from the reference imaging dataset. An example of IGRT would include comparison of a cone beam computed tomography (CBCT) dataset, acquired on the treatment machine, with the computed tomography (CT) dataset from planning. IGRT would also include matching planar kilovoltage (kV) radiographs or megavoltage (MV) images with digital reconstructed radiographs (DRRs) from the planning CT.
An abdominal x-ray is an x-ray of the abdomen. It is sometimes abbreviated to AXR, or KUB.
Photostimulated luminescence (PSL) is the release of stored energy within a phosphor by stimulation with visible light, to produce a luminescent signal. X-rays may induce such an energy storage. A plate based on this mechanism is called a photostimulable phosphor (PSP) plate and is one type of X-ray detector used in projectional radiography. Creating an image requires illuminating the plate twice: the first exposure, to the radiation of interest, "writes" the image, and a later, second illumination "reads" the image. The device to read such a plate is known as a phosphorimager.
Automatic Exposure Control (AEC) is an X-ray exposure termination device. A medical radiographic exposure is always initiated by a human operator but an AEC detector system may be used to terminate the exposure when a predetermined amount of radiation has been received. The intention of AEC is to provide consistent x-ray image exposure, whether to film, a digital detector or a CT scanner. AEC systems may also automatically set exposure factors such as the X-ray tube current and voltage in a CT.
A panoramic radiograph is a panoramic scanning dental X-ray of the upper and lower jaw. It shows a two-dimensional view of a half-circle from ear to ear. Panoramic radiography is a form of focal plane tomography; thus, images of multiple planes are taken to make up the composite panoramic image, where the maxilla and mandible are in the focal trough and the structures that are superficial and deep to the trough are blurred.
In medical imaging, an anti-scatter grid is a device for limiting the amount of scattered radiation reaching the detector, thereby improving the quality of diagnostic medical x-ray images. The grid is positioned on the opposite side of the patient from the x-ray source, and between the patient and the X-ray detector or film. Reducing the amount of scattered x-rays increases the image's contrast resolution, and consequently the visibility of soft tissues.
Phase-contrast X-ray imaging or phase-sensitive X-ray imaging is a general term for different technical methods that use information concerning changes in the phase of an X-ray beam that passes through an object in order to create its images. Standard X-ray imaging techniques like radiography or computed tomography (CT) rely on a decrease of the X-ray beam's intensity (attenuation) when traversing the sample, which can be measured directly with the assistance of an X-ray detector. However, in phase contrast X-ray imaging, the beam's phase shift caused by the sample is not measured directly, but is transformed into variations in intensity, which then can be recorded by the detector.
X-ray detectors are devices used to measure the flux, spatial distribution, spectrum, and/or other properties of X-rays.
An occult fracture is a fracture that is not readily visible, generally in regard to projectional radiography ("X-ray"). Radiographically, occult and subtle fractures are a diagnostic challenge. They may be divided into 1) high energy trauma fracture, 2) fatigue fracture from cyclical and sustained mechanical stress, and 3) insufficiency fracture occurring in weakened bone. Independently of the cause, the initial radiographic examination can be negative either because the findings seem normal or are too subtle. Advanced imaging tools such as computed tomography, magnetic resonance imaging (MRI), and scintigraphy are highly valuable in the early detection of these fractures.
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