Dose-reduction experiment during a cervical vertebrae examination

e-Poster: C-798
Congress: ECR 2007
Type: Scientific Exhibit
Topic: Radiographers / Conventional X-ray
Authors: R. Pedersen 1 , O. Muharemovic 2 , M. Nielsen 3 ; 1 Copenhagen F/DK, 2 Copenhagen
(hvidovre)/DK, 3 Copenhagen Nv/DK

MeSH: Neck [A01.598]

Thyroid Gland [A06.407.900]
Dose-Response Relationship, Radiation [G03.850.810.250.180]
Abnormalities, Radiation-Induced [G03.850.810.300.360.031]

Keywords: Dose Reduction, Radiography, Thyroid Glandel, Cervical Vertebrae

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1. Purpose

For our study we have collected data from a representative number of 21 x-ray departments in east Denmark (Sealand and
Lolland Falster) concerning the used parameters during cervical vertebrae examination and we have established that there are
major differences in these used parameters.

Inspired by the ALARA principle (As Low As Reasonably Achievable) (1) we have examined the posibilitys regarding a dose
reduction by optimizing several different parameters without compromizing image quality.

During a cervical vertebrae examination the thyroid glandle is radiated entirely, as well as up to 50% of the oesophagus. Both
organs have a tissue weighting factor w T = 0,05 (2) thus a possible risk factor that could lead to stochastic damage.

One of the central differences among the X-ray departments is their use of AP or PA projections, which results in differences
in dose to the above mentioned organs due to their anatomical placement. We have examined the exposure and dose impact
these two projections have on image quality. By a PA projection and especially by a lateral projection during a cervical spine
examination a natural air gap occurs because of the increased OID (object-to-image distance).

Because of the neck regions limited size one can discuss the prerequisite of using an anti-scatter grid during cervical spine
examinations even though some departments have allready abolished it. The majority of the departments using an
anti-scattering grid are using different grid ratios from 8:1 to 16:1. Dendy PP et al. (3) recommend that a grid with ratio 8:1 is
used during exposures below 85 kV and a grid with higher ratio during exposures above 85 kV. McVey G et al. (4) has shown
a 21 % dosereduction using the most optimal type of grid.

The majority of the departments from which data have been collected are using 'to-knob' technique although they are in
possession of equipment with AEC (Automatic Exposure Control).

It has raised questions about whether an appropiate kV in combination with AEC can decrease radiation dose, because AEC is
programmed to regulate the time of exposure, so a suitable darkening of the film can be attained (5) .

The purpose of this experiment is to examine the possibility of dose reduction during a cervical vertebrae examination by
adjusting predetermined parameters, and still maintaining acceptable image quality.

2. Methods and Materials

To better understand the problem and the extend of the differences between the x-ray departments we have established contact
in form of the following questionnaire (Table 1).

ModalityCR/DR Orbix/Wallstand AECYes/No kV mAs SIDSourceImageDistance GridYes/No Gridtype AP/PA

and ratio
- - - - - - - - -

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Table 1 (Questionnaire to fill in by the x-ray departments with the chosen parameters for the Col. Cerv. projection)

Table 1 has illustrated the most essential differences between the parameters being used by the respective departments. This have given us an
good idea of how to design our experiment. We decided to research the possibilities of dose reduction and still maintaining acceptable image
quality by using CR modality equiped with AEC in three different kV areas, three different grid design and three posible projektions AP/PA
og LAT.

The Aldersson Fantom (Fig. 1) which is divided in slices and is equivalent to a human body in condition of x-ray attenuation characteristics
is used to measure the absorbed organ dose (D, the per mass unit absorbed energy by ionizing radiation deposited in the organ) in the thyroid
glandel (w T = 0,05).

During a Columna Cervicalis examination the entire thyroid glandel is radiated wheras the surrounding organs are radiated partially.
Therfore the dose to those organs will not contribute in the same level to the effektive dose as the dose deposited in the thyroid glandel
because the tissue weighting factor (w ) reflect the relative contribution to the total stochastic damage (6) . Organ dose in the thyroid
T

glandel has been measured by TLD-tablets (Thermo luminiscens dosimeters) that contains Lithium Fluroid Chrystals which are capable of
storing information about radiation dose (7) .

To evaluate the image quality in our study we have designed and build a Plexiglass Phantom equivalent in the x-ray attenuation
characteristics of the Aldersson Phantoms neck-region. The basis of comparison was lgM-value (Logarithm of the median of the histogram)
which is AGFA's term for sensitivity and average exposure in the image and describes the energy levels which is equal to the middle of the
digital 12 bit grey scale value.

Equivalent x-ray attenuation characteristics between the two phantoms was acheived in getting the equal lgM-value for both Aldersson and
the plexiglass phantom with identical parameter design.

The final Plexiglass phantom design (Fig.2) contained 11 depressions with depths from 0,1 to 2,1 mm with 0,2 mm intervals that resulted in
a variation through the plexiglass plates of the image contrast (C). Besides the contrast depressions we have placed a 5 x 5cm line pair
phantom (Nuclear Associates-Carls Place. N.Y. 07-527) made of 0,001mmPb with purpose to assess spatial resolution (SR) which is defined
by the ability of an imaging system to distinctly differentiate two objects as they become smaller and closer together (8) .

The final Plexiglass phantom design (Fig.3) contained also 0,5x5x20 cm Aluminium plate which is designed to imitate Columna Cervicalis
placed on top of the measuring scale. The rest of the phantom was filled with Plexiglas plates so that the phantom total thickness was in the
range of 10 cm. This design could with small corrections simulate every appropriate projection and this gave the opportunity to make an
objective assessment of image quality in relation to dose by three respondents.

A pc based statistic program (SAS JMP) has been used to carry out an analysis of varians (ANOVA). The purpose of this analysis is to split
the observations into components representing the different variables which could have an affect on them. The effect and importance of
these variables could be valuated by calculation.

3. Results

Dose (D):

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A reference measurement made with the existing parameters from the department where the study was carried out, resulted in
absorbed organdose (D) in the thyroid glandel of 0,406 mSv during an AP projektion and D = 0,125 during a LAT projektion
(those are the departments standard projektions). The measurements were carried out with two-knob technique at 60 kV, 20
mAs and grid with a ratio r=12:1. Furthermore a measurement for PA projektion was made with the same parameters (not
standard in the concerning department) where D = 0,074. This value is reference to all PA projektions exposed with AEC.

In figur 4 the results for organ dose can be read for all study designs we have measured. The diagram is divided into the three
kV areas 55, 60 and 66 kV in the horizontal axis and the organ dose results in the thyroid gland can be read on the vertical
axis.

In the tabel below the diagram are the kV ranges divided in coloums and projektions with belonging grid ratios are divided in
lines (the unit r=0 referes to when grid is not used at all).

Contrast (C):

Assessment of the contrast in the images exposed with the departments standard parameters which also are our references,
resulted in the same value for all three projektions C = 0,7 mm in deph. From figure 5 we can observe that values for the AP
and PA projektions carried out with AEC are approximately the same provided that same kV range and grids are used. The
best contrast for AP and PA projektions is achieved with grid r=12:1 by all three kV ranges. We observed negligible contrast
decrease with grid r=8:1. By increasing kV contrast values varies from 0,7 mm in deph in the best image to 0, 96 mm in deph
for the worst. The contrast remain the same or decreased a bit with the same grid and projection.

55 kV 60 kV 66 kV
LAT r=12:1 0,83 0,76 0,83
LAT r=8:1 0,7 0,7 0,7
LAT r=0 0,7 1 0,83

Table 2. Contrast for LAT projection with AEC (the lowest values means best contrast). Reference is C=0,7 deph in mm.

Spatial resolution (SR)

With an AP projection made with standard parameters of the department SR is assessed to 1,8 lp/mm. By a similar PA projection SR
decreased to 1,46 lp/mm and during LAT projection SR = 1,33 1p/mm.

In figure 6 an AP projection with grid r=12:1 and r=8:1 with AEC results in the same SR value in all three kV areas, whereas a decreasing of
SR is observed when grid is not used at all. The PA projection shows a lower SR compared to an AP projection in all three kV ranges and
all grid combinations. Also here a decreasing in SR is being observed when grid is not used.

During LAT projections (Table 3) a grid r=8:1 increases SR in relation to a grid r=12:1 and without a grid at all in all three kV areas.

55 kV 60 kV 66 kV
LAT r=12:1 1,2 1,2 1,2

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LAT r=8:1 1,3 1,4 1,4
LAT r=0 1,26 1,2 1,2

Table 3. SR for LAT projection with AEC. The reference value for LAT is SR= 1,33 lp/ mm.

Control values

To make sure that to phantoms are equivalent to each other we have controlled all exposures by their lgM values and mAs product and they
were the same.

Discussion

Results show a significant dose reduction (p<0,0001) in absorbed dose in the thyroid glandel (up to 80%) during a PA projection compared
to AP. This can be explained with the thyroid glandels anatomical position as the photons during a PA projection will be attenuated by
columna cervicalis and the surrounding tissues. Richard R. Carlton et al. emphasize that organs with high radiation sensitivity should be
placed nearest to the film (9) . This dose reduction will affect the effective dose as the thyroid gland contributes with a relatively high w T

(5% of total body dose). By using AEC we have reduced organ dose to the thyroid glandel by increasing the kV (Fig. 7). An increased kV
will result in a less percentage of the soft (low energy) photons which will be absorbed in the tissue and accordingly increase dose to the
patient but without contributing to the image (10) . Our results are equal to the ones showed in a phantom study where a dose reduction of
20-30% is obtained by using a higher kV (11) .

When we replace a grid with r=12:1 with one with r=8:1 we can achieve a significant dose reduction (p=0,0008) in all projections and if we
furthermore remove the grid completely the reduction is considerable (Fig.8). Besides attenuating the scattered radiation, the grid also
attenuates a part of the primary beam. Higher attenuation of the primary beam will result in an increased dose to the patient as the AEC will
compensate for loss in intensity by regulating the time of exposure with an increased mAs as a result (12) .

There is no variation in contrast during PA and LAT projection compared to the reference measurement. The assessment has shown that
there is no difference in contrast when kV is increased from 55 to 66 kV when projection and grid ratio are held constant. This is probably
the cause of the fact that 55 and 66 kV are so close to each other on the absorption kV curve and the differences in contrast therefore are
minimal (Fig. 9).

When we change grid ratio from r=12:1 to r=8:1 a slight decreasing of contrast image is observed without affecting the diagnostic quality in
the image. AP and PA projections without using grid a decreasing of the contrast occurs in such a degree that it has to be considered whether
the considerable dose reduction compensates for the lack in image contrast before possible implementation.

In LAT projection the variations in contrast are marginal so here it is possible to remove the grid completely. It is possible that the natural
air gab that is present during a LAT projection of columna cervicalis is large enough to remove the scattered radiation to such a degree that
this radiation has no influence on the image (13) .

Assessment of SR shows that a PA projection in average is 14% lower than a AP during all exposures. Dendy et al. says that an increased
object to image distance (OID) leads to a distortion in geometrical sharpness. This distortion occurs in our study because it is columna
cervicalis we assess and this is moved further from the film when we change the projection from AP to PA (larger OID) (14) . This has an
effect on the image in form of the magnification (M) when an increased OID and thereby decreased source to object distance (SOD) obtain a
magnified and at the same time more disturbed picture. The magnification can be calculated from the following formula (15) :

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We know that our used grid with r=12:1 has a selectivity ( S) on 6.4 and the grid with r=8:1 has a S= 4.3. The grid that absorbs the
largest amount of scattered radiation compared to the primary radiation is characterized by a larger degree of selectivity ( S).

The better the grid is to remove scattered radiation and attenuate less primary radiation the higher selectivity it has (16) . For AP and PA
projections our results has shown a significantly better SR (p<0,0001) with grid r=12:1 than with a grid r=8:1 or without grid at all because
of the highest selectivity factor is in grid r=12:1.

By a LAT projection SR is nearly the same during all exposures.

4. Conclusions

We can conclude that AEC can be used with advantage during columna cervicalis examinations.

We have achieved a dose reduction during AP, PA and LAT projections while maintaining image quality with certain
parameter designs compaired with the to-knob technique witch is normally used at the department where we carried out our
study.

The parameter design carried out with AEC which can match the reference measurement made with the standard protocol of
the department is an AP projection carried out with AEC 66 kV and with a grid r=12:1. With this parameter design the
absorbed dose in the thyroid gland has been significantly (p<0,0001) reduced by 60% where C is maintained and with a slight
decrease in SR ca. 8%.

When we optimize the projection and make a PA projection instead of AP with AEC, 66 kV and grid r=12:1 we achieve a
significant (p<0,0001) dose reduction on 90%. With this parameter design the contrast is maintained and there was spatial
resolution decrease of 22% compared to the reference.

Our project shows that we can optimize kV by increasing it from 55 to 66 kV during all three projections and reduce dose
significantly (p=0,0003) while image quality is maintained.

During AP/PA projections a significantly (p<0,0001) enhancement of the C and SR is achieved with grid r=12:1 compared to
grid r=8:1 but this difference is minimal (0,2 mm in depth which equals 11%). A decreasing of image quality is more visible
with grid r=12:1 compared to no grid at all.

The parameter design for an LAT projection carried out with AEC which best can match the reference measurement made
with standard protocol is made with 66 kV and a grid r=8:1. By those parameters a significant (p=0,0008) dose reduction by
74% is achieved where C is maintained and SR is improved by 5%. Our project shows that if a grid r=8:1 is used during a LAT
projection both C and SR is maintained by all kV ranges and a significantly (p=0,0008) dose reduction is achieved compared
to the reference. LAT projections without grid does not decrease the image quality significantly. A loss in SR of 10% and in C
of 18% is seen but this should be compared to a dose reduction of 85%.

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5. Personal Information

see: [cvunavn_300dpi.bmp]

Bachelor in Radiography Omar Muharemovic, Hallingparken 14, 2660 Brøndby Strand, Email: omarradiograf@hotmail.com

Bachelor in Radiography Rasmus Pedersen, Hegnshusene 8, 2700 Brønshøj, Email: radiograf@privat.dk

Bachelor in Radiography Martin Drost Nielsen, Sjællandsgade 59 a, 1.-102, 2200 København N, Email:
mdn1976@gmail.com

see: [cvulogoo_300dpi.bmp]

see: [Rasmus]

Rasmus

see: [Omar and Martin]

Omar and Martin

6. References

1. Bushberg JT, Seibert JA, Leidholdt EM, Boone JM: The essential physics of medical imaging . Second edition.
Philadelphia: Lippincott Williams & Wilkins, 2002: 792

2.Sundhedsstyrelsens bekendtgørelse nr. 823 af 31. oktober 1997

3. Dendy PP et al.: Physics for Diagnostic Radiology IOP Publishing Ltd and Individual Contributors 1999 - Second Edition:
124.

4. McVey G, Sandborg M, Dance DR and Carlsson GA : A study and optimization of lumbar spine X-ray imaging systems.
2003 [Online: 16122005]

5. Dendy PP et al.: Physics for Diagnostic Radiology IOP Publishing Ltd and Individual Contributors 1999 - Second Edition:
137

6. Jensen PH, Lauridsen B, Søgaard-Hansen J og Warming L: Kursus i helsefysik - 3. udg.. - Roskilde: Forskningscenter
Risø, 2001: 22.

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7. Bushberg JT et al.: The essential physics of medical imaging . Second edition. Philadelphia: Lippincott Williams &
Wilkins, 2002: 641 og 750.

8. Seibert JA et al.: Practical Digital Imaging and Pacs , United States of America Medical Physics Publishing, 1999: 139.

9. Carlton RR, Adler MA: Principles of Radiographic Imaging 3. edition Delmar 2001: 210.

10. Carlton RR, Adler AM: Principles of Radiographic Imaging 3. edition Delmar 2001: 212.

11. Axelsson B , Petersen U , Wiltz HJ : Digital skeletal radiography. Reduction of absorbed dose by adaptation of
exposure factors and image processing. 2001 [Online: 16122005]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi ?cmd=Retrieve&db=PubMed&list_uids=11736707&dopt=Abstract

12. Dendy PP et al. Physics for Diagnostic Radiology IOP Publishing Ltd and Individual Contributors 1999 - Second
Edition: 272.

13. Carlton RR, Adler AM: Principles of Radiographic Imaging 3. edition Delmar 2001: 276.

14. Dendy PP et al. Physics for Diagnostic Radiology IOP Publishing Ltd and Individual Contributors 1999 - Second
Edition.- side 222-223.

15. Carlton RR, Adler AM: Principles of Radiographic Imaging 3. edition Delmar 2001: 416-418.

16. Carlton RR, Adler AM: Principles of Radiographic Imaging 3. edition Delmar 2001: 272.

7. Mediafiles:

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Fig. 1

Alderson Phantom

Fig. 2

Measure unit of plexiglass phantom

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Fig. 3

Final plexiglass phantom design

Fig. 4

Fig. 5

Fig. 6

Fig. 7

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Fig. 8

Fig. 9

Omar and Martin

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Rasmus

cvulogoo_300dpi.bmp

cvunavn_300dpi.bmp

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