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
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Article info
Publication history
Accepted:
July 19,
2022
Received:
June 13,
2022
Identification
Copyright
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