Observer reliability between juvenile and adolescent idiopathic scoliosis in measurement of stable Cobb's angle

A Novel Classification of Juvenile and Adolescent Idiopathic Scoliosis for Conservative Treatment

BACKGROUND

The operative classification of scoliosis is well-developed but inadequate for guiding conservative treatment. The current conservative classification for juvenile and adolescent idiopathic scoliosis (JAIS) exhibits noticeable deficiencies. This study aimed to establish the Peking Union Medical College Hospital (PUMCH) classification and assess its clinical value in the conservative treatment of JAIS.

METHODS

This study consisted of 2 parts. First, it involved a retrospective analysis of patients treated for JAIS in the Department of Rehabilitation Medicine, the ∗∗∗ Union Medical College Hospital, between January 2013 and June 2020. Second, it involved an ambispective cohort study that enrolled patients with JAIS in the above hospital between July and December 2020.

RESULTS

A total of 989 patients with JAIS were enrolled, with 899 patients for establishing the PUMCH classification and 90 patients with JAIS for validating the PUMCH classification. The classification demonstrated an average reliability of 88.22% with a kappa coefficient of 0.862. After 1 week, the remeasured results presented a mean reproducibility of 92.78% and a kappa coefficient of 0.908. After 1-year follow-up, the Cobb angle decreased significantly from 16.61 ± 2.88° to 12.16°± 9.97° (P = 0.002) in 51 patients with PUMCH-scoliosis-specific exercise (SSE) treatment, while the Cobb angle increased significantly from 15.74 ± 2.75° to 17.64 ± 5.60° (P = 0.014) in 39 patients without PUMCH-SSE treatment.

CONCLUSIONS

The PUMCH-SSE classification demonstrates good inter-observer reliability and intra-observer reproducibility. In addition, the classification may be used to guide the conservative treatment of JAIS in clinical settings.

Spino-pelvic radiological parameters: Comparison of measurements obtained by radiologists using the traditional method versus spine surgeons using a semi-automated software (Surgimap)

Background

Spinopelvic balance measurement is a key point to get an appropriate diagnosis and treatment in a group of spine pathologies; thus, it seems necessary the evaluation of different methods for obtaining the most reliable values. For that reason, different automatic and semi-automatic computer-assisted tools have been developed, and one example of them is Surgimap.

Purpose

To demonstrate that the sagittal balance measurements with Surgimap are equal and more time-efficient than with Agfa-Enterprise.

Material and Methods

Retrospective-prospective study. Biased comparative analysis of radiographic measurements performed on two different occasions (96 h interval), between two spine surgeons using Surgimap and two radiologists using the traditional Cobb method (TCM) with the Agfa-Enterprise program in 36 full spine lateral X-ray, determining inter- and intra-observer reliability and the mean time required to obtain the measurements.

Results

Measurements with both methods demonstrated an excellent intra-observer correlation (Surgimap: PCC 0.95 [0.85-0.99]; TCM: PCC 0.90 [0.81-0.99]). Inter-observer correlation also demonstrated an excellent relationship (PCC >0.95). Thoracic kyphosis (TK) demonstrated the lowest levels of inter-observer correlation (PCC: 0.75). The average time in seconds with TCM was 154.6, while with the Surgimap it was 41.8 s.

Conclusion

Surgimap proved to be equally reliable and 3.5 times faster. Therefore, in consistency with the available literature, our results would allow us to promote the use of Surgimap as a clinical diagnostic tool considering precision and efficiency.

Computerized image understanding system for reliable estimation of spinal curvature in idiopathic scoliosis

Analysis of scoliosis requires thorough radiographic evaluation by spinal curvature estimation to completely assess the spinal deformity. Spinal curvature estimation gives orthopaedic surgeons an idea of severity of spinal deformity for therapeutic purposes. Manual intervention has always been an issue to ensure accuracy and repeatability. Computer assisted systems are semi-automatic and is still influenced by surgeon’s expertise. Spinal curvature estimation completely relies on accurate identification of required end vertebrae like superior end-vertebra, inferior end-vertebra and apical vertebra. In the present work, automatic extraction of spinal information central sacral line and medial axis by computerized image understanding system has been proposed. The inter-observer variability in the anatomical landmark identification is quantified using Kappa statistic. The resultant Kappa value computed between proposed algorithm and observer lies in the range 0.7 and 0.9, which shows good accuracy. Identification of the required end vertebra is automated by the extracted spinal information. Difference in inter and intra-observer variability for the state of the art computer assisted and proposed system are quantified in terms of mean absolute difference for the various types (Type-I, Type-II, Type-III, Type-IV, and Type-V) of scoliosis.

Comparison of spinal curvature parameters as determined by the ZEBRIS spine examination method and the Cobb method in children with scoliosis

BACKGROUND AND PURPOSE

The most common and gold standard method to diagnose and follow-up on scoliosis treatment is to capture biplanar X-ray images and then use these to determine the sagittal frontal spinal curvature angles by the Cobb method. Reducing exposure to radiation is an important aspect for consideration, especially regarding children. The ZEBRIS spinal examination method is an external, non-invasive measurement method that uses an ultrasound-based motion analysis system. The aim of this study is to compare angle values of patients with adolescent idiopathic scoliosis (AIS) determined by the ZEBRIS spine examination method with the angle values defined by the gold standard Cobb method on biplanar X-ray images.

METHODS

Subjects included 19 children with AIS (mean age 14.5±2.1 years, range 8-16 years, frontal plane thoracic Cobb angle 19.95±10.23°, thoracolumbar/lumbar angle 16.57±10.23°). The thoracic kyphosis and lumbar lordosis in the sagittal plane and the thoracic and lumbar scoliosis values were calculated by the Cobb method on biplanar X-ray images. The sagittal frontal spinal curvature angles were calculated from the position of the processus spinosus of 19 vertebrae, as determined by the ZEBRIS spine examination method. The validity of the ZEBRIS spine examination method was evaluated with Bland-Altman analyses between the sagittal and frontal spinal curvature parameters calculated from data determined by the ZEBRIS spine examination method and data obtained by the Cobb method on the X-ray images.

RESULTS AND DISCUSSION

Thoracic spinal curvature angles in sagittal and in frontal planes can be measured with sufficient accuracy. The slopes of the linear regression lines for thoracic kyphosis (TK) and thoracic scoliosis (TSC) are close to one (1.00 and 0.79 respectively), and the intercept values are below 5 degrees. The correlation between the TK and TSC values determined by the two methods is significant (p = 0.000) and excellent (rTK = 0.95, rTSC = 0.85). The differences are in the limit of agreement. The lumbar lordosis (LL) in the sagittal plane shows a very good correlation (rLL = 0.76); however the differences between the angles determined by the two methods are out of the limit of agreement in patients with major lumbar lordosis (LL≥50°). The thoracolumbar/lumbar spinal curvature angles in the frontal plane determined by ZEBRIS spine examination were underestimated at curvatures larger than 15°, mainly due to the rotational and pathological deformities of the scoliotic vertebrae. However, the correlation between lumbar scoliosis (LSC) values determined by the two methods is significant (p = 0.000) and excellent (rLSC = 0.84), the slopes are below one (0.71), the intercept values are below 5 degrees, and the differences between the angles determined by the two methods are within the limits of agreement. We could conclude that ZEBRIS spinal examination is a valid and reliable method for determination of sagittal and frontal curvatures during the treatment of patients with scoliosis. However, it cannot replace the biplanar X-ray examination for the visualization of spinal curvatures in the sagittal and frontal planes and the rotation of vertebral bodies during the diagnosis and annual evaluation of the progression.

Relationship between thoracic kyphosis and neural axis abnormalities in patients with adolescent idiopathic scoliosis

PURPOSE

Previous studies have suggested an association between increased thoracic kyphosis and neural axis abnormalities in patients with adolescent idiopathic scoliosis (AIS). However, the basis for this finding is unclear, and this association has been mainly noted in retrospective studies on a non-consecutive series of patients. The purpose of this study was to assess the relationship between thoracic kyphosis and neural axis abnormalities in patients with AIS.

METHODS

We studied a consecutive series of AIS patients treated with spinal fusion. Thoracic kyphosis (T2 to T12) was measured from preoperative lateral radiographs. All patients underwent a spine magnetic resonance imaging (MRI) prior to surgery, and MRI reports were reviewed to determine the presence of neural axis abnormalities. Statistical analyses included descriptive statistics and chi-squared analysis.

RESULTS

This study included 210 patients with AIS. There were no significant differences in age or gender between patients with thoracic hypokyphosis (kyphosis < 20°), normal thoracic kyphosis (kyphosis 20° to 40°) and thoracic hyperkyphosis (kyphosis > 40°) (p > 0.05). Neural axis abnormalities were present in 17.9% of patients with thoracic hypokyphosis, 9.8% of patients with normal thoracic kyphosis and 13.6% of patients with thoracic hyperkyphosis (p = 0.60). There were no significant differences in rates of Chiari malformation, syrinx, intra-spinal masses and other central nervous system abnormalities between groups (p > 0.05).

CONCLUSIONS

Thoracic kyphosis was not associated with neural axis abnormalities in our consecutive series of patients with AIS. Increased thoracic kyphosis may not be a reliable indicator for the presence of neural axis abnormalities in patients with AIS.

LEVEL OF EVIDENCE

IV.

COMPARISON OF COBB ANGLE MEASUREMENT IN SCOLIOSIS BY RESIDENTS AND SPINE EXPERTS

ABSTRACT Objective: The adolescent idiopathic scoliosis (AIS) is a spine deformity that occurs in both the coronal plane and the sagittal plane of patients between 10 and 17 years. The Cobb method is the most widely used to determine the angular value of scoliosis and it is defined as the "gold standard". The goal is to verify the reproducibility of the measured angles between orthopedic residents and spinal pathologies specialists, comparing the variability of the angles measured by professionals with greater and lesser experience. Method: A total of 10 radiographs of patients diagnosed with AIS were assessed. Radiographs were handed over to 7 orthopedists specialized in spine and 14 orthopedic residents. The measurement of the angles for each of the examiners was described using means and standard deviations and intraclass correlations were calculated, as well as the measure of repeatability, and Bland-Altman plots were designed with the results of the measurements of each group of examiners, according to experience, to assess the agreement/reproducibility of Cobb angle measurements. Results: Each examiner obtained a resulting average of 10 cases summation. In order to assess trends in variability of the measurements of the angles of each group graphs were plotted based on the arithmetic mean of each of the 10 cases by the total number of participants in the group versus the standard deviation in each case. Conclusion: There was a poor correlation (ICC=0.4) in the measurement of Cobb in both groups, demonstrating difficulties in the method, which cannot be overcome by the expertise.

Reliability and reproducibility analysis of the Cobb angle and assessing sagittal plane by computer-assisted and manual measurement tools

Background

Although many studies on reliability and reproducibility of measurement have been performed on coronal Cobb angle, few results about reliability and reproducibility are reported on sagittal alignment measurement including the pelvis. We usually use SurgimapSpine software to measure the Cobb angle in our studies; however, there are no reports till date on its reliability and reproducible measurements.

Methods

Sixty-eight standard standing posteroanterior whole-spine radiographs were reviewed. Three examiners carried out the measurements independently under the settings of manual measurement on X-ray radiographies and SurgimapSpine software on the computer. Parameters measured included pelvic incidence, sacral slope, pelvic tilt, Lumbar lordosis (LL), thoracic kyphosis, and coronal Cobb angle. SPSS 16.0 software was used for statistical analyses. The means, standard deviations, intraclass and interclass correlation coefficient (ICC), and 95% confidence intervals (CI) were calculated.

Results

There was no notable difference between the two tools (P = 0.21) for the coronal Cobb angle. In the sagittal plane parameters, the ICC of intraobserver reliability for the manual measures varied from 0.65 (T2–T5 angle) to 0.95 (LL angle). Further, for SurgimapSpine tool, the ICC ranged from 0.75 to 0.98. No significant difference in intraobserver reliability was found between the two measurements (P > 0.05). As for the interobserver reliability, measurements with SurgimapSpine tool had better ICC (0.71 to 0.98 vs 0.59 to 0.96) and Pearson’s coefficient (0.76 to 0.99 vs 0.60 to 0.97). The reliability of SurgimapSpine measures was significantly higher in all parameters except for the coronal Cobb angle where the difference was not significant (P > 0.05).

Conclusion

Although the differences between the two methods are very small, the results of this study indicate that the SurgimapSpine measurement is an equivalent measuring tool to the traditional manual in coronal Cobb angle, but is advantageous in spino-pelvic measurement in T2-T5, PT, PI, SS, and LL.

The effectiveness of the Pilates method: reducing the degree of non-structural scoliosis, and improving flexibility and pain in female college students

OBJECTIVE

To evaluate the effectiveness of Pilates with regard to the degree of scoliosis, flexibility and pain.

METHOD

The study included 31 female students divided into two groups: a control group (CG = 11), which had no therapeutic intervention, and an experimental group (EG = 20), which underwent Pilates-based therapy. We used radiological goniometry measurements to assess the degree of scoliosis, standard goniometry measurements to determine the degree of flexibility and the scale of perceived pain using the Borg CR 10 to quantify the level of pain.

RESULTS

The independent t test of the Cobb angle (t = - 2.317, p = 0.028), range of motion of trunk flexion (t = 3.088, p = 0.004) and pain (t = -2.478, p = 0.019) showed significant differences between the groups, with best values in the Pilates group. The dependent t test detected a significant decrease in the Cobb angle (Δ% = 38%, t = 6.115, p = 0.0001), a significant increase in trunk flexion (Δ% = 80%, t = -7.977, p = 0.0001) and a significant reduction in pain (Δ% = 60%, t = 7.102, p = 0.0001) in the EG. No significant difference in Cobb angle (t = 0.430, p = 0.676), trunk flexion, (t = 0.938p = 0.371) or pain (t = 0.896, p = 0.391) was found for the CG.

CONCLUSION

The Pilates group was better than control group. The Pilates method showed a reduction in the degree of non-structural scoliosis, increased flexibility and decreased pain.

To what degree is digital imaging reliable? Validation of femoral neck shaft angle measurement in the era of picture archiving and communication systems

OBJECTIVES

This study investigates the reliability of femoral neck shaft angle (NSA) measurements made with the software and images available in routine clinical practice.

METHODS

Using the Centricity Enterprise™ (GE Healthcare Pty Ltd Piscataway, NJ) picture archiving and communication system (PACS), the NSA of the proximal femur was measured from anteroposterior radiographs of adult hips. 3 independent observers, using a standardised technique, performed a total of 120 measurements.

RESULTS

The Pearson's correlation coefficient for the intraobserver agreement was 0.98 (p<0.01) and for interobserver measurements 0.86 (p<0.01). Bland-Altman plots revealed the limits of intraobserver agreement to be ±2.5°, but interobserver limits of agreement to be ±6°. The intraclass correlation coefficient (ICC) was also calculated. The interobserver ICC was 0.62 (0.42-0.78, 95% confidence interval (CI); p<0.001). The intraobserver ICC was 0.98 (0.95-0.99, 95% CI; p<0.001).

CONCLUSION

PACS software has many advantages, but when using systems that can display angle measurements to one-tenth of a degree caution must be exercised to ensure that reliability of these measurements is not overestimated. We found that in the context of measuring the NSA of the proximal femur the reliability of the measurement, even under the best conditions, is only ±6° for different observers.

Automatic quantification of spinal curvature in scoliotic radiograph using image processing

Choosing the most suitable treatment for the scoliosis relies heavily on accurate and reproducible spinal curvature measurement from radiographs. Our objective is to reduce the variability in spinal curvature measurement by reducing the user intervention and bias. In order to determine the reliability of the spinal curvature measurement as it is in the clinical measurement of scoliosis a methodological survey has been carried out that concludes with inter and intra observer error variation. The proposed method list out horizontal inclination of all the vertebrae's in terms of slopes using active contour models and morphological operators. This facilitates the radiologist to decide end vertebrae and hence inter/intra observer variation is completely eliminated. Tables 1 and 2 shows the observer error variation between manual and proposed methods in terms of mean and standard deviation.

A comparison of thoracolumbosacral orthoses and SpineCor treatment of adolescent idiopathic scoliosis patients using the Scoliosis Research Society standardized criteria

BACKGROUND

SpineCor is a relatively new bracing system that uses dynamic bracing concepts in the treatment of adolescent idiopathic scoliosis (AIS). Limited data are available regarding its effectiveness. This study compared treatment outcomes of 2 groups of AIS patients treated via either a conventional rigid thoracolumbosacral orthoses (TLSO) or a SpineCor nonrigid orthosis.

METHODS

We identified 2 scoliosis patient cohorts: 35 patients treated with a TLSO and 32 patients treated with a SpineCor orthosis. All patients included in these groups conformed with the Scoliosis Research Society (SRS) standardized criteria for AIS bracing: (1) Risser < or =2, (2) curve magnitude 25 to 40 degrees, (3) age > or =10 years. Outcomes were SRS standardized with failure being defined as curve progression > or =6 degrees, or ever exceeding 45 degrees, or having surgery recommended before skeletal maturity. All patients were followed through the completion of brace treatment or attainment of other treatment end points. The Yates corrected chi test and unpaired t test were used for data analysis.

RESULTS

The 35 patients (32 girls, 3 boys) in the TLSO group had an average age of 13 years (range: 11.1-16.8) and an average primary curve magnitude of 33 degrees (range: 25-40 degrees). Follow-up averaged 2 years (range: 8-61 m) from the beginning of brace treatment. The 32 patients (28 girls, 4 boys) in the SpineCor group had an average age of 13 years (range: 11-15.2) and an average primary curve magnitude of 31 degrees (range: 25-40 degrees). Follow-up for this group averaged 2 years and 6 months (range: 13-73 mo) from the beginning of brace treatment. No significant difference (P=0.75) was found using the more strict outcome measure (< or =5-degree curve progression) as the success rates were 60% (21/35) for TLSO and 53% (17/32) for SpineCor. Similarly, no significant difference (P=0.62) was found using the more liberal outcome measure (never reached 45 degrees) as the success rates were 80% (28/35) for TLSO and 72% (23/32) for SpineCor.

CONCLUSIONS

We were unable to identify any significant differences in brace treatment outcomes when comparing TLSO and SpineCor treated patients.

Reversal of childhood idiopathic scoliosis in an adult, without surgery: a case report and literature review

BACKGROUND

Some patients with mild or moderate thoracic scoliosis (Cobb angle <50-60 degrees) suffer disproportionate impairment of pulmonary function associated with deformities in the sagittal plane and reduced flexibility of the spine and chest cage. Long-term improvement in the clinical signs and symptoms of childhood onset scoliosis in an adult, without surgical intervention, has not been documented previously.

CASE PRESENTATION

A diagnosis of thoracic scoliosis (Cobb angle 45 degrees) with pectus excavatum and thoracic hypokyphosis in a female patient (DOB 9/17/52) was made in June 1964. Immediate spinal fusion was strongly recommended, but the patient elected a daily home exercise program taught during a 6-week period of training by a physical therapist. This regime was carried out through 1992, with daily aerobic exercise added in 1974. The Cobb angle of the primary thoracic curvature remained unchanged. Ongoing clinical symptoms included dyspnea at rest and recurrent respiratory infections. A period of multimodal treatment with clinical monitoring and treatment by an osteopathic physician was initiated when the patient was 40 years old. This included deep tissue massage (1992-1996); outpatient psychological therapy (1992-1993); a daily home exercise program focused on mobilization of the chest wall (1992-2005); and manipulative medicine (1994-1995, 1999-2000). Progressive improvement in chest wall excursion, increased thoracic kyphosis, and resolution of long-standing respiratory symptoms occurred concomitant with a >10 degree decrease in Cobb angle magnitude of the primary thoracic curvature.

CONCLUSION

This report documents improved chest wall function and resolution of respiratory symptoms in response to nonsurgical approaches in an adult female, diagnosed at age eleven years with idiopathic scoliosis.