Highlights
- •Systematic training and structured protocol are required to conduct measurement.
- •Complicated methods and intervertebral disc degeneration affected the inter-rater agreement on measurements.
- •Method 7 is the best reproducible method to measure disc height index for all intervertebral disc segmental levels with a good-to-excellent intra- and inter-rater reliability and agreement.
Abstract
Purpose
To evaluate intra- and inter-rater agreement and reliability of seven reported disc
height index (DHI) measurement methods on standing lateral X-ray of lumbar spine.
Methods
The adult patients who had standing lateral X-ray of lumbar spine were recruited.
Seven methods were used to measure DHI of each lumbar intervertebral disc level, including
a ratio of sum of anterior and posterior disc height (DH) to disc diameter (Method
1), a ratio of middle DH to mid-vertebral body height (Method 2), a ratio of middle
DH to disc diameter (Method 3), a ratio of the mean of anterior, middle, and posterior
DH to the sagittal diameter of the proximal vertebral body (Method 4), a ratio of
DH to vertebral height which cross the centre of adjacent vertebral bodies (Method
5), a ratio of the mean of anterior, middle, and posterior DH to the mean of proximal
and distal vertebral body height (Method 6), and a ratio of the sum of anterior and
posterior DH to the sum of superior and inferior disc depth (Method 7). Two raters
conducted the measurements (one medical student (SS) and the other an experienced
spine surgeon (XC)). Bland and Altmańs Limits of Agreement (LOA) with standard difference
were calculated to examine intra- and inter-rater agreements between two out of seven
methods for DHI. Intra-class correlations (ICC) with 95% confidence intervals were
calculated to assess intra- and inter-rater reliability.
Results
The intra-rater reliability in DHI measurements for 288 participants were ICCs from
0.807 (0.794, 0.812) to 0.922 (0.913, 0.946) by rater 1 (SS) and from 0.827 (0.802,
0.841) to 0.918 (0.806, 0.823) by rater 2 (XC). Method 2, 3, and 5 on all segmental
levels had bias (95 % CI does not include zero) or/and out of the acceptable cut-off
proportion (>50 %). A total of 609 outliers in 9174 segmental levels’ LOA range. Inter-rater
reliability was good-to-excellent in all but method 2 (0.736 (0.712, 0.759)) and method
5 (0.634 (0.598, 0.667)). ICCs of related lines to good-to-excellent reliability methods
was excellent in all but only indirect lines in method 1 and 4 (ICCs lie in the range
from 0.8 to 0.9).
Conclusion
Following a structured protocol, intra- and inter-rater reliability was good-to-excellent
for most DHI measurement methods on X-ray. However, the complicated methods (more
indirect lines) and IVD degeneration (nucleus pulposus degeneration and disc herniation)
potentially affected the agreement on inter-rater measurements. Method 7 is the best
reproducible method to measure disc height index for all intervertebral disc segmental
levels with a good-to-excellent intra- and inter-rater reliability and agreement.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Clinical NeuroscienceAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- What low back pain is and why we need to pay attention.The Lancet. 2018; 391: 2356-2367
- The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features.Spine (Phila Pa 1976). 2010; : 531-536
- Effect of aging and degeneration on disc volume and shape: A quantitative study in asymptomatic volunteers.J Orthop Res. 2006; 24: 1086-1094
- Magnetic resonance imaging in low back pain: general principles and clinical issues.Phys Ther. 1998; 78: 738-753
- Mechanical disorders of the low back.Lea & Febiger, Philadelphia1973
- Measurement of intervertebral disc space height.Spine (Philadelphia, Pa 1976). 1977; 2: 282-286
- Radiographic evaluation of the lumbosacral disc height.Skeletal Radiol. 1999; 28: 638-643
- Disc height and segmental motion as risk factors for recurrent lumbar disc herniation.Spine (Phila Pa 1976). 2009; 34: 2674-2678
- Intervertebral disc height loss demonstrates the threshold of major pathological changes during degeneration.Eur Spine J. 2015; 24: 1944-1950
- Risk factors for lumbar intervertebral disc height narrowing: a population-based longitudinal study in the elderly.BMC Musculoskelet Disord. 2015; 16: 344
- A method for quantitative measurement of lumbar intervertebral disc structures: an intra- and inter-rater agreement and reliability study.Chiropr Man Therap. 2013; 21: 26
- Validity and reliability of computerized measurement of lumbar intervertebral disc height and volume from magnetic resonance images.Spine J. 2014; 14: 2773-2781
- Novel Methods to Measure Height and Volume in Healthy and Degenerated Lumbar Discs in MRIs: A Reliability Assessment Study.Diagnostics (Basel). 2022; 12
- Statistical methods used to test for agreement of medical instruments measuring continuous variables in method comparison studies: a systematic review.PLoS ONE. 2012; 7: e37908
- Statistical methods for assessing agreement between two methods of clinical measurement.Int J Nurs Stud. 2010; 47: 931-936
- Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed.J Clin Epidemiol. 2011; 64: 96-106
- Statistical methods for assessing measurement error (reliability) in variables relevant to sports medicine.Sports Med. 1998; 26: 217-238
- Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects.J Bone Joint Surg Am. 2005; 87: 260-267
- MRI evaluation of lumbar disc degenerative disease.J Clin Diagn Res. 2015; 9 (TC04-9)
- Lumbar degenerative disc disease: current and future concepts of diagnosis and management.Adv Orthop. 2012; 2012970752
- The Pfirrmann classification of lumbar intervertebral disc degeneration: an independent inter- and intra-observer agreement assessment.Eur Spine J. 2016; 25: 2728-2733
- Schmorl's nodes: common, highly heritable, and related to lumbar disc disease.Arthritis Rheum. 2007; 57: 855-860
- Modic changes: a systematic review of the literature.Eur Spine J. 2008; 17: 1289-1299
- Early pattern of degenerative changes in individual components of intervertebral discs in stressed and nonstressed segments of lumbar spine: an in vivo magnetic resonance imaging study.Spine (Phila Pa 1976). 2014; 39: 1084-1090
- A guideline of selecting and reporting intraclass correlation coefficients for reliability research.J Chiropr Med. 2016; 15: 155-163
- The development of a quality appraisal tool for studies of diagnostic reliability (QAREL).J Clin Epidemiol. 2010; 63: 854-861
- Magnetic resonance imaging of the spine.J Am Acad Orthop Surg. 2009; 17: 22-30
- Inter- and intra-rater reliability for measurement of range of motion in joints included in three hypermobility assessment methods.BMC Musculoskelet Disord. 2018; 19: 376
- When to use agreement versus reliability measures.J Clin Epidemiol. 2006; 59: 1033-1039
- Radiographic measurement of the lumbar spine. A clinical and experimental study in man.Spine (Phila Pa 1976). 1985; 10: 236-241
Article info
Publication history
Accepted:
July 19,
2022
Received:
June 13,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
