Radiographic Resource Utilization in the Initial Referral and Evaluation of Patients With Adolescent Idiopathic Scoliosis

How well do we assess the adequacy of bending films in scoliosis?

Aims

To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so.

Methods

Six surgeons and eight radiographers were invited to participate in four online surveys. The generic survey comprised erect and left and right bending radiographs of eight individuals with scoliosis, with an average age of 14.6 years. Respondents were asked to indicate whether each bending film was optimal (adequate) or suboptimal. In the first survey, they were also asked if they currently assessed the adequacy of bending films. A similar second survey was sent out two weeks later, using the same eight cases but in a different order. In the third survey, a guide for assessing bending film adequacy was attached along with the radiographs to introduce the novel T1-45B method, in which the upper endplate of T1 must tilt ≥ 45° from baseline for the study to be considered optimal. A fourth and final survey was subsequently conducted for confirmation.

Results

Overall, 12 (86%) of 14 respondents did not use any criteria to assess the bending film adequacy; the remaining two each described a different invalidated method. In total, 12 (86%) of the respondents felt T1-45B was easy to learn and apply. There was fair to substantial intra-rater reliability (k = 0.25 to 0.88) which improved to fair to almost perfect (k = 0.38 to 0.88) post-introduction of the guide. Inter-rater reliability varied considerably among the rater groups but similarly increased following introduction of the guide (kS1 = 0.19 to 0.34, kS2 = 0.33 to 0.43 vs kS3 = 0.49 to 0.5, kS4 = 0.35 to 0.43).

Conclusion

Many surgeons and radiographers do not assess spinal bending films for adequacy. We propose that the change in the plane of the upper endplate of T1 on side-bending can be used in this evaluation. In the T1-45B method, a change of ≥ 45° on side bending qualifies as an adequate bend effort.

How useful is pre-referral pediatric spine imaging?

PURPOSE

Primary care physicians rely on radiology reports to confirm a scoliosis diagnosis and inform the need for spine specialist referral. In turn, spine specialists use these reports for triage decisions and planning of care. The objectives were to determine (1) the adequacy of index images to inform treatment decisions at the initial consultation and (2) the utility of index radiology reports for appropriate triage decisions.

METHODS

A retrospective chart review was conducted including all idiopathic scoliosis patients seen for initial consultation, aged three to 18 years, between January 1 and April 30, 2021. A score out of five was generated based on the adequacy of index images to provide accurate Cobb angle measurements and determine skeletal maturity. Index images were considered inadequate if repeat imaging was necessary. Index radiology reports, associated imaging, and new imaging, if obtained at the initial consultation, were compared.

RESULTS

Of the 94 patients reviewed, 79% (n = 74) required repeat imaging at the initial consultation, of which 74% (n = 55) were due to insufficient quality and/or limited field of view. Of index images available for review at the initial consult (n = 80), 41.2% scored five out of five, and 32.5% scored two or below. Comparing index radiology reports to initial visit evaluation with ≤ 60 days between imaging (n = 49), discrepancies in Cobb angle were found in 24.5% (95% CI 14.6, 38.1) of patients. The Risser stage was reported in 14% of index radiology reports.

CONCLUSION

Although pre-referral pediatric spine radiographs serve a diagnostic purpose, most are inadequate for comprehensive idiopathic scoliosis evaluation.

LEVEL OF EVIDENCE

III.

Adolescent Idiopathic Scoliosis for Pediatric Providers

Adolescent idiopathic scoliosis occurs in 2% to 3% of the adolescent population, affecting people between ages 10 and 16 years. Scoliosis onset is usually earlier in girls than in boys-generally occurring between ages 10 and 14 years for girls and 12 and 16 years for boys. The cause of idiopathic scoliosis is unknown. It is probably multifactorial. Much of the research on the etiology has focused on connective tissue abnormalities, nutritional deficiency, and genetic factors. [Pediatr Ann. 2022;51(9):e364-e369.].

Microdose protocol stereoradiography has similar reliability to standard low-dose protocol during concurrent Sanders skeletal maturity staging

PURPOSE

Decreasing radiation exposure is important for scoliosis patients who require serial imaging. Microdose protocol stereoradiography is now increasingly utilized. Previous studies have reported similar reliability of concurrent Sanders skeletal maturity staging based on standard low-dose stereoradiography and standard hand radiographs. The purpose of our study was to investigate the reliability and radiation exposure of concurrent Sanders staging using microdose protocol compared to a standard protocol for adolescent idiopathic scoliosis. We hypothesized that surgeon-performed Sanders staging would have similar reliability when comparing microdose and standard-dose imaging protocols.

METHODS

A randomized survey of 30 hand images using standard protocol spinal stereoradiography and an equal number from microdose protocol were distributed to six experienced pediatric orthopaedic spine surgeons. Images were graded by each surgeon according to the Sanders skeletal maturity grading system. Items were again randomized and graded after a 2-week interval. Fleiss' weighted kappa for inter and intraobserver reliability was calculated and an unpaired t test was used to test for significance.

RESULTS

Interobserver reliability for all modalities was in the strong to almost perfect agreement (average weighted κ > 0.8) range. For the microdose protocol, κ was 0.82 and 0.84 for each separate round of grading. Standard low-dose protocol κ was 0.83 and 0.79. Intraobserver κ was 0.86 for microdose and 0.82 for standard. Average radiation for microdose was significantly less radiation (82.6%) than standard stereoradiography (0.3 ± 0.1 mGy vs. 1.9 ± 0.4 mGy, p < 0.001).

CONCLUSIONS

Sanders staging reliability of a well-positioned hand during scoliosis stereoradiography was similarly excellent for both microdose and standard low-dose protocol. Microdose protocol used less radiation while still preserving the reliability of Sanders staging.