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The British Journal of Radiology, 76 (2003), 177188 DOI: 10.

1259/bjr/52734084

2003 The British Institute of Radiology

A study and optimization of lumbar spine X-ray imaging systems


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G MCVEY, D.Phil, 2M SANDBORG, PhD, 1D R DANCE, PhD, FIPEM and 2G ALM CARLSSON, PhD, FInstP

Joint Department of Physics, The Royal Marsden NHS Trust, Fulham Road, London SW3 6JJ, UK and 2Department of Radiation Physics, Faculty of Health Sciences, Linkoping University, SE581 85 Linkoping, Sweden

Abstract. A Monte Carlo program has been developed that incorporates a voxel phantom of an adult patient in a model of the complete X-ray imaging system, including the anti-scatter grid and screenlm receptor. This allows the realistic estimation of patient dose and the corresponding image (optical density map) for a wide range of equipment congurations. This paper focuses on the application of the program to lumbar spine anteroposterior and lateral screenlm examinations. The program has been applied to study the variation of physical image quality measures and effective dose for changing system parameters such as tube voltage, grid design and screenlm system speed. These variations form the basis for optimization of these system parameters. In our approach to optimization, the best systems are those that can match (or come close to) the calculated image quality measure of systems preferred in a recent European clinical trial, but with lower patient dose. The largest dose savings found were 21% for a 400 speed class system with a grid having a strip density of 40 cm21 and a grid ratio of 16. A further dose saving of 13% was possible when a 600 speed class system was employed. The best systems found from the optimization correspond to those recommended by the European Commission guidelines on image quality criteria for diagnostic radiographic images.

Lumbar spine radiographs allow clinicians to judge the conguration and alignment of bones with a high degree of accuracy. Malalignment or other changes in the shape of the vertebrae can then be identied and may imply the presence of a tumour, fracture or infection. Lumbar spine radiography is a routine examination for lower back pain, which is very common; 27 patients per 1000 inhabitants in the UK undergo plain radiography of the lumbar spine each year [1]. These examinations contribute 4.3% of the annual collective effective dose for all medical and dental exposures compared with 0.9% for chest examinations in the UK [2]. Optimization is necessary to balance the requirement for good image quality with low patient dose. The Commission of the European Communities (CEC) image quality criteria [3] describe the presentation of the normal anatomy in a lumbar spine radiograph. Almen et al [4] have evaluated the image quality of lumbar spine radiographs using the CEC criteria [3]. These studies showed that systems using a low tube voltage (70 kV) and a medium speed class (400) for the screenlm receptor fullled more of the image criteria for the anteroposterior (AP) projection than those using high tube voltage and high speed class. The systems using high speed class (600) and low tube voltage (77 kV) fullled more criteria for the
Received 8 April 2002 and in revised form 30 August 2002, accepted 21 October 2002. Current address for G McVey: North Wales Medical Physics, Glan Clwyd Hospital, Bodelwyddan, Denbighshire LL18 5UJ, UK. This work was supported by grants from the Commission of European Communities (Nos. FI4P CT950005 and FIGM-CT200000036). The Swedish authors were supported by grants from the Swedish Radiation Protection Institute, SSI (Nos. SSI P1018.97 and SSI P1083.98), and the Swedish Foundation for Strategic Research (No. R98:006).

lateral (LAT) projection than those using low speed class and high tube voltage. Vano et al [5] optimized lumbar spine imaging by varying different technical parameters and found the largest dose saving by decreasing the optical density by changing the settings of the automatic exposure control (AEC). Almen et al did not study the effect of optical density as they did not use AEC. The assessment by Almen et al [4] of clinical image quality has been complemented by theoretical modelling as part of the same project. A realistic Monte Carlo model of the patient (voxel phantom) and the complete imaging system has been developed [6] for this purpose. The model can be used to calculate physical measures of image quality and patient dose. In Sandborg et al [7], the correlations between our calculated physical measures of image quality and the clinical assessments of image quality are presented for chest and lumbar spine radiographs. For the latter, the signal-to-noise ratio (SNR) of trabecular structures was found to be a good predictor of clinical image quality. This paper presents the application of the Monte Carlo program to the study and optimization of lumbar spine imaging. The optimization approach is similar to that used, with the same model, for chest radiography [8] and involves the use of a reference system known to be of good image quality. Preliminary results for this study are outlined in Dance et al [9]. In this paper, our preliminary study is considerably extended so that the inuence of tube voltage, grid design, screenlm speed and operating optical density are all considered for both AP and LAT projections.

Methods and materials


Monte Carlo model and voxel phantom
A Monte Carlo computer program has been developed to simulate diagnostic X-ray examinations. It is based on
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our earlier work, which employed a homogeneous phantom in a model of the complete imaging system [10, 11]. For the present model, the program has been extended by the inclusion of a voxel phantom to provide a more accurate model of the patient. The program transports photons through the patient and the anti-scatter grid to the imaging device. The energy imparted to the voxel phantom allows the patient dose to be calculated and the energy imparted to the screen allows the image quality measures to be calculated. These parameters are discussed in more detail below. The voxel phantom used is that developed by Zubal et al [12, 13] and was obtained by segmentation of a series of CT slices of an adult male. Female organs (breasts, uterus and ovaries) were added by us to facilitate the calculation of effective dose [14]. An extra layer of voxels was included in the phantom to model the couch top. For the AP view, the dimensions of the voxel phantom were 899 mm from the top of the head to the bottom of the pelvis (236 voxels), 356 mm wide (128 voxels) and 214 mm thick (77 voxels). The phantoms length was adjusted to correspond to the sitting height of the average European male [15]. The phantoms width and thickness were found by the comparison of calculations of entrance air kerma for the voxel phantom with measurements from a patient study [6, 16]. Each voxel in the phantom belongs to 1 of 55 organs and each organ is associated with one of four tissue types: average soft tissue (1030 kg m23); lung (260 kg m23); average bone (1490 kg m23); or bone spongiosa (1180 kg m23). Tissue compositions were obtained from the International Commission on Radiation Units and Measurements (ICRU) [17], except for average bone, which was taken from Kramer [18]. Figure 1 shows the model of the voxel phantom and the components of the imaging system. The photon spectrum was obtained from Birch et al [19]. A grid was used as the anti-scatter technique and was specied in terms of strip density N, lead strip width d, grid ratio r and the materials in the interspaces and covers. The model of the image receptor included the cassette front, uorescent screen and lm characteristic (H and D) curve, measured by Dr F Verdun, Lausanne (personal communication). The Monte Carlo code calculates the contrast and SNR of anatomical details at different positions in the image to provide a physical measure of image quality. These parameters were calculated with a large number of photon histories so that the uncertainty of their values is less than 3% (1 standard deviation).

Figure 1. The imaging system included in the Monte Carlo


model of the lumbar spine anterior-posterior projection. The bony structures in the voxel phantom have been highlighted.

Important contrast details


The important contrast details used for the calculation of image quality were carefully selected to correspond to the diagnostic requirements described in the CEC image quality criteria [3] and following discussions with local radiologists in London and Linkoping. Lumbar spine X-ray images help the clinician appraise the presentation of the lumbar spine vertebrae and thus, all the details chosen represent bony anatomy. For modelling the AP projection, the L1, L3 and L5 transverse processes were selected as low contrast details with thicknesses of 2.0 mm (L1T), 3.5 mm (L3T) and 5.0 mm (L5T), respectively. For modelling the LAT projection, the L1, L3 and
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L5 spinous processes were selected as low contrast details with thicknesses of 5.0 mm (L1S), 5.5 mm (L3S) and 6.0 mm (L5S), respectively. The thicknesses were obtained from measurements on a skeleton. All bony processes were simulated as cortical bone (1920 kg m23) and their contrast was calculated against a background of soft tissue. Small high contrast details were also chosen. These were the trabecular structures on the L1, L3 and L5 vertebrae in the AP projection, referred to subsequently as L1D, L3D and L5D, respectively. For the LAT projection, the trabecular structures were selected to be at an anterior position on the L1 and L5 vertebrae and at a posterior position on the L5 vertebra, referred to subsequently as L1F, L5F and L5B, respectively). All of the trabecular structures were 1 mm thick. This is quite similar to the important detail size of 0.3 mm to 0.5 mm given in the CEC image quality criteria document [3]. Trabecular structures were simulated as bone marrow cavities (1030 kg m23) and their contrast was calculated against a background of cortical bone. The compositions of the anatomical details and tissue backgrounds were taken from the ICRU [17].
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Optimization of lumbar spine X-ray imaging systems

Image quality and patient dose parameters Contrast Contrast was calculated in the Monte Carlo program as the difference in optical density (DOD) beside and behind the important details superimposed on the voxel phantom. The effects of lm gradient and imaging system unsharpness were taken into account in the calculation of DOD using: 1 DOD~ log10 (e)|c(ODdet )|Ce |cdf MTF
The H and D curve was measured in accordance with the ISO-standard [20] by Dr F Verdun, Lausanne (Private Communication, 1998). The lm gradient (c) was derived from the H and D curve for the OD beside the detail (ODdet). The quantity cdfMTF is the reduction in contrast caused by the total system unsharpness (total modulation transfer function, MTFtot). Image receptor (screenlm) and geometric unsharpness (focal spot size and magnication) are all taken into account in the calculation of the MTFtot. The MTFs of the screenlm combination were also measured by Dr F Verdun, Lausanne (personal communication). Sandborg et al [8] describes the calculation of cdfMTF. The object contrast Ce was found from Monte Carlo calculations of energy imparted to the uorescent screen per unit area: E(p1 ){E(p2 ) 1 | 2 C ~ E(p1 ) 1z E(s )=E(p1 ) Here, ep1 and ep2 are the energy imparted to the receptor per unit area by primary photons beside and behind the detail, respectively, and es is the energy imparted to the receptor per unit area by scattered photons. The notation E denotes the expectation value. It was assumed that the detail does not alter the distribution of scattered photons in the imaging plane.

including that from the lm. These corrections are derived following the methods of Nishikawa and Yaffe [26]. A more detailed description of the implementation is given by Sandborg et al [8].

Calculation of entrance air kerma The Monte Carlo program calculates air kerma, without backscatter, at the entrance surface of the phantom, air kerma at the surface of the cassette front and energy imparted to the screen per unit area. The entrance air kerma for a xed OD can be calculated using these quantities combined with the H and D curve measured in terms of the cassette entrance air kerma. The calculation was implemented in two parts. In the rst part, the experimental set-up used to measure the H and D curve was simulated and the air kerma at the surface of the cassette front and the energy imparted to the screen per unit area calculated. In this way, the H and D curve was expressed as the OD for a given value of the energy imparted to the screen per unit area. In the second part, the voxel phantom in the lumbar spine imaging system under investigation was simulated. Ratios of energy imparted to the screen per unit area to the incident air kerma at the phantom were calculated for approximately 200 evenly spaced points of interest across the whole image and the median ratio found. The calibrated H and D curve was used to convert an OD to be used as a normalization point, for example, the median OD of a radiograph or set of radiographs, to an energy imparted per unit area. The entrance air kerma was then calculated by this value of the energy imparted divided by the median value of the ratio. Effective dose Effective dose has been used in this work to quantify the radiation risk. The voxel phantom was segmented into organs each with known mass. The Monte Carlo code calculated the energy imparted to each voxel associated with an organ. The organ dose was obtained by dividing the sum of the energy imparted to all voxels of an organ with the mass of that organ. The effective dose was then found by combining the organ doses with the tissue weighting factors according to the International Commission on Radiological Protection [14]. The Monte Carlo code calculates the ratio of the effective dose to the incident air kerma at the voxel phantom surface. The effective dose for a given situation was found from the product of this ratio and the incident air kerma (see previous section). Validation of the model The Monte Carlo program has been validated in two parts. Firstly, Monte Carlo calculations of OD behind polymethyl methacrylate (PMMA) phantoms were compared with measurements carried out under carefully controlled conditions. Good agreement, within 13% was found providing that there was detailed knowledge of the imaging system [6, 16]. Secondly, patient images were collected and the entrance air kerma measured for chest and lumbar spine examinations in both frontal and lateral projections. The images were digitized and analysed. Measurements of contrast were extracted from the digitized radiographs. For the lumbar spine AP projection, it was
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Signal-to-noise ratio The SNR of the ideal observer, SNRI [21], of a small detail at an optical density ODdet was obtained using: s A SNRI (ODdet )~SNRMC (edet )| | AMC 3
SNRDF(ODdet ) The SNRMC (edet) was calculated by the Monte Carlo program. It was obtained from the energy imparted to an area of the detector AMC with and without the detail being present assuming that the only noise source is quantum mottle and neglecting image unsharpness. The SNR2 was I scaled from the area of the detector element AMC5 0.25 mm2 to the area of the detail A. The SNRMC due to quantum noise has been shown to give good agreement with experiments [22, 23] for details with diameters larger than or equal to 3 mm. Hence, as many of the details used in our Monte Carlo model were similar to or smaller than 3 mm, the model needs to take into account the effect of image unsharpness. This was implemented using the SNR degradation factor SNRDF, which also accounts for: (i) the different efciencies with which the signal and quantum noise are transferred through the screen caused by light emitted from different depths in the screen [24]; (ii) the statistical variations in the transport of light from the screen to the lm [25]; and (iii) the total system noise
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found that the calculated entrance air kerma was slightly lower than the minimum value in the range of measured entrance air kermas. This was due to the voxel phantom being slightly thinner than required. However, as the calculated entrance air kermas were within the range of measured values for the other projections, it was decided not to increase the thickness of the voxel phantom for the lumbar spine AP projection as the calculated value was still reasonably representative of the range of calculated values. The program was also successfully validated by comparing the calculated contrast of important anatomical details and the calculated dynamic range of the image with the range of measured values [6, 16]. The voxel phantom was thus found to be sufciently representative of a patient undergoing both chest and lumbar spine X-ray examinations.

Reference system and optimization In order to optimize the parameters used in X-ray imaging systems, one system had to be identied that provided good image quality, and this was designated as the reference system. Thus, we determined a suitable reference system to be the imaging system that produced images with the highest image quality as judged by an expert panel of European radiologists in a recent clinical trial [4]. These preferred images were thus the reference images. Table 1 shows the characteristics of the reference imaging systems for the AP and LAT views. The reference systems used 72 kV with a 400 speed class screenlm system for the AP view and 77 kV with a 600 speed class screenlm system for the LAT view. The preferred system from the clinical trial corresponds to the good radiographic practice outlined in the CEC image criteria document [3], except that a lower tube voltage was used than suggested by the guidelines. In our theoretical study, we have investigated what happens to the image quality and the patient dose if the imaging parameters are varied from their reference values. The range of the parameters studied is also given in Table 1. This study allows a greater understanding of the optimization results.

A good quality image may be one that fulls its diagnostic purpose but may not always be an image with the highest possible contrast or SNR [27]. In our optimization scheme, it was decided to use the best systems from the clinical trials as the reference systems and the images they produce as the reference images. It was assumed that an image for which the contrast or SNR were 10% lower than those in the reference image would still full its diagnostic purpose. Values of SNRI and DOD were calculated for each detail for a specied scatterrejection technique, speed class, OD and lm type for tube voltages between 60 kV and 110 kV in the AP view and between 70 kV and 110 kV in the LAT view. The tube voltages required to give 0.9 of the appropriate SNRI and DOD value for each detail were then deduced. The detail requiring the lowest tube voltage is referred to as the limiting detail. This tube voltage is the highest employable that ensures all details full the criterion of the associated image quality measure being greater than or equal to 0.9 of that for the reference system. The effective dose is calculated for this limiting tube voltage and compared with the values for the reference system. The procedure is then repeated for different imaging systems and the system resulting in the lowest effective dose is the optimum.

Results
Effect of varying image system parameters on patient dose and image quality Tube voltage Figure 2 shows the results for the AP projection of varying the tube voltage between 60 kV and 110 kV on (a) the effective dose, (b) the contrast of the L5 transverse process and (c) the SNR of a trabecular structure on the L1 vertebra. The reference system gives an incident air kerma without backscatter of 0.88 mGy and an effective dose of 0.12 mSv. The calculated incident air kerma is within the range of entrance surface doses given in Hart et al [28]. The calculated effective dose is lower than would be expected for example, from the effective doses given in

Table 1. The parameters for the anteroposterior (AP) and lateral reference imaging systems. The range of imaging system parameters is also given
AP imaging systems Parameters Tube voltage Filtration Focal spot size Focuslm distance Grid ratio Strip density Strip width Cover material Interspace material Speed class Screen material Screen types Film type Median OD Range 60110 kV 4.7 mmAl 0.9 mm 1.46 m 816 4070 cm21 2040 mm Aluminium and carbon bre Aluminium and carbon bre 320, 400 and 600 Gd2O2S Lanex Medium/Regular, Lanex Regular Plus and Lanex Fast a Kodak TML 0.23.0 Reference system 72 kV 4.7 mmAl 0.9 mm 1.46 m 10 52 cm21 36 mm Aluminium Carbon bre 400 Gd2O2S Lanex Regular Plus
a Kodak TML 1.36

Lateral imaging systems Range 70110 kV 4.7 mmAl 0.9 mm 1.46 m 816 4070 cm21 2040 mm Aluminium and carbon bre Aluminium and carbon bre 320, 400 and 600 Gd2O2S Lanex Medium/Regular, Lanex Regular Plus and Lanex Fast a Kodak TML 0.23.0 Reference system 77 kV 4.7 mmAl 0.9 mm 1.46 m 10 52 cm21 36 mm Aluminium Carbon bre 600 Gd2O2S Lanex Fast
a Kodak TML 1.36

OD, optical density. aEastman Kodak Campany, Rochester, NY.

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Figure 2. The effect of tube voltage on (a) effective dose, (b) optical density (OD) difference of the L5 transverse process and (c)
signal-to-noise ratio (SNR) of a trabecular structure on the L1 vertebra for the anteroposterior projection. The effect of tube voltage on (d) effective dose, (e) OD difference of the L3 spinous process and (f) SNR of a trabecular structure on the front of the L1 vertebra for the lateral projection.

Hughes [29], owing to the voxel phantom thickness being slightly thinner than is required. However, this will not affect the results as they are quoted relative to the reference system values in this paper. The effective dose decreases by 73% between 60 kV and 110 kV. The three transverse processes show approximately the same variation of contrast with tube voltage. The same applies to the SNR for the three trabecular structures. For example, the contrast of the L5 transverse process decreases by 54% between 60 kV and 110 kV, with a similar decrease in SNR of 58% for the L5 trabecular structure. Figure 2 also shows the results for the LAT projection of varying the tube voltage between 70 kV and 110 kV on (d) the effective dose, (e) the contrast of the L3 spinous process and (f) the SNR of a trabecular structure on the front of the L1 vertebra. The reference system gives an incident air kerma of 2.57 mGy and an effective dose of 0.14 mSv. Again, the calculated incident air kerma compares well with Hart et al [28] and the calculated effective dose is lower than expected [29] due to the thickness of the voxel phantom. The effective dose decreases by 59% between 70 kV and 110 kV, which is a smaller decrease than for the AP view owing to the smaller voltage range. The SNR and contrast show a similar variation with tube voltage. There is a 47% decrease in the SNR of a trabecular structure on the L5 vertebra and a 43% decrease in the contrast of a L5 spinous process between 70 kV and 110 kV. The variation of the contrast and SNR is less for the LAT projection than
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the AP projection as a smaller range of tube voltages was studied.

Grid design Figure 3 shows the results for the AP projection of increasing the grid ratio (r5816) for three grids: (1) strip density N540 cm21, strip width d540 mm, aluminium covers and interspaces; (2) the same parameters except with carbon bre covers and interspaces; and (3) N570 cm21, d520 mm, carbon bre covers and interspaces. The gure shows the variation of (a) effective dose, (b) contrast of the L3 transverse process and (c) the SNR of the trabecular structure on the L3 vertebra. The results are shown relative to the reference system, which has a grid constructed with N552 cm21, r510, d536 mm with aluminium covers and carbon bre interspaces. The effective dose increases for increasing grid ratio for all grids, for example, increasing by 34% for the aluminium grid between r58 and r516. The carbon bre grids give the lowest effective dose. For the carbon bre grid with N540 cm21, the effective dose is lower by 11% (r58) compared with the mixed material grid, and lower by 13% (r58) compared with the aluminium grid. There is a further dose reduction by increasing the strip density and decreasing the strip width. The effective dose for the N570 cm21, d520 mm grid is lower by 19% (r58) than for the N540 cm21 carbon bre grid. There is a contrast and SNR advantage to using the
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Figure 3. The effect of two grids with strip density N540 cm21 with aluminium and carbon bre covers and interspaces and a third
grid with a strip density N570 cm21, strip width d520 mm with carbon bre covers and interspaces on (a) effective dose, (b) optical density (OD) difference of the L3 transverse process and (c) signal-to-noise ratio (SNR) of the trabecular structure on the L3 vertebra for the anteroposterior projection. The effect of the same grids on (d) effective dose, (e) OD difference of the L3 spinous process and (f) SNR of the trabecular structure at an anterior position on the L5 vertebra for the lateral projection.

carbon bre grids (r.8) rather than the mixed material or aluminium grids. There is a 13% increase in the L3 transverse process contrast and a 14% increase in the SNR of the L3 trabecular structure for a grid with N540 cm21, r516. The contrast and SNR advantage is less for increasing strip density and decreasing strip width. There is only a 5% increase in the L3 transverse process contrast and a 4% increase in the L3 trabecular structure SNR for a grid with N570 cm21, d520 mm, r516. The loss of contrast and SNR for reducing the lead strip width is only slightly compensated for by increasing the strip density. Figure 3 also shows the results for the LAT projection for increasing grid ratio for the three grids mentioned above. The results show the variation of (d) effective dose, (e) the contrast of the L3 spinous process and (f) the SNR of the trabecular structure at an anterior position on the L5 vertebra. The dose reductions obtained with a carbon bre grid are less for the LAT view than the AP view owing to the higher tube voltage. The effective dose for the N540 cm21 grid (r58) is 6% less than the reference system. By increasing the strip density and decreasing the strip width the dose is decreased by a further 14%. The contrast and SNR advantages from using carbon bre grids in the LAT view are generally the same or smaller than for the AP view. The contrasts obtained using the N540 cm21, r516 and N570 cm21, d520 mm, r516 grids are 8% and 5% greater than for the reference system. The corresponding increases in SNR for these grids compared with the reference system are 14% and 3%,
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respectively. For grids with low grid ratios where there is less contrast or SNR than the reference system, the tube voltage does not need to be decreased signicantly, especially if carbon bre grids are used since the loss of contrast and SNR is small. For carbon bre grids with high grid ratios, the tube voltage may be increased without losing contrast or SNR and therefore, such a system may have a signicantly reduced dose.

Screenlm speed Figure 4 shows the results for the AP projection of varying the speed class between 320 and 600 (all using TML lm) on (a) the effective dose, (b) the contrast of the L3 transverse process and (c) the SNR of the trabecular structure on the L3 vertebra. The results are shown at both 72 kV and 90 kV. The effective dose decreases by 42% as the speed class increases from 320 to 600 for both 72 kV and 90 kV X-rays. At 72 kV, the contrast of the L3 transverse process is near its maximum value for the 400 speed class system. The contrast decreases by 10% and 3% when the 400 speed class system is replaced by a 320 and 600 speed class systems, respectively. This is due to differences in the shape of the H and D curves for the different screenlm combinations. At 72 kV, the SNR of the trabecular structure varies by a greater amount than the contrast. The SNR decreases by 19% for increasing the speed class from 320 to 600. Similar variations of contrast and SNR are observed at 90 kV. If a 600 speed class system is used instead of a 400 speed class system, the tube
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Figure 4. The effect of screenlm speed class on (a) effective dose, (b) optical density (OD) difference of the L3 tranverse process and (c) signal-to-noise ratio (SNR) of the trabecular structure on the L3 vertebra for the anteroposterior projection. The effect of screenlm sensitivity class on (d) effective dose, (e) OD difference of the L3 spinous process and (f) SNR of the trabecular structure at an anterior position on the L5 vertebra for the lateral projection.

voltage has to be decreased slightly to regain the loss of contrast but signicantly more to regain the loss of SNR. However, large dose reductions are still possible due to the greater sensitivity of the system, despite signicantly lower tube voltages being required to maintain contrast and SNR. Figure 4 also shows the results for the LAT projection of varying the speed class between 320 and 600 on (d) effective dose, (e) contrast of the L3 spinous process and (f) the SNR of the trabecular structure at an anterior position on the L5 vertebra. The effective dose decreases by 43% with increasing speed class from 320 to 600 for both 77 kV and 95 kV. At 77 kV, the contrast of the L3 spinous process is lower by 10% and the SNR of the trabecular structure is higher by 23% for the 320 speed class system. There are similar results at 95 kV.

Optical density Figure 5 shows the results for the AP projection of varying the value of the median OD between 0.2 and 3.0 using the Lanex Regular (Eastman Kodak Campany, Rochester, NY) screen with TML lm on (a) effective dose, (b) the contrast of the L1, L3 and L5 transverse processes and (c) the SNR of the trabecular structures on the L1, L3 and L5 vertebrae. The effective dose increases linearly with OD between 0.4 and 1.6. There is a rapid increase in effective dose above an OD of 1.6 due to the shape of the TML H and D curve. The effective dose is 22% greater at a median OD of 1.6 than at the median OD of 1.36 used in the reference system. The transverse processes have a maximum contrast at different
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median ODs due to the differing OD beside each anatomical detail and, therefore, their position on the H and D curve. The L1, L3 and L5 transverse processes have maximum contrasts at ODs of 1.6, 1.4 and 1.2, respectively. The contrast of the L3 process at an OD of 1.6 is very similar to that at 1.36. The trabecular structures also have a maximum SNR at different median ODs. The details on the L1, L3 and L5 vertebrae have maximum SNRs at ODs of 2.6, 2.4 and 2.2, respectively. The maximum SNR values are 47%, 33% and 20% greater than the SNR values for the L1, L3 and L5 trabecular structures using the reference system. Figure 5 also shows the results for the LAT projection of varying the median OD between 0.4 and 3.0 on (d) effective dose, (e) the contrast of the L1, L3 and L5 spinous processes and (f) the SNR of the trabecular structures on the L1 and L5 vertebrae. The effective dose shows the same variation as for the AP projection with a 23% increase at a median OD of 1.6 compared with the effective dose at a median OD of 1.36. The maximum contrast values occur at an OD of 1.0 for the L1 and L3 processes and at an OD of 1.8 for the L5 process. These maximum contrasts are at most 8% greater than the contrast of the details obtained with the reference system. The maximum SNR values occur at an OD of 2.0 for the details on the anterior position of the L1 and L5 vertebra and at an OD of 2.6 for the detail on the posterior position on the L5 vertebra. The maximum SNR values are 38%, 12% and 16% greater, respectively, than the SNR values for the posterior positioned detail on the L5
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Figure 5. The effect of median optical density (OD) on (a) effective dose, (b) OD difference and (c) signal-to-noise ratio (SNR) for the anteroposterior projection. The effect of median OD on (d) effective dose, (e) OD difference and (f) SNR for the lateral projection.

vertebra and the anterior positioned details on the L5 and L1 vertebrae using the reference imaging system.

Results of optimization Scatter rejection technique Table 2 shows the tube voltages for the six important details which give 0.9 of the contrast and SNR values for the lumbar spine AP reference system. These results are for
Table 2. The tube voltages which produce 10% lower contrast
(DOD, difference in optical density) or signal-to-noise ratio (SNR) for the six anatomical details (see Important Contrast Details section) than obtained with the lumbar spine anteriorposterior reference system using an imaging system with a N540 cm21, r58, d540 mm grid and a Lanex Regular/TML screenlm system (400 speed class). The corresponding effective dose relative to the value for the reference imaging system (Eastman Kodak Campany, Rochester, NY) is also given. The detail which limits the optimization, i.e. the one which requires the lowest tube voltage, is written in bold italics Detail L5T L3T L1T L5D L3D L1D Image quality measure DOD DOD DOD SNR SNR SNR Tube voltage (kV) 78.3 77.1 77.0 76.4 75.8 75.5 Relative effective dose 0.76 0.78 0.78 0.80 0.81 0.82

an imaging system using a grid with N540 cm21 and r58 and a Lanex Regular/TML screenlm system (400 speed class). The table shows that there are differences in the voltage required for each detail. The lowest tube voltage is found for the L1 trabecular structure. The imaging requirement for this detail then limits the tube voltage to be less than or equal to this value so that the image quality criterion is met for all six details. The L1 trabecular structure was found to be the limiting detail for this grid, and for some of the other grids investigated (Table 3), as in these cases the SNR for this detail had the largest response to tube voltage. Thus for the grid under investigation, the largest dose saving that can be achieved is 18%. Table 3 shows the optimization of different grid designs using the Lanex Regular/TML screenlm system (400 speed class) for the AP projection. The highest tube voltages that satisfy the image quality criterion and the corresponding effective doses calculated with these systems are compared with the reference system, which is also 400 speed class. All scatter-rejection techniques produce a dose saving compared with the reference system except for the grid with N570 cm21, r58 and d536 mm. The largest dose saving is for a grid with N570 cm21, r516 and d520 mm, which gives 22% lower effective dose than the reference system. These dose reductions are partly owing to the lower attenuation of the carbon bre covers and interspace of the grids studied compared with the mixed material grid used in the reference system. The large dose reductions obtained for a large grid ratio are also owing to the fact that the tube voltage has to be increased
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Optimization of lumbar spine X-ray imaging systems Table 3. The best tube voltages and the corresponding values of
the relative effective dose for each grid studied with a Lanex Regular/TML screenlm system (Eastman Kodak Campany, Rochester, NY) (400 speed class) for the anterior-posterior projection. The limiting detail (see Important Contrast Details section) and the image quality measure (difference in optical density (DOD) or signal-to-noise ratio (SNR)) are also given. The systems which give the lowest patient dose are written in bold italics Scatter rejection technique N (cm21), r, d (mm) 40,08,40 40,12,40 40,16,40 70,08,36 70,12,36 70,16,36 70,08,20 70,12,20 70,16,20 Detail Image quality measure SNR SNR DOD SNR SNR SNR SNR SNR SNR Best tube voltage (kV) 76 81 85 72 79 82 69 57 79 Relative effective dose 0.82 0.80 0.79 1.02 0.89 0.86 0.92 0.82 0.78

Table 5. The best tube voltages and the corresponding values of


the relative effective dose for each grid studied with a Lanex Fast/TML screenlm system (Eastman Kodak Campany, Rochester, NY) (600 speed class) for the anterior-posterior projection. The limiting detail (see Important Contrast Details section) and the image quality measure (difference in optical density (DOD) or signal-to-noise ratio (SNR)) are also given. The system which gives the lowest patient dose is written in bold italics Scatter rejection technique N (cm21), r, d (mm) 40,08,40 40,12,40 40,16,40 70,08,36 70,12,36 70,16,36 70,08,20 70,12,20 70,16,20 Detail Image quality measure SNR SNR SNR SNR SNR SNR SNR SNR SNR Best tube voltage (kV) 71 76 79 68 74 77 65 70 74 Relative effective dose 0.74 0.67 0.66 0.89 0.78 0.74 0.83 0.73 0.67

L1D L1D L5T L3D L1D L5D L1D L1D L1D

L1D L3D L5D L3D L3D L5D L1D L1D L3D

N, strip density; r, grid ratio; d, lead strip width.

N, strip density; r, grid ratio; d, lead strip width.

substantially in order to reduce the contrast and SNR to exactly match the image quality criterion. The opposite was found for the chest AP projection [8] where grids with a low grid ratio were found to be optimal. This was due to the increase in effective dose with increasing tube voltage above 110 kV. Table 4 shows the optimization of different grid designs using the Lanex Regular/TML screenlm system for the LAT projection. It was found that there are no dose savings for these grids compared with the reference system. This is due to the reference system using the more sensitive Lanex Fast screenlm system (600 speed class). Therefore, a compromise for a 400 speed class imaging system would be to use a N540 cm21 and r58 grid in both the AP and LAT projections. This provides a small overall dose saving of 5% compared with the respective AP and LAT reference imaging systems.

AP projection. The highest tube voltages for the 600 speed class system are on average 5 kV less than the highest tube voltages for the 400 speed class system (Table 3). The tube voltage is lower than for the 400 speed class system in order to recover the reduction in SNR for the faster system (Figure 4). Overall, the use of the faster screenlm system results in greater dose savings than the 400 speed class systems. For example, for the N540 cm21 and r516 grid, the effective dose is 34% lower than for the reference system. There is a similar effect on the LAT projection using a faster screenlm system. The highest tube voltage which meets the imaging requirements for the 600 speed class is about 4 kV lower than the highest tube voltage for the 400 speed class. The largest dose reductions are for the grids with N540 cm21 with the effective dose values between 12% and 15% smaller than the effective dose produced by the reference imaging system.

Screenlm speed Table 5 shows the results of the optimization of scatterrejection technique using the 600 speed class system for the
Table 4. The best tube voltages and the corresponding values of the relative effective dose for each grid studied with a Lanex Regular/TML screenlm system (Eastman Kodak Campany, Rochester, NY) (400 speed class) for the lateral projection. The limiting detail (see Important Contrast Details section) and the image quality measure (difference in optical density (DOD) or signal-to-noise ratio (SNR)) are also given. The system which gives the lowest patient dose is written in bold italics
Scatter rejection technique N (cm21), r, d (mm) 40,08,40 40,12,40 40,16,40 70,08,36 70,12,36 70,16,36 Detail Image quality measure DOD DOD DOD SNR DOD DOD Best tube voltage (kV) 84 90 90 82 87 90 Relative effective dose 1.09 1.12 1.22 1.18 1.24 1.26

L1S L3S L1S L5B L3S L1S

N, strip density; r, grid ratio; d, lead strip width.

Optical density Figure 6 shows the optimization of the median OD, ODmed in the AP projection. The median OD was varied between 80% and 150% of the reference system value of 1.36. The system studied used a grid with N540 cm21 and r512 and a Lanex Regular/TML screenlm system. Figure 6a shows the variation of the highest tube voltage that fullls the image quality requirement as a function of ODmed. The corresponding limiting detail and image quality parameter type are shown for each data point. The highest tube voltage increases with increasing ODmed until a maximum value of 81 kV is reached at an ODmed of 1.36 and then decreases. Below an ODmed of 1.36, the contrast and SNR of each detail all increase with increasing ODmed. The limiting detail is the trabecular structure on the L1 vertebra as its SNR has the largest response with ODmed. Above an ODmed of 1.36, the contrasts of the L5 and L3 transverse processes decrease with increasing ODmed. Therefore, the tube voltage has to be decreased in order to recover the reduced contrast to meet the required image quality criterion. The L5 transverse process is the limiting
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G McVey, M Sandborg, D R Dance and G Alm Carlsson

Figure 6. The optimization of median optical density with (a) the highest tube voltage consistent with the requirement to obtain at least 90% of the image quality of the reference system for all details considered and (b) the corresponding values of the effective dose relative to the reference system values for the anterior-posterior view. The optimization of median optical density with (c) the highest tube voltage and (d) the corresponding effective dose for the lateral view.

detail as its contrast has the largest decrease with increasing ODmed. Figure 6b shows that there are dose savings below an ODmed of 1.50 with the effective dose being 25% lower than the value for the reference system at an ODmed of 1.09. There is a similar variation with ODmed for the lateral projection. The system used is a 40 cm21, r512 grid with a Lanex Regular/TML screenlm system. Figure 6c shows that the highest tube voltage reaches a maximum value of 90 kV at an ODmed of 1.22. Figure 6d shows that there is a minimum dose at an ODmed of 1.09 with the effective dose being 7% lower than reference system value. The highest tube voltage is lower at an ODmed of 1.09 than at 1.36 in order to recover the lower SNR as ODmed decreases (Figure 5). There is a small dose saving due to using the carbon bre grid rather than the mixed material grid.
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Discussion
Our work on the optimization of the scatter rejection technique has shown that the tube voltage could be decreased or increased in order to produce a dose reduction depending on the grid design. Vano et al [5] increased the tube voltage from 60 kV to 90 kV to produce a dose reduction of 35% whilst maintaining image quality for the lumbar spine AP examination. However, Almen et al [4] have shown that increasing the tube voltage from 70 kV to 90 kV signicantly alters the image quality of AP lms, whereas increasing from 77 kV to 95 kV does not signicantly alter the image quality of LAT lms. In our optimization studies, the tube voltages that fullled the image quality criterion were less than 85 kV for the AP lms and 90 kV for the LAT lms.
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Optimization of lumbar spine X-ray imaging systems Table 6. The optimum imaging system conguration found in this work for the lumbar spine anteroposterior and lateral projections compared with the examples of good radiographic technique given by the Commission of the European Communities (CEC) guidelines [3]
Parameters AP imaging systems CEC guidelines Tube voltage Filtration Focal spot size Focuslm distance Grid ratio Strip density Strip width Speed class 7590 kV 3.0 mmAl ,1.3 mm 1.15 m (1.0 to 1.5 m) 10 40 cm21 400 Results of optimization 79 kV 4.7 mmAl 0.9 mm 1.46 m 16 40 cm21 40 mm 600 Lateral imaging systems CEC guidelines 8095 kV 3.0 mmAl ,1.3 mm 1.15 m (1.0 to 1.5 m) 10 40 cm21 400 Result of optimization 82 kV 4.7 mmAl 0.9 mm 1.46 m 8 40 cm21 40 mm 600

Further evidence that our work closely corresponds to that of Almen et al is given by Sandborg et al [30]. Sandborg showed that the physical parameters such as contrast and SNR could be used to predict the order that the imaging systems were ranked by the European radiol ogists [4]. For example, in the AP projection Almen et al found signicant differences in image quality for changing tube voltage, but not for changing speed class. This can also be demonstrated from our study of changing the image parameters and observing their effect on calculated image quality. By increasing the tube voltage from 70 kV to 90 kV, a large decrease of 28% was observed in the calculated contrast and SNR whereas only a small decrease of 10% was seen in the SNR for increasing the speed class from 400 to 600. It is therefore reassuring that the work in this paper is consistent with changes in image quality observed clinically.

Conclusions
The results of varying the different imaging parameters shows how straightforward it is to have high image quality and high patient dose, e.g. low tube voltage and to have low image quality and low patient dose, e.g. high tube voltage. Conversely, it is difcult to balance high image quality and low patient dose. The optimization of radiographic imaging involves several different parameters. Therefore, it is very useful that a Monte Carlo model can be used to point out imaging systems that give low patient dose whilst still maintaining the same image quality as reference systems. These systems are worth investigation in future, more time-consuming, clinical trials. For 400 speed class systems using grids in the AP projection, a dose reduction of between 8% and 22% can be achieved. A further dose reduction of 13% is possible with a 600 speed class system using a grid. Table 6 shows the imaging system conguration that produced the largest dose reduction in our work. Dose reductions of a similar size can be obtained for a grid with a high grid ratio (r516), a high strip density (N570 cm21) and a small lead strip width (d520 mm). For 400 speed class systems using grids in the LAT projection, only a small dose reduction of 7% could be achieved by reducing the operating OD from 1.36 to 1.09. The largest dose reduction of 15% was obtained using the 600 speed class screenlm system shown in Table 6. The scope for large dose reductions in the LAT projection was restricted as a 600 speed class screenlm system was used
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as the reference system. For both AP and LAT projections, the dose advantage of using carbon bre components has been shown throughout this work as the reference system used a grid constructed from aluminium and carbon bre. Our work clearly shows that the largest dose reductions are for 600 speed class systems. However, in a recent review [28] of patient doses from screenlm imaging in the UK for the year 2000, the National Radiological Protection Board (NRPB) shows that there are signicantly fewer 600 speed class systems in use compared with 400 speed class systems. The review [28] also shows the continuing trend for lower dose per lumbar spine radiograph of 37% in the period from 1984 to 1995 and 18% in the period from 1995 to 2000. The NRPB state that this is due to the increasing use of faster screenlm combinations. Therefore, our work highlights that there are still potential optimizations to be made in lumbar spine radiography. It is also reassuring to know that the systems found by the optimizations are similar to those recommended by the CEC guidelines [3] as given in Table 6.

Acknowledgment
Dr F R Verdun (Lausanne, Switzerland) is thanked for supplying measured H and D curves, modulation transfer function and noise power spectra of the screenlm combinations used in this work. Alexandr Malusek is acknowledged for the image of the voxel phantom in Figure 1.

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