Splines and Active Shape Model for Segmentation of Pelvic X-Ray Images

Rebecca Smith and Kayvan Najarian

Abstract X-ray segmentation is a challenging problem, particularly when dealing with complex bone structures such as the human pelvis. However, initial diagnosis of traumatic pelvic injuries is typically made via x-ray images, due to low cost and lack of disruption to the patient. Diagnosis is a complex task, as fractures in different regions of the pelvis display different characteristics. An effective decision-making system for such injuries therefore requires accurate segmentation of the key pelvic structures, so specic features may be searched for in the fracture detection process. Previous work in x-ray image segmentation has focused on the use of deformable model techniques, such as Active Shape Model (ASM). However, the low resolution and blurred lines of x-ray images can cause the model to converge to false edges. This paper combines standard Active Shape Model with the use of cubic spline interpolation to regulate deformation, taking advantage of the natural curvature of the pelvic structure. This extended algorithm is compared with standard ASM on both normal and injured cases, and is shown to improve performance even in the presence of fracture.

I. INTRODUCTION Fractures of the pelvis are among the most severe injuries that can be suffered by a major trauma patient. They frequently prove life-threatening, and are strongly associated with impact injuries such as those sustained in moving vehicle accidents. A six-year case study of 119 male pelvic trauma patients at a large level 1 trauma center found that 42.8% of fractures were caused by motor vehicle collisions (MVC) [1]. Traumatic pelvic fractures can also be caused by crush injuries (10%) and falls (30%) [2]. These fractures can lead to laceration of the surrounding soft tissue and damage to the neural and vascular structures. They may also affect neighboring structures such as the urogental system. As a result, traumatic pelvic injuries are often very complex, and are associated with a high mortality rate. Fractures due to high-energy impacts, causing destruction of pelvic ring integrity, are associated with a mortality rate of between 5 and 20% [2]. Many of those who survive suffer permanent disability. Acetabular fractures, although not as potentially life threatening, are also associated with signicant morbidity [3]. Most deaths in pelvic trauma patients are not due to the fracture itself, but to other complications [4]. Severe hemorrage is a particularly high risk. In such cases the patient may
This work was supported by the National Science Foundation under Grant No.IIS0758410. R. Smith is with the Department of Computer Science, Virginia Commonwealth University, Richmond, VA 23842 USA smithr@vcu.edu K. Najarian is an Associate Professor of Computer Science at the Virginia Commonwealth University, and director of the Biomedical Signal Analysis program at Virginia Commonwealth University Reanimation Engineering Shock (VCURES), Richmond, VA 23284 USA. knajarian@vcu.edu

die from the hemorrage itself, via exsanguination and shock, or due to other conditions resulting from hemorrage, such as severe infection [5]. Prompt and appropriate treatment of pelvic injury is therefore vital to patient survival. X-ray imaging is a vital rst diagnostic step in cases of pelvic trauma. Taking an x-ray is fast, cheap, and causes relatively little disturbance to the injured patient. The resulting image can quickly reveal the extent of damage to the pelvic structure, including fractures, pelvic ring disruption, and widening of the pubic bone gap. However, due to the complex structure of the pelvis and the low resolution of xray images, fractures may be hard to recognize; discussion with physicians suggested uncertainty even among medial professionals. A system capable of quickly identifying pelvic fracture may therefore prove useful in a trauma center environment. Fracture location has considerable impact on both severity and treatment of the injury, as well as the appearance of the fracture in a radiograph image; therefore the rst step in constructing such a system is to correctly segment the pelvis into distinct regions and identify specic structures. This paper focuses on two specic structures in the pelvis: the iliac crests and the pelvic ring. The pelvic ring is valuable as a reference point for detection of other strutures, as it typically maintains integrity in all but the most severe cases. The iliac crests are common sites of fracture in the dataset used, and accurate segmentation is therefore vital before fracture detection can occur. By isolating and detecting these two structures within x-ray images, we build a valuable base for future automatic fracture identication. The use of ASM in detecting specic pelvic structures has shown promising results [6], [7]. However, a frequent challenge in segmenting radiographs comes from the wide variation in contrast and sharpness across machines. Furthermore, bones frequently overlap within the pelvis, so structures are less clearly dened. These two factors can cause the ASM algorithm to converge to false edges. To prevent this, one might consider strongly limiting the degree of deformation. However, this is only an option when the shapes in the test image closely resemble those in the training set, which is not the case for x-rays since there are differences in size, patient position, and specic patient anatomy. On the other hand, allowing too much deformation can lead to loss of shape structure - more specically, the curvature across a given sequence of points is not maintained. This paper proposes an algorithm which combines the standard ASM approach with a spline-based method that controls shape deformations by penalizing those that move greatly away from the curvature of the target shape. Adding this further constraint reduces

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the problems of false edges, overlapping bones, and low resolution images. Such an approach is of particular merit in dealing with pelvic x-rays, since most structures of interest show strong and consistent curvature. For example, the pelvic ring typically resembles an ellipse. A. Prior Work A large number of studies in medical image segmentation have focused on MRI and CT images, including those of the pelvic and abdominal areas [8], [9]. The segmentation of x-ray radiographs, however, has received less attention. This can be partly attributed to the additional challenges and complexities involved. For example, x-ray absorption rates vary across different body tissues, which can lead to indistinct edges and may also make it difcult to distinguish between organs, skin, and bone. The latter problem is exacerbated by low contrast; more specically, bone structures become difcult to isolate from the surrounding soft tissue. This is especially problematic when multiple bones overlap, and is therefore a major challenge in dealing with pelvic radiographs. Not only do the femurs and spine overlap with the main structure of the pelvis, but there are numerous organs contained within the pelvic structure. Pelvic x-rays are prone to another specic complication: the presence of gas inside the colon, which causes dark shadows to appear over the iliac fossa. Early attempts at radiograph segmentation varied in their approach. Manos [10] employed region growing and merging according to size, similarity, and connectivity. Labels were assigned to the resulting regions based on their grey level information. However, this method did not incorporate spatial information or existing anatomical knowledge. Several studies focused specically on the identication of lung regions in chest radiographs. McNitt-Gray [11] classied each pixel in the radiograph image according to various locally calculated features. Duryea [12] and Pietka [13], meanwhile, applied rule-based heuristics, while Vittitoe [14] used Markov random eld models. More recent efforts have focused on the use of deformable models. These methods are able to segment complex structures and perform well in practical applications, as they account for natural variability of a structure in shape and appearance. By using a learning-based model approach, prior knowledge of the problem can be incorporated and the degree of variation can be learned from a set of annotated training examples. Two specic learning-based algorithms, Active Shape Model (ASM) and Active Appearance Model (AAM), have proven successful in segmenting CT, MRI, and x-ray images [15], [16], [17]. The use of splines for segmentation of images has also been explored in recent years, including specic applications in the medical eld. Most work has focused on the use of B-splines. Combining splines with active contour methods is a popular approach; for example, active contour methods based on B-splines have been used for segmentation of video images [18] with considerable success. In the medical eld, another study used B-splines with polar-transformed active contours to segment microcalcications in mammograms

[19]. One experiment evaluated the use of B-spline snakes in measuring articular cartilage in MRI images; the method corresponded well with manual segmentation results [20]. Another applied 3D cylinder B-spline for detecting carotid arteries in MRI scans [21]. However, these studies all involve the use of general B-splines. The algorithm proposed in this paper uses the simple and more specic cubic spline interpolation, which is fast and suitable for the application. It uses polynomials formed by natural cubic splines, as opposed to cubic B-splines. Futhermore, no study has yet explored the use of cubic splines with the ASM algorithm, particularly for medical imaging applications. Cubic splines were chosen since they best capture the curvature of the main pelvic structures. The combined ASM/spline algorithm takes an iterative approach. Figure 1 presents an overview of a single iteration; the details will be made clear in the following section.

Fig. 1. Flowchart describing each iteration of the search process for the target shape in a new image using combined spline/ASM

II. METHOD A. Data The data was provided by Carolinas Healthcare System (CHS), and consisted of 40 pelvic fracture patients. The dataset was ltered to include only those x-rays taken upon the patients initial arrival at the hospital, prior to surgery and internal xation. All x-rays were resized to a standard width of 1000 pixels, though image height varied across the set. Due to the signicant differences in pelvic anatomy between male and female patients, the dataset was divided by gender. The systems user must therefore specify the patients gender

before structure detection can be performed; however, this information is readily available and should not complicate the process in a trauma center environment. The training set used in this paper consisted of ve male patients, all suffering from pelvic fracture. Fifteen male patients were reserved for testing. B. General Active Shape Model Algorithm ASM (Active Shape Model) generates a statistical model of the shape of an object; this model can then be deformed over a number of iterations to t the same object in a new image. The approach is therefore of great use in image segmentation and object detection. The target shape is rst dened by a set of landmark points chosen by the user. This is done across a set of training images, and a Point Distribution Model (PDM) that describes the target shape is generated. The nal labeled training set contains N shapes, each labeled with k landmarks. Using these landmarks, each shape can be represented as a vector of (x, y ) coordinates, which represent each landmark in sequence. Maintaining this sequence is crucial, as the shape is dened by both the landmarks and the connectivity between them. The training shapes must then be correctly aligned, to compensate for the wide variation across images - in this study caused by the differences between patients in pose angle and position. Given two shape vectors zi and zj , a transform Ts,,Xt ,Yt is calculated and applied which aligns zi to zj , where s is the scaling value, is the rotation angle, Xt is the horizontal translation and Yt is the vertical translation. The translation values are particularly vital in dealing with pelvic x-ray images, as there is no standard initial position for each patient. Principal Component Analysis is applied after training shape alignment; each shape can then be approximated using: xx + Pb (1)

sample from the model mean, given by:

f (gs ) = (gs g )T Sg 1(gs g )

(2)

The pixel with the lowest value of f (gs ) is designated as the new best position for the model point. This process is repeated for each point in turn and the shape parameters b are then updated to t these new positions before the next iteration begins. The algorithm halts when an iteration results in no signicant changes in b. Note that the success of ASM is highly dependent on correct initialization. If the starting shape is placed incorrectly, the algorithm cannot converge to the correct edges. This issue is a particular problem when the location of the object varies across the test images, as in the x-rays used in this study (due to variations in patient position). Initialization can be controlled manually, but this is time-consuming and defeats the purpose of the proprosed automated fracture detection system. Instead, automatic initialization is performed using the method proposed in [6]. C. Cubic Spline Interpolation A spline is a piecewise function dened by polynomials [22]. The aim of spline interpolation is to t a spline to a set of data points - in other words to interpolate an existing function f . Spline interpolation is often preferred to polynomial interpolation, since it offers similar performance for low-order polynomials and is less error-prone at higher orders. Cubic spline interpolation focuses on spline functions of degree 3. Given n + 1 distinct knots (points) xi where i = 0 . . . n and n + 1 corresponding knot values yi , the aim is to nd a piecewise cubic spline function S (x) such that S0 x [x0 , x1 ] S1 x [x1 , x2 ] (3) S (x) = ... Sn1 x [xn1 , xn ] Each Si (x) is a polynomial of degree three. For cublic spline interpolation, three specic constraints apply. First, the interpolating property requires that S (xi ) = f (xi ). Secondly, the splines must connect - i.e. S (i 1)(xi ) = Si (xi ) for i = 1, . . . , n 1. Finally, the derivatives must be equal so that S (x) = S (x) = S (x). D. Combined Spline/ASM Algorithm The algorithm described in this paper incorporates splines into the quality of t function described in Equation 2. When considering landmark point pj = (xj , yj ), where j = 1 . . . k (and k is the total number of landmarks) an interpolated spline function is constructed using m points on each side of the model point. In other words, a sequence of points s is used for interpolation, where: s = pim , . . . , pi2 , pi1 , pi+1 , pi+2 , . . . , pi+m (4)

where P contains the t eigenvectors of the covariance matrix, and b is a t-dimensional vector dening the model parameters. The possible change in b is constrained to a specic maximum value to ensure that the generated shape remains similar to those in the training set. The training images are also used to construct a statistical grey-level model. This is done by sampling the neighboring pixels of each landmark point; more specically, a model is built for each individual landmark by sampling the derivative of the intensity values along the prole normal to the landmark in each training image. The sampled derivatives are normalized. The mean value g and covariance matrix Sg are calculated for each landmark point. Once both the shape and grey-level models have been constructed, shape detection can be performed in test images. Detection is initialized using the mean shape and the search is performed iteratively. In each iteration, each landmark point is considered in turn. A user-specied number of pixels a are sampled along the prole normal to each model point, and the quality of t of each pixel sample as a new model point position is calculated as the Malanobis distance of the

The resulting spline function is used to predict the location of point pi , using its x-coordinate, to give the predicted point

location lp = (xl , yl ). As in the standard ASM algorithm, a pixels are sampled along the prole to the model point, and the quality of t calculated for each. At each prole pixel qi = (xq , yq ), where i = 1 . . . a, the distance between qi and lp is calculated and squared to obtain an error measure e: e = abs(xq xl ) + abs(yq yl ) The quality of t function then becomes:
f (gs ) = (gs g )T Sg 1(gs g ) + e

the curvature of the desired shape is particularly useful when the test image display a different range of intensity values to the training set.

(5)

(6)

where is chosen via experimental results. For the application described in this paper, the optimal value of was found to be 0.00001. Two further requirements are applied. First, landmarks on sharp angles - such as the edge of the pubic bone - are designated as corner points. If a corner point is encountered when building the interpolation sequence s, the sequence is terminated at that point. This ensures formation of a smooth curve; sudden sharp turns can lead to inaccurate results. Secondly, the algorithm checks the gradient between successive points in the sequence s. A high gradient value implies that the points lie on a near-vertical line. In this case, cubic interpolation is not applied, as prediction based on the x-coordinate has shown to be unreliable. This is a relatively rare occurence in pelvic CT images, and is typically only an issue on the inner edge of the pubic bones. III. RESULTS After training on a set of ve labeled images, the algorithm was tested on a second set of ten images. Tests focused on two specic pelvic structures: the iliac crests and the pelvic ring. Both show strong curvature, and the pelvic ring in particular is an important reference point for other structures, since it typically maintains integrity in all but the most severe cases. A. Detection of Iliac Crests The training set of images for iliac crest detection consisted of ve x-rays taken from male patients. Each crest was labelled with 27 landmark points, including two corner points (at either end of the landmark sequence). Figures 2 and 3 illustrate the improved performance of the ASM/spline algorithm in detecting the left iliac crest. Edge detection is more accurate using the combined approach, particularly in maintaining the curvature of the crest. Of the fteen images tested, standard ASM and combined ASM/spline yielded similar acceptable results (as manually evaluated by the participating physician). Five images showed noticeably improved performance using the combined algorithm; in these ve cases, crest detection using standard ASM was deemed unacceptable. In the remaining two cases, both methods yielded unacceptable results. It is worth noting that the ve images where the combined algorithm clearly outperformed standard ASM showed considerable variation in contrast and brightness from the training image set. This suggests that the ability of splines to regulate

Fig. 2.

Detection of left ilium crest using standard ASM

Fig. 3. Detection of left ilium crest using combined ASM/spline algorithm

B. Detection of Pelvic Ring Similar to the iliac crest experiment, the training set of images for pelvic ring detection consisted of ve x-rays taken from male patients. In each image, the ring was labelled with 26 landmark points. Since the ring is both a closed shape and resembles an ellipse, no corner points were dened. Figures 4 and 5 illustrate the improved performance of the ASM/spline algorithm in detecting the pelvic ring. Of the fteen images tested, standard ASM and combined ASM/spline yielded similar acceptable results in ve. Seven images showed noticeably improved performance using the combined algorithm; this may be due to the increased overlapping of bones in the pelvic ring, as well as the presence of internal organs which lead to less clearly dened edges. In the remaining three cases, both methods yielded unacceptable results. Again, the combined algorithm performs well on images that show differences in constrast and brightness from the training set. It also preserves curvature well, despite the blurred edges present in some parts of the pelvic ring. Note that in Figure 4, standard ASM converges to the inner edge of the pubic bone; a common problem in pelvic ring detection which is avoided by the use of splines to constrain deformation.

B. Future Works Future work will involve testing the combined algorithm on a larger dataset, and obtaining statistical validation of improved performance. Other features which may improve detection will also be studied and used to control shape deformation. The algorithm will also be tested on other medical images containing curved structures, specically ultrasound scans which present similar segmentation challenges as x-ray images. V. ACKNOWLEDGMENTS This material is based upon work supported by the National Science Foundation under Grant No.IIS0758410.
Fig. 4. Detection of pelvic ring using standard ASM

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Fig. 5.

Detection of pelvic ring using combined ASM/spline algorithm

IV. CONCLUSIONS AND FUTURE WORKS A. Conclusions This paper presents a method to detect pelvic structures in x-ray images using a combined spline/ASM algorithm. Specically, spline function construction and interpolation is used to maintain the curvature of the target shape while still allowing sufcient deformation to match the shape to new images. The combined algorithm shows performance either equal to or exceeding standard ASM across the test image dataset. In particular, the combined approach performs well on images that show substantial variation in constrast, brightness and sharpness from the training dataset. After accurately detecting each structure, the appropriate regions can later be analyzed to detect particular types of fracture. The algorithm proposed in this paper will therefore be a valuable component of a larger modular system.

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