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Radiography

Radiography is an imaging technique


using X-rays to view the internal form of an
object. To create the image, a beam of X-
rays, a form of electromagnetic radiation,
are produced by an X-ray generator and are
projected toward the object. A certain
amount of X-ray is absorbed by the object,
dependent on its density and structural
composition. The X-rays that pass through
the object are captured behind the object
by a detector (either photographic film or a
digital detector). The generation of flat two
dimensional images by this technique is
called projectional radiography. In
computed tomography (CT scanning) 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 (axial,
coronal, and sagittal) which can be further
processed to produce a three dimensional
image.
Radiography

Projectional radiography of the knee in a modern


X-ray machine.

System Musculoskeletal
Subdivisions Interventional, Nuclear,
Oncological
Significant diseases Cancer, Bone fractures
Significant tests Screening tests, X-ray,
CT, MRI, PET, Bone
scan

Specialist Radiographer
Applications of radiography include
medical (or "diagnostic") radiography and
industrial radiography. Similar techniques
are used in airport security (where "body
scanners" generally use backscatter X-
ray).

Medical uses
Radiography
Medical diagnostics

ICD-9-CM 87 , 88.0 -88.6

MeSH D011859

OPS-301 code 3-10...3-13 , 3-20...3-26


Since the body is made up of various
substances with differing densities, X-rays
can be used to reveal the internal structure
of the body on film by highlighting these
differences using attenuation, or the
absorption of X-ray photons by the denser
substances (like calcium-rich bones). The
discipline involving the study of anatomy
through the use of radiographic films is
known as radiographic anatomy. Medical
radiography acquisition is generally carried
out by radiographers, while image analysis
is generally done by radiologists. Medical
radiography includes a range of modalities
producing many different types of image,
each of which has a different clinical
application.

Projectional radiography

Acquisition of projectional radiography, with an X-ray


generator and a detector.

The creation of images by exposing an


object to X-rays or other high-energy forms
of electromagnetic radiation and capturing
the resulting remnant beam (or "shadow")
as a latent image is known as "projection
radiography." The "shadow" may be
converted to light using a fluorescent
screen, which is then captured on
photographic film, it may be captured by a
phosphor screen to be "read" later by a
laser (CR), or it may directly activate a
matrix of solid-state detectors (DR—
similar to a very large version of a CCD in a
digital camera). Bone and some organs
(such as lungs) especially lend themselves
to projection radiography. It is a relatively
low-cost investigation with a high
diagnostic yield. The difference between
soft and hard body parts stems mostly
from the fact that carbon has a very low X-
ray cross section compared to calcium.

Computed tomography

Images generated from computed tomography,


including a 3D rendered image at upper left.

Computed tomography or CT scan


(previously known as CAT scan, the "A"
standing for "axial") uses a high amount of
ionizing radiation (in the form of X-rays) in
conjunction with a computer to create
images of both soft and hard tissues.
These images look as though the patient
was sliced like bread (thus, "tomography"--
"tomo" means "slice"). The exams are
generally short, most lasting only as long
as a breath-hold. Contrast agents are often
used, depending on the tissues needing to
be seen. Radiographers perform these
examinations, sometimes in conjunction
with a radiologist (for instance, when a
radiologist performs a CT-guided biopsy).

Dual energy X-ray


absorptiometry
DEXA, or bone densitometry, is used
primarily for osteoporosis tests. It is not
projection radiography, as the X-rays are
emitted in 2 narrow beams that are
scanned across the patient, 90 degrees
from each other. Usually the hip (head of
the femur), lower back (lumbar spine), or
heel (calcaneum) are imaged, and the
bone density (amount of calcium) is
determined and given a number (a T-
score). It is not used for bone imaging, as
the image quality is not good enough to
make an accurate diagnostic image for
fractures, inflammation, etc. It can also be
used to measure total body fat, though this
is not common. The radiation dose
received from DEXA scans is very low,
much lower than projection radiography
examinations.

Fluoroscopy

Fluoroscopy is a term invented by Thomas


Edison during his early X-ray studies. The
name refers to the fluorescence he saw
while looking at a glowing plate
bombarded with X-rays.[1]

The technique provides moving projection


radiographs. Fluoroscopy is mainly
performed to view movement (of tissue or
a contrast agent), or to guide a medical
intervention, such as angioplasty,
pacemaker insertion, or joint
repair/replacement. The latter can often
be carried out in the operating theatre,
using a portable fluoroscopy machine
called a C-arm.[2] It can move around the
surgery table and make digital images for
the surgeon. Biplanar Fluoroscopy works
the same as single plane fluoroscopy
except displaying two planes at the same
time. The ability to work in two planes is
important for orthopedic and spinal
surgery and can reduce operating times by
eliminating re-positioning.[3]

Angiography
Angiogram showing a transverse projection of the
vertebro basilar and posterior cerebral circulation.

Angiography is the use of fluoroscopy to


view the cardiovascular system. An iodine-
based contrast is injected into the
bloodstream and watched as it travels
around. Since liquid blood and the vessels
are not very dense, a contrast with high
density (like the large iodine atoms) is
used to view the vessels under X-ray.
Angiography is used to find aneurysms,
leaks, blockages (thromboses), new vessel
growth, and placement of catheters and
stents. Balloon angioplasty is often done
with angiography.

Contrast radiography

Contrast radiography uses a radiocontrast


agent, a type of contrast medium, to make
the structures of interest stand out visually
from their background. Contrast agents
are required in conventional angiography,
and can be used in both projectional
radiography and computed tomography
(called "contrast CT").[4][5]

Other medical imaging

Although not technically radiographic


techniques due to not using X-rays,
imaging modalities such as PET and MRI
are sometimes grouped in radiography
because the radiology department of
hospitals handle all forms of imaging.
Treatment using radiation is known as
radiotherapy.

Industrial radiography
Industrial radiography is a method of non-
destructive testing where many types of
manufactured components can be
examined to verify the internal structure
and integrity of the specimen. Industrial
Radiography can be performed utilizing
either X-rays or gamma rays. Both are
forms of electromagnetic radiation. The
difference between various forms of
electromagnetic energy is related to the
wavelength. X and gamma rays have the
shortest wavelength and this property
leads to the ability to penetrate, travel
through, and exit various materials such as
carbon steel and other metals. Specific
methods include industrial computed
tomography.

Radiography may also be used in paleontology, such


as for these radiographs of the Darwinius fossil Ida.

Image quality
Sharpness of a radiographic image is
strongly determined by the size of the X-
ray source. This is determined by the area
of the electron beam hitting the anode. A
large photon source results in more
blurring in the final image and is worsened
by an increase in image formation
distance. This blurring can be measured
as a contribution to the modulation
transfer function of the imaging system.

Radiation dose
The dosage of radiation applied in
radiography varies by procedure. For
example, the effective dosage of a chest x-
ray is 0.1 mSv, while an abdominal CT is
10 mSv.[6] The American Association of
Physicists in Medicine (AAPM) have
stated that the "risks of medical imaging
at patient doses below 50 mSv for single
procedures or 100 mSv for multiple
procedures over short time periods are too
low to be detectable and may be
nonexistent." Other scientific bodies
sharing this conclusion include the
International Organization of Medical
Physicists, the UN Scientific Committee on
the Effects of Atomic Radiation, and the
International Commission on Radiological
Protection. Nonetheless, radiological
organizations, including the Radiological
Society of North America (RSNA) and the
American College of Radiology (ACR), as
well as multiple government agencies,
indicate safety standards to ensure that
radiation dosage is as low as possible.[7]

Shielding

Lead is the most common shield against


X-rays because of its high density
(11340 kg/m3), stopping power, ease of
installation and low cost. The maximum
range of a high-energy photon such as an
X-ray in matter is infinite; at every point in
the matter traversed by the photon, there
is a probability of interaction. Thus there is
a very small probability of no interaction
over very large distances. The shielding of
photon beam is therefore exponential
(with an attenuation length being close to
the radiation length of the material);
doubling the thickness of shielding will
square the shielding effect.

Minimum thickness
X-rays generated by peak voltages below
of lead

75 kV 1.0 mm

100 kV 1.5 mm

125 kV 2.0 mm

150 kV 2.5 mm

175 kV 3.0 mm

200 kV 4.0 mm

225 kV 5.0 mm

300 kV 9.0 mm

400 kV 15.0 mm

500 kV 22.0 mm

600 kV 34.0 mm

900 kV 51.0 mm

The following table shows the


recommended thickness of lead shielding
in function of X-ray energy, from the
Recommendations by the Second
International Congress of Radiology.[8]

Campaigns

In response to increased concern by the


public over radiation doses and the
ongoing progress of best practices, The
Alliance for Radiation Safety in Pediatric
Imaging was formed within the Society for
Pediatric Radiology. In concert with the
American Society of Radiologic
Technologists, the American College of
Radiology, and the American Association
of Physicists in Medicine, the Society for
Pediatric Radiology developed and
launched the Image Gently campaign
which is designed to maintain high quality
imaging studies while using the lowest
doses and best radiation safety practices
available on pediatric patients.[9] This
initiative has been endorsed and applied
by a growing list of various professional
medical organizations around the world
and has received support and assistance
from companies that manufacture
equipment used in radiology.

Following upon the success of the Image


Gently campaign, the American College of
Radiology, the Radiological Society of
North America, the American Association
of Physicists in Medicine, and the
American Society of Radiologic
Technologists have launched a similar
campaign to address this issue in the
adult population called Image Wisely.[10]
The World Health Organization and
International Atomic Energy Agency (IAEA)
of the United Nations have also been
working in this area and have ongoing
projects designed to broaden best
practices and lower patient radiation
dose.[11][12][13]

Provider payment
Contrary to advice that emphasises only
conducting radiographs when in the
patient's interest, recent evidence
suggests that they are used more
frequently when dentists are paid under
fee-for-service [14]

Equipment

A plain radiograph of the elbow.


AP radiograph of the lumbar spine.

Sources

In medicine, projectional radiographs and


computed tomography images generally
use X-rays created by X-ray generators,
which generate X-rays from X-ray tubes.

A number of other sources of X-ray


photons are possible, and may be used in
industrial radiography or research; these
include betatrons, and linear accelerators
(linacs) and synchrotrons. For gamma
rays, radioactive sources such as 192Ir,
60Co or 137Cs are used.

Grid

A Bucky-Potter 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.[15]
Detectors

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).[16][17][18]
Image intensifiers and array
detectors

As an alternative to X-ray detectors, image


intensifiers are analog devices that readily
convert the acquired X-ray image into one
visible on a video screen. This device is
made of a vacuum tube with a wide input
surface coated on the inside with caesium
iodide (CsI). When hit by X-rays material
phosphors which causes the
photocathode adjacent to it to emit
electrons. These electron are then focus
using electron lenses inside the intensifier
to an output screen coated with
phosphorescent materials. The image
from the output can then be recorded via a
camera and displayed.[19]

Digital devices known as array detectors


are becoming more common in
fluoroscopy. These devices are made of
discrete pixelated detectors known as thin-
film transistors (TFT) which can either
work indirectly by using photo detectors
that detect light emitted from a scintillator
material such as CsI, or directly by
capturing the electrons produced when the
X-rays hit the detector. Direct detector do
not tend to experience the blurring or
spreading effect caused by
phosphorescent scintillators of or film
screens since the detectors are activated
directly by X-ray photons.[20]

Dual-energy
Dual-energy radiography is where images
are acquired using two separate tube
voltages. This is the standard method for
bone densitometry. It is also used in CT
pulmonary angiography to decrease the
required dose of iodinated contrast.[21]

History

 
Taking an X-ray image with early Crookes tube
apparatus, late 1800s.

Radiography's origins and fluoroscopy's


origins can both be traced to 8 November
1895, when German physics professor
Wilhelm Conrad Röntgen discovered the X-
ray and noted that, while it could pass
through human tissue, it could not pass
through bone or metal.[22] Röntgen
referred to the radiation as "X", to indicate
that it was an unknown type of radiation.
He received the first Nobel Prize in Physics
for his discovery.[23]
There are conflicting accounts of his
discovery because Röntgen had his lab
notes burned after his death, but this is a
likely reconstruction by his biographers:
[24][25] Röntgen was investigating cathode
rays using a fluorescent screen painted
with barium platinocyanide and a Crookes
tube which he had wrapped in black
cardboard to shield its fluorescent glow.
He noticed a faint green glow from the
screen, about 1 metre away. Röntgen
realized some invisible rays coming from
the tube were passing through the
cardboard to make the screen glow: they
were passing through an opaque object to
affect the film behind it.[26]
 

The first radiograph

Röntgen discovered X-rays' medical use


when he made a picture of his wife's hand
on a photographic plate formed due to X-
rays. The photograph of his wife's hand
was the first ever photograph of a human
body part using X-rays. When she saw the
picture, she said, "I have seen my
death."[26]
The first use of X-rays under clinical
conditions was by John Hall-Edwards in
Birmingham, England on 11 January 1896,
when he radiographed a needle stuck in
the hand of an associate.[27] On 14
February 1896, Hall-Edwards also became
the first to use X-rays in a surgical
operation.[28]

The United States saw its first medical X-


ray obtained using a discharge tube of
Ivan Pulyui's design. In January 1896, on
reading of Röntgen's discovery, Frank
Austin of Dartmouth College tested all of
the discharge tubes in the physics
laboratory and found that only the Pulyui
tube produced X-rays. This was a result of
Pulyui's inclusion of an oblique "target" of
mica, used for holding samples of
fluorescent material, within the tube. On 3
February 1896 Gilman Frost, professor of
medicine at the college, and his brother
Edwin Frost, professor of physics, exposed
the wrist of Eddie McCarthy, whom Gilman
had treated some weeks earlier for a
fracture, to the X-rays and collected the
resulting image of the broken bone on
gelatin photographic plates obtained from
Howard Langill, a local photographer also
interested in Röntgen's work.[29]
X-rays were put to diagnostic use very
early; for example, Alan Archibald
Campbell-Swinton opened a radiographic
laboratory in the United Kingdom in 1896,
before the dangers of ionizing radiation
were discovered. Indeed, Marie Curie
pushed for radiography to be used to treat
wounded soldiers in World War I. Initially,
many kinds of staff conducted
radiography in hospitals, including
Physicists, Photographers, Physicians,
Nurses, and Engineers. The medical
speciality of radiology grew up over many
years around the new technology. When
new diagnostic tests were developed, it
was natural for the Radiographers to be
trained in and to adopt this new
technology. Radiographers now perform
fluoroscopy, computed tomography,
mammography, ultrasound, nuclear
medicine and magnetic resonance
imaging as well. Although a nonspecialist
dictionary might define radiography quite
narrowly as "taking X-ray images", this has
long been only part of the work of "X-ray
Departments", Radiographers, and
Radiologists. Initially, radiographs were
known as roentgenograms,[30] while
Skiagrapher (from the Ancient Greek words
for "shadow" and "writer") was used until
about 1918 to mean Radiographer.
See also
Autoradiograph
Background radiation
Computer-aided diagnosis
Imaging science
List of civilian radiation accidents
Medical imaging in pregnancy
Radiation
Radiation contamination
Radiographer
Thermography

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External links
Wikimedia Commons has media related to
X-rays.

MedPix Medical Image Database


Video on X-ray inspection and industrial
computed tomography , Karlsruhe
University of Applied Sciences
NIST's XAAMDI: X-Ray Attenuation and
Absorption for Materials of Dosimetric
Interest Database
NIST's XCOM: Photon Cross Sections
Database
NIST's FAST: Attenuation and Scattering
Tables
A lost industrial radiography source
event
RadiologyInfo - The radiology
information resource for patients:
Radiography (X-rays)

Further reading
Radiation Safety in Industrial
Radiography , Specific Safety Guide No.
SSG-11, International Atomic Energy
Agency, Vienna, 2011.
Howard H. Seliger: Wilhelm Conrad
Röntgen and the Glimmer of Light.
Physics Today, November 1995, 25-31,
http://hdl.handle.net/10013/epic.43596.
d001
Shroy, Jr., Robert E. (1995). "X-Ray
equipment". In Bronzino, J.D. The
Biomedical Engineering handbook. CRC
Press and IEEE Press. pp. 953–960.
ISBN 0-8493-8346-3.
Herman, Gabor T. (2009). Fundamentals
of Computerized Tomography: Image
Reconstruction from Projections (2nd
ed.). Springer. ISBN 978-1-85233-617-2.