DPX SERIES OPERATOR TRAINING

AP SPINE IMAGE: Acquisition and Analysis

This presentation is designed for use by Applications Instructors

training Operators in the acquisition and analysis of AP Spine scans.

The first three slides are for instructor use only and NOT for
presentation to customers.
 USE OF THIS PRESENTATION:
NOTES TO THE INSTRUCTOR

• This presentation covers scanning and analysis for DPX series

scanners including:
– DPX- IQ, DPX- MD, DPX- A, DPX- alpha, DPX and DPX- L.
• Patient positioning and scan file analysis are basically the same for all
scanners. (DPX-IQ software provides the option to analyze vertebral
body ROIs, but the others do not.)
• Most of the slides in this presentation show examples using IQ
software, but may be applied to training on all systems.
• IMPORTANT: There are differences in scan mode selection criteria
between systems!
– There are different slides outlining the table specific criteria in the
acquisition section of this presentation.
• Review Notes Page for slides: 8, 33
 BEGIN CUSTOMER TRAINING
PRESENTATION WITH THE NEXT SLIDE
(Slide # 4)
DPX SERIES OPERATOR TRAINING
AP SPINE IMAGE: Acquisition and Analysis

DPX, DPX-L, DPX-A, DPX-alpha

DPX-IQ, DPX-MD
 INTRODUCTION:
Essentials for Accurate and Repeatable Results

• You will learn:

– Proper Patient Positioning
– Correct Scan Mode Selection
– Correct Scan Acquisition
– Correct and Consistent Scan File Analysis
• Improper positioning or incorrect scan acquisition may result in
unreliable scan results and may complicate scan file analysis.
• LUNAR software will correctly auto analyze most scans with proper
patient positioning and correct scan acquisition.
• If you follow the fundamental instructions outlined, you will have
consistent, accurate results and reduce the amount of time you spend
analyzing scans.
 INTRODUCTION:
Scanning the Lumbar Spine Region

• LUNAR software offers the ability to

1 monitor bone mineral density for:
– Total Body 1
– Spine (AP and Lateral) 2
2 – Forearm 3
– Hand 4
3
5 – Femur 5
– (Orthopedic - not shown)
4
• This tutorial covers scan image
acquisition and analysis for AP Spine.
• Let’s begin at the main menu of the
LUNAR software.
CHOOSE THE CORRECT SCAN OPTION

• Select AP SPINE
OPTIONS, if not
already selected.
• FEMUR OPTIONS is
the current selection.
• Press F6 - Select
Scan Type.
• Femur is highlighted.
• Use the arrow key
to highlight AP Spine.
• Press the Esc key to
enable AP SPINE
OPTIONS from the
main menu.

Esc F6
 ENTER PATIENT INFORMATION
• Press F1 - Scan Patient.
The Patient Directory
appears.
• Press F1 - Search. Type in
the patient’s last name.
• Press the Esc key.
(“TEACHER” is highlighted,
as it is closest alphabetically
to the name SMITH.)
• If new patient, press F4 - Add
New Patient. The Mandatory
Information screen appears.
SMITH • Type in information.
• Enter Ethnic code.
• Enter Disease codes (up to
3), Fracture codes (up to 3),
or F1 - Optional
Information, if desired.
• Press the Esc key, to begin
AP Spine Acquisition.
Esc F1 F4
 ENTERING PATIENT INFORMATION:
Avoid Mistakes

• Searching for the patient’s name each time you scan a patient will help
eliminate the mistake of entering a patient multiple times. A patient
should only be entered into a directory ONE time.
• Make sure that the patient’s name has been typed in correctly before
scanning the patient.
– Remember to enter the first name on the first line.
– Do not assume the name typed on your records has been spelled correctly.
It is best to confirm correct spelling (as well as birth date) with the patient.
• Measure the patient’s height and weight and enter your measured
values. If a patient is in for a repeat scan, you may need to update the
height and weight values.
• You need only enter the name, birth date, height, weight, sex and
ethnic code to scan a patient. All other information is optional.
CHOOSE THE CORRECT SCAN MODE

• The scan mode

currently selected is
Hi-Res Medium 750.
• Measure the
thickness of the
patient in the region
to be scanned to
determine if this is
the appropriate scan
mode.
 MEASURE PATIENT THICKNESS
IN THE REGION TO BE SCANNED
• Measure the thickness of the patient in the
lumbar region to determine the correct
scan mode. For DPX-IQ:

CM
30 30cm

Hi-Res Medium 3000

25

22 cm
20
Hi-Res Fast 3000

15 15 cm
Hi-Res Medium 750
12 cm
Our patient is 20cm thick, use Hi-Res Fast 3000. 10
 MEASURE PATIENT THICKNESS
IN THE REGION TO BE SCANNED
• Measure the thickness of the patient in the
lumbar region to determine the correct
scan mode. For DPX(L, alpha) :

CM
30 30cm
Medium 3000
26 cm
25

20 Fast 3000

15 15 cm
Medium 750
12 cm
Our patient is 20cm thick, use Fast 3000. 10
 MEASURE PATIENT THICKNESS
IN THE REGION TO BE SCANNED
• Measure the thickness of the patient in the
lumbar region to determine the correct scan
mode. For DPX- MD, DPX, DPX- A:

CM
30 30cm
Detail 750
28 cm
Slow 750
25
24 cm

20
Medium 750
15

12 cm
Our patient is 20cm thick, use Medium 750. 10
(See notes page for this slide.)
 SCANNING A PEDIATRIC PATIENT:
Choosing the correct scan mode

• Measure the thickness of the patient in the region to be scanned.

• The Pediatric scan mode is “Pediatric 300” and is recommended for
patients 6 - 16 cm thick in the region to be scanned.
– You may use this mode if your patient is 6 - 12 cm thick in this region.
– You may use this mode if your patient is 12 - 16 cm thick in this region
AND has scans previously acquired in Pediatric 300 mode.
• If you are scanning a pediatric patient FOR THE FIRST TIME and the
patient is greater than 12 cm, use the appropriate adult scan mode for
your system. For example, if your pediatric patient is 14 cm in the
scan region, use a Med. 750 scan mode to scan this patient.
• (Pediatric software is for investigational use ONLY in the USA.)
CHANGE SCAN MODE, IF NECESSARY
• The appropriate scan
mode for our sample
patient is Hi-Res Fast
3000.
• Press F1- Verify
Values. Hi-Res Medium
750 is currently
highlighted.
• Press the arrow key
to highlight Hi-Res Fast
3000.
• Press the Esc key to
change the scan mode
in the Acquisition
screen.
Home
• Press the Home key to
implement mode
selection.
• Press the Esc key and
Esc F1 position the patient.
 POSITION THE PATIENT PROPERLY
• Proper patient positioning is essential for reproducible results.
• Improper positioning may result in unreliable scan results and
complicate scan file analysis.
• PATIENT’S SHOULDERS SHOULD BE SQUARE.
• PATIENT SHOULD BE CENTERED ON THE TABLE.
• PATIENT’S HIPS SHOULD BE SQUARE.
• REMOVE HEAVILY-ATTENUATING MATERIALS FROM SCAN REGION.

DPX-IQ
 MOVE SCAN ARM AND ELEVATE PATIENT’S LEGS
• Once the patient is centered and square on the table, press
the Esc key to move the arm to the initial starting position.
• The patient localizer light will illuminate.
• Elevate the patient’s legs onto the foam leg block.
• The patient’s legs should be elevated after the scan arm moves over the
patient to avoid possible contact between the patient and the moving scan
arm.
The edge of the block
should be located at
the bend in the knees.

DPX-IQ
 PROPER ELEVATION OF THE LEGS
• The patient’s legs are elevated to reduce the natural
curvature of the lumbar spine and separate the vertebrae.

2. The edge of the block

should be located at the
bend in the knees.
1. Use the block height
that most closely matches the
length of the upper leg. BE
CONSISTENT WHEN
PERFORMING REPEAT
SCANS.

3. The legs should

o o
create a 60 to 90 angle
with the tabletop.

4. MAKE SURE THE PATIENT IS STILL CENTERED AND

SQUARE ON THE TABLETOP ONCE THE LEGS ARE ELEVATED .
ADJUST SCAN ARM START POSITION
• Use the directional
switches to center the
localizer light approximately
POWER LASER 5 cm below the navel. This
is approximately 1cm to 2
cm below the top of the
iliac crest.
• The scan should begin in
the middle of L5.

CENTER

DPX-IQ
5cm
SCANNING THE LUMBAR VERTEBRAE
WHAT YOU SHOULD SEE WHILE SCANNING

• T12 - You will see the ribs of T12

appear as you near the end of the
scan. Scan several lines of T12.
• L1 - Scan all of L1
• L2 - Scan all of L2
• L3 - Scan all of L3
• L4 - Scan all of L4
• L5 - Starting the scan in L5
ensures that all of L4 appears in
the scan and can then be
analyzed. Several lines of the
iliac crest will also appear in the
scan.
 ACQUIRE THE AP SPINE SCAN IMAGE
• Once the localizer light has
been properly positioned over
the patient, press the Esc key
to begin acquisition.
T12
• Monitor the first few scan lines.
Ribs – 1) The spine should be
L1
centered in the image.
3) L5 L2 – 2) Approximately 5 - 15
L3 scan lines of iliac crest
2) 5 - 15 lines
should be acquired. The
L4 right and left iliac crests
29
137 should appear to be
SOURCE N
ON
symmetrical, if the
patient’s hips are properly
1) Centered positioned.
– 3) Several lines of L5
should be acquired to
ensure that all of L4 will
be scanned.
• Continue scanning several
lines into T12. (Use ribs as
landmarks.)
Esc
RESTART SCAN, IF NECESSARY
• If the scan is started in the
wrong position, stop the
scan and reposition the
scan arm.
• This scan started too high,
in L4. NO iliac crest is
visible in the first few lines.
• Press F1 - Abort Scan
Process.
• Answer N (no) to “Continue
scan?” prompt.
29
14
• Answer Y (yes) to “Restart
N
SOURCE ON
Scan?” prompt. Answer Y
(yes) to “Are you sure?”
prompt.
• Press F1 - Reposition
Scan.
• Adjust the position of the
localizer light using the
positioning switches as
shown before.
• Press the Esc key to rescan
Esc F1 the patient.
 SAVE DATA FOR ANALYSIS
• Once the scan has been
correctly acquired, stop the
scan and save the data.
• Press F1 - Abort Scan
Process.
• Answer N (no) to “Continue
scan?” prompt.
• Answer N (no) to “Restart
Scan?” prompt.
29
137 • Answer Y (yes) to “Save
N
SOURCE ON data?” prompt.
• Remove the foam leg
block before the arm
returns to home position.
• The scan arm will return to
home position. Remove
the patient from the table.
• Press the Esc key to return
to the main menu.

Esc F1
 ANALYZE AP SPINE IMAGE
• From the main menu, press
F2 - Analyze Scan.
• Highlight the patient’s name.
This patient was just
scanned, therefore the name
is already highlighted in the
L1 Patient Directory.
L2 • Press the Esc key.
1 3 2 • This scan has not yet been
L3
analyzed and is the scan just
L4 acquired. Press the Esc key
to continue.
• Review the mandatory
information and press the
Esc key to continue.
• Press F2 - Auto Analysis.
• Check:
– 1
Labels
– Intervertebral Markers 2
– Edge Markers 3
• Press Esc if labels, markers
and edges are correct.
Esc F2
CHANGE LABELS, IF NECESSARY

• If the scan had been started

incorrectly (in L4), the
vertebral bodies may be
incorrectly labeled as shown.
• Press F3 - Label Vertebrae.
• The current incorrect label
sequence is L2, L3, L4.
• Use the arrow key to
highlight the correct
sequence: L1, L2, L3.
• Press the Esc key to
correctly label the vertebrae
on the image: L1, L2, L3.
• L4 is not labeled. It will be
necessary to add a marker,
to include L4 in the analysis.

Esc F3
ALTER MARKERS, IF NECESSARY
• L4 is not currently labeled.
• We want to insert a marker
below L3. Currently the
active marker is on line 128.
• Use the arrow key to
select the intervertebral
marker below L3. (On line
45 in this example.)
• Press F4 - Insert Marker.
• A marker will be inserted
directly below the marker we
had selected. This new
marker is now active and
can be altered.
• Press F2 - Alter Marker.
• Use the arrow key to
move the marker to the
intervertebral space between
L4 and L5. (The “valley” in
the histogram.)
• There are misplaced bone
edges that will also need
adjustment.
F2 F4
MOVE EDGE MARKERS, IF NECESSARY
• Occasionally edge markers
will be misplaced due to a
calcification in the tissue,
very low BMD in a region of
a vertebra or an artifact.
• To adjust misplaced edges,
press F7 - Profiles.
• The first misplaced edge (on
line 67), needs to be moved
to the bone edge.
• Use the arrow key to
move the edge marker to
the bone edge.
• Use the arrow key to
change lines. Move the
next misplaced marker.
• Continue to move edges a
line at a time, until all have
been correctly placed. The
last marker moved was on
line 61.
• Press the Esc key to return
Esc F7 to the bone results screen.
 SAVE DATA AND PRINT
• Ensure labels,
intervertebral markers and
edge markers are correct.
• If you wish to print a graph
of results for a region other
than L2 - L4, you may use
the arrow keys to highlight
the region you wish to print.
• The default region for a
correctly acquired and
analyzed AP Spine scan is
L2 - L4.
• Press the Esc key to view
the graph.
• Press F1 - Save Changes.
The screen will flash briefly
while changes are saved.
• Press F2 - Print. Type in
the number of copies you
wish to print.
• Press the Esc key twice.
• Answer N (no) to prompt to
Esc F1F2 return to main menu.
 REVIEW:
Essentials for Accurate and Repeatable Results

• Entering Patient Information:

– Search for the patient name, this will prevent multiple entries of a patient
into the database. ENTER A PATIENT INTO A DATABASE ONE TIME.
– Enter information correctly before scanning the patient.
– Enter measured values for the patient’s height and weight.

• Proper Patient Positioning:

– Make sure the patient is centered and square on the table.
– Elevate the patients legs. Use the foam leg block consistently.

• Correct Scan Mode Selection:

– Measure the thickness of the patient in the region to be scanned. Choose
the correct scan mode accordingly.
 REVIEW, CONTINUED:
Essentials for Accurate and Repeatable Results

• Correct Scan Acquisition:

– Begin the scan in L5. Spine should be centered in the image, hips square.
– Scan all of L4, L3, L2 and L1. Spine should remain centered in the image.
– End the scan several lines into T12. (Watch for ribs in image.)
• Correct and Consistent Scan File Analysis:
– Let the computer do the analysis.
– Check vertebral labels, intervertebral markers and edge markers . Adjust
only if necessary.
– Save the analysis (even if you do not make any changes) and print.
 AVOID COMMON MISTAKES:
Frequently asked questions.
• Q1: I noticed an artifact (blue) in the image while scanning the spine.
What might have caused it and will it affect scan results?
• A1: An artifact may affect scan results. Check the following:
– Ask if the patient has any implants in the region being scanned.
Herrington rods, pins and clips from open heart surgery are examples of
objects that may be apparent in an AP spine scan.
– Make sure the patient is not wearing any heavily attenuating material, like
suspenders or garments with wire support.
– Make sure the patient has no heavily attenuating material in a pocket.
Coins will be apparent if they are in the scan region.
– Ensure the patient has not recently undergone a procedure involving a
radiopaque substance (barium) or a radioisotope. Have the patient return
for a scan at least 72 hours after such a procedure. (Or schedule the
densitometry scan before this type of procedure. (See example to follow.)
 AVOID COMMON MISTAKES:
Example of an artifact in the scan region.

• This patient has barium in the colon.

• Intervertebral
markers are
misplaced.
• No results
• The vertebrae have been
are not all reported.
correctly
labeled.

• All edges are misplaced

 AVOID COMMON MISTAKES:
Frequently asked questions.
• Q2: When I try to compare this patient’s scan to an older scan, why
don’t I see any other scans listed for this patient? Our records show
this patient was scanned at our facility a year ago.
• A2: There may be several explanations, check the following:
– Make sure you are looking in the directory of the older scan. If the
patient’s file has been archived, you will need to change the directory you
are viewing to the archive path. (Press F1 - Change Directory in the
compare scan screen.)
– If the patient was entered as a new patient when they returned, you will not
be able to compare the new scan to the old. The computer will recognize
the two scans as scans for different patients. It is best to search the
patient directory, before entering a patient as new when you scan. This is
especially important if there are multiple technologists performing
densitometry scans on a single system.
 AVOID COMMON MISTAKES:
Frequently asked questions.
• Q3: Why didn’t the software properly place intervertebral markers or
label the vertebral bodies correctly?
• A3: The software may incorrectly place intervertebral markers or
incorrectly label vertebral bodies as the result of:
– Improper patient positioning,
– Incorrect scan acquisition,
– Occasionally, vertebrae are mislabeled due to the condition of the bone of
a vertebra being analyzed.
– (See examples to follow.)
• Proper patient positioning and correct scan acquisition will eliminate
many of these errors.
 AVOID COMMON MISTAKES:
Example of problem scan.

• This scan shows incorrect positioning and acquisition.

• The patient’s spine does

• The scan started too low
not remain centered in the
in the pelvis and all of L5
image. This suggests that
was scanned. This
the patient’s shoulders
resulted in:
may not have been square
– Both L4 and L5 are during acquisition.
labeled “L4”
– The intervertebral
marker is improperly
placed below L5. L5

• The correct location for

this marker is shown.
 AVOID COMMON MISTAKES:
Example of problem scan.

• This scan shows incorrect positioning and acquisition.

• The patient’s spine does

• The scan was aborted
not remain centered in the
too soon. Only a portion
image. This suggests that
of L1 was scanned. This
L1 the patient’s shoulders
resulted in: may not have been square
– The mislabeling of L2, during acquisition.
L3 and L4.

• The scan should have

been allowed to continue
several lines into T12.
 AVOID COMMON MISTAKES:
Example of problem scan.

• This scan shows incorrect acquisition and bone abnormality

requiring intervention in the auto analysis.

• The scan started too low

in the pelvis. This may
have caused:
– The omission of the L4 L1 Correct L2, L3 marker location.
label. It will be
necessary to add a
marker to include this
vertebra in the analysis. L4
• The condition of patient’s
bone has caused:
– The software to
incorrectly place the
intervertebral marker in
L3.