Inter- and intraobserver reliability of the vertebral, local and segmental kyphosis in 120 traumatic lumbar and thoracic burst fractures: evaluation in lateral X-rays and sagittal computed tomographies

Abstract

Evaluation of the kyphosis angle in thoracic and lumbar burst fractures is often used to indicate surgical procedures. The kyphosis angle could be measured as vertebral, segmental and local kyphosis according to the method of Cobb. The vertebral, segmental and local kyphosis according to the method of Cobb were measured at 120 lateral X-rays and sagittal computed tomographies of 60 thoracic and 60 lumbar burst fractures by 3 independent observers on 2 separate occasions. Osteoporotic fractures were excluded. The intra- and interobserver reliability of these angles in X-ray and computed tomogram, using the intra class correlation coefficient (ICC) were evaluated. Highest reproducibility showed the segmental kyphosis followed by the vertebral kyphosis. For thoracic fractures segmental kyphosis shows in X-ray “excellent” inter- and intraobserver reliabilities (ICC 0.826, 0.802) and for lumbar fractures “good” to “excellent” inter- and intraobserver reliabilities (ICC = 0.790, 0.803). In computed tomography, the segmental kyphosis showed “excellent” inter- and intraobserver reliabilities (ICC = 0.824, 0.801) for thoracic and “excellent” inter- and intraobserver reliabilities (ICC = 0.874, 0.835) for the lumbar fractures. Regarding both diagnostic work ups (X-ray and computed tomography), significant differences were evaluated in interobserver reliabilities for vertebral kyphosis measured in lumbar fracture X-rays (p = 0.035) and interobserver reliabilities for local kyphosis, measured in thoracic fracture X-rays (p = 0.010). Regarding both fracture localizations (thoracic and lumbar fractures), significant differences could only be evaluated in interobserver reliabilities for the local kyphosis measured in computed tomographies (p = 0.045) and in intraobserver reliabilities for the vertebral kyphosis measured in X-rays (p = 0.024). “Good” to “excellent” inter- and intraobserver reliabilities for vertebral, segmental and local kyphosis in X-ray make these angles to a helpful tool, indicating surgical procedures. For the practical use in lateral X-ray, we emphasize the determination of the segmental kyphosis, because of the highest reproducibility of this angle. “Good” to “excellent” inter- and intraobserver reliabilities for these three angles could also be evaluated in computed tomographies. Therefore, also in computed tomography, the use of these three angles seems to be generally possible. For a direct correlation of the results in lateral X-ray and in computed tomography, further studies should be needed.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    Bernhardt M, Bridwell KH (1989) Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and the thoracolumbar junction. Spine 14(7):717–721

    Article  CAS  PubMed  Google Scholar 

  2. 2.

    Böhler J (1972) Conservative treatment of thoracic and lumbar spinal fractures. Z Unfallmed Berufserkr 108:100–104

    Google Scholar 

  3. 3.

    Briggs AM, Wrigley TV, Tully EA, Adams PE, Greig AM, Bennell KL (2007) Radiographic measures of thoracic kyphosis in osteoporosis: Cobb and vertebral centroid angles. Skeletal Radiol 36:761–767

    Article  CAS  PubMed  Google Scholar 

  4. 4.

    Carman DL, Browne RH, Birch JG (1990) Measurement of scoliosis and kyphosis radiographs. J Bone Joint Surg 72-A:328–333

    Google Scholar 

  5. 5.

    Chan DP, Seng NK, Kaan KT (1993) Nonoperative treatment in burst fractures of the lumbar spine (L2–L5) without neurologic deficits. Spine 18:320–325

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    Cobb JR (1948) Outline for the study of scoliosis. American Academy of Orthopaedic Surgeons Instructional Course Lectures No. 5. JW Edwards, Ann Arbor, pp 261–275

    Google Scholar 

  7. 7.

    Cowell HR (1990) Radiographic measurements and clinical decisions. J Bone Joint Surg 72-A:319

    Google Scholar 

  8. 8.

    Dimar JR 2nd, Carreon LY, Labelle H, Djurasovic M, Weidenbaum M, Brown C, Roussouly P (2008) Intra- and inter-observer reliability of determining radiographic sagittal parameters of the spine and pelvis using a manual and a computer-assisted methods. Eur Spine J 17(10):1373–1379

    Article  PubMed  Google Scholar 

  9. 9.

    Eysel P, Hopf C, Füderer S (2001) Kyphotic deformities in fractures of the thoracolumbar spine. Orthopäde 30:955–964

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Farcy JPC, Weidenbaum M, Glassman SD (1990) Sagittal index in management of thoracolumbar burst fractures. Spine 15(9):958–965

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    Gebhard F, Schultheiss M (2008) Surgical treatment of fractures of the lumbar spine. In: Käfer W, Cakir B, Mattes T, Reichel H (eds) Orthopedic spine surgery. An instructional course book, chap 14. Steinkopf, Darmstadt, pp 129–136

    Google Scholar 

  12. 12.

    Gelb DE, Lawrence GL, Bridwell KH, Blanke K, McEnery KW (1995) An analysis of sagittal spinal alignment in 100 asyptomatic middle and older aged volunteers. Spine 20(12):1351–1358

    CAS  PubMed  Google Scholar 

  13. 13.

    Glayas P, Mac-Thiong JM, Parent S, de Guise JA, Labelle H (2009) Assessment of lumbosacral kyphosis in spondylolisthesis: a computer-assisted reliability study of six measurement techniques. Eur Spine J 18(2):212–217

    Article  Google Scholar 

  14. 14.

    Goultallier D, Louis R (1977) Therapeutic indications in unstable fractures of the spine. Rev Chir Orthop Reparatrice Appar Mot 63(5):475–481

    Google Scholar 

  15. 15.

    Gstoettner M, Sekyra K, Walochnik N, Winter P, Wachter R, Bach CM (2007) Inter- and intraobserver reliability assessment of the Cobb angle: manual versus digital measurement tools. Eur Spine J 16(10):1587–1592

    Article  PubMed  Google Scholar 

  16. 16.

    Harrison DE, Harrison DD, Cailliet R, Janik TJ, Holland B (2006) Radiographic analysis of lumbar lordosis. Centroid, Cobb, TRALL, and Harrison posterior tangent methods. Spine 26(11):E235–E242

    Article  Google Scholar 

  17. 17.

    Kaneda K, Abumi K, Fujiya M (1984) Burst fractures with neurologic deficits of the thoracolumbar–lumbar spine. Spine 9:788–795

    Article  CAS  PubMed  Google Scholar 

  18. 18.

    Koller H, Acosta F, Hempfing A, Rohrmüller D, Tauber M, Lederer S, Resch H, Zenner J, Klampfer H, Schwiger R, Bogner R, Hitzl W (2008) Long-term investigation of nonsurgical treatment for thoracolumbar and lumbar burst fractures: an outcome analysis in sight of spinopelvic balance. Eur Spine J 17:1073–1095

    Article  PubMed  Google Scholar 

  19. 19.

    Kuklo TR, Polly DW, Owens BD, Zeidman SM, Chang AS, Klemme WR (2001) Measurement of thoracic and lumbar burst fracture kyphosis. Spine 26(1):61–66

    Article  CAS  PubMed  Google Scholar 

  20. 20.

    Kuklo TR, Potter BK, O’Brien MF, Schroeder TM, Lenke LG, Polly DW Jr (2005) Spinal Deformity Study Group. Reliability analysis for digital adolescent idiopathic scoliosis measurements. J Spinal Discord Tech 18(2):152–159

    Article  Google Scholar 

  21. 21.

    Lee SW, Hong JT, Son BC, Sung JH, Kim IS, Park CK (2007) Analysis of accuracy of kyphotic angle measurement for vertebral osteoporotic compression fractures. J Clin Neurol 14:961–965

    Article  Google Scholar 

  22. 22.

    Mac-Thiong JM, Pinel-Giroux FM, de Guise JA, Labelle H (2007) Comparison between constrained and non-constrained Cobb techniques for the assessment of thoracic kyphosis and lumbar lordosis. Eur Spine J 16(9):1325–1331

    Article  PubMed  Google Scholar 

  23. 23.

    McAffee PC, Yuan HA, Ladda NA (1982) The unstable burst fracture. Spine 7:365–373

    Article  Google Scholar 

  24. 24.

    McLain RF, Sparling E, Benson DR (1993) Early failure of short-segment pedicle instrumentation for thoraco-lumbar fractures. J Bone Joint Surg Am 75:162–169

    CAS  PubMed  Google Scholar 

  25. 25.

    Morrissy RT, Goldsmith GS, Hall EC, Kehl D, Cowie GH (1990) Measurement of the Cobb angle on radiographs of patients who have scoliosis. Evaluation of intrinsic error. J Bone Joint Surg 72-A:320–327

    Google Scholar 

  26. 26.

    Pfeilschifter J et al (eds) (2006) Evidence based consensus guidelines for osteoporosis. Prophylaxis, diagnostic work-up and therapy for women at the menopause and men older than 60 years. Long version 2006. Insurance association of the German speaking sience communities of osteology (DVO). Schattauer, Stuttgart, pp 1–343

  27. 27.

    Polly DW, Kilkelly FX, McHale KA, Asplund LM, Mulligan M, Chang AS (1996) Measurement of lumbar lordosis. Evaluation of intraobserver, interobserver, and technique variability. Spine 21(13):1530–1536

    Article  PubMed  Google Scholar 

  28. 28.

    Seel EH, Verrill CL, Metha RL, Davies EM (2005) Measurement of fracture kyphosis with the Oxford Cobbometer. Intra- and interobserver reliabilities and comparison with other techniques. Spine 30(8):964–968

    Article  PubMed  Google Scholar 

  29. 29.

    Silber JS, Lipetz JS, Hayes VM, Lonner BS (2004) Measurement variability in the assessment of sagittal alignment of the cervical spine: a comparison of the gore and the Cobb methods. J Spinal Discord Tech 17(4):301–305

    Article  Google Scholar 

  30. 30.

    Stagnara P, Mauroy CD, Gonon GP, Costanzo G, Dimmet J, Pasquet A (1982) Reciprocal Angulation of vertebral bodies in a sagittal plane: approach to references for the evaluation of kyphosis and lordosis. Spine 7(4):335–342

    Article  CAS  PubMed  Google Scholar 

  31. 31.

    Street J, Lenehan B, Albietz J, Bishop P, Dvorak M, Fisher C (2009) Intraobserver and interobserver reliability of measures of kyphosis in thoracolumbar fractures. Spine 9:464–469

    Article  Google Scholar 

  32. 32.

    Stotts AK, Smith JT, Santora SD, Roach JW, Roach JW, D`Astous JL (2002) Measurement of the spinal kyphosis: implications for the management of Scheuermann’s kyphosis. Spine 27(19):2143–2146

    Article  PubMed  Google Scholar 

  33. 33.

    Tallroth K, Ylikoski M, Landtman M, Santavirta S (1994) Reliability of radiological measurements of spondylolisthesis and extension-flexion radiographs of the lumbar spine. Eur J Radiol 18(3):227–231

    Article  CAS  PubMed  Google Scholar 

  34. 34.

    Trojan E (1972) Langfristige Ergebnisse von 200 Wirbelbrüchen der Brust/Lendenwirbelsäule ohne Lähmung. Z Unfallmed Berufserkr 2:122–134

    Google Scholar 

  35. 35.

    Zhang J, Lou E, Le LH, Hill D, Raso J, Wang Y (2008) Computer-assisted Cobb angle measurement on posterior radiographs. Stud Health Technol Inform 140:151–156

    CAS  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Benjamin Ulmar.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Ulmar, B., Brunner, A., Gühring, M. et al. Inter- and intraobserver reliability of the vertebral, local and segmental kyphosis in 120 traumatic lumbar and thoracic burst fractures: evaluation in lateral X-rays and sagittal computed tomographies. Eur Spine J 19, 558–566 (2010). https://doi.org/10.1007/s00586-009-1231-2

Download citation

Keywords

  • Spine
  • Fracture
  • Kyphosis
  • Cobb angle
  • Intra- and interobserver reliability