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Measuring procedures to determine the Cobb angle in idiopathic scoliosis: a systematic review

European Spine Journal volume 22, pages 2360–2371 (2013)Cite this article

Abstract

Background

Scoliosis of the vertebral column can be assessed with the Cobb angle (Cobb 1948). This examination is performed manually by measuring the angle on radiographs and is considered the gold standard. However, studies evaluating the reproducibility of this procedure have shown high variability in intra- and inter-observer agreement. Because of technical advancements, interests in new procedures to determine the Cobb angle has been renewed. This review aims to systematically investigate the reproducibility of various new techniques to determine the Cobb angle in idiopathic scoliosis and to assess whether new technical procedures are reasonable alternatives when compared to manual measurement of the Cobb angle.

Method

Systematic review. Studies examining procedures used to determine the Cobb angle were selected. Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias. Statistical results of reliability and agreement were summarised and described.

Results

Eleven studies of new measuring procedures were included, all reporting the reproducibility. The new procedures can be divided into computer-assisted procedures, automatic procedures and smartphone apps.

Conclusions

All investigated measuring procedures showed high degrees of reliability. In general, digital procedures tend to be slightly better than manual ones. For all other measurement procedures (automatic or smartphone), results varied. Studies implementing vertebral pre-selection and observer training achieved better agreement.

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Abbreviations

D2L, D4L, D6L:

Digital two, four or six landmarks

DH:

Digital horizontal

A:

Automatic

S:

Smartphone

ICC:

Intraclass Correlation

R:

Correlation Coefficient

QUADAS:

Quality Assessment of Diagnostic Accuracy Studies

QAREL:

Quality Appraisal of Reliability Studies

NA:

Not assessed

SD:

Standard Deviation

SEM:

Standard Error of Measurement

MAD:

Mean Absolute Difference

CI:

Confidence Interval

References

  1. Cobb JR (1948) Outline for the study of scoliosis. Am Acad Orthop Surg Instr Course Lect 5:261–275

    Google Scholar 

  2. Romano M, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Kotwicki T, Maier-Hennes A, Negrini S (2012) Exercises for adolescent idiopathic scoliosis. Cochrane Database Syst Rev 8:CD007837. doi:10.1002/14651858.CD007837.pub2

    PubMed  Google Scholar 

  3. Negrini S, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Grivas TB, Kotwicki T, Maruyama T, Romano M, Vasiliadis ES (2010) Braces for idiopathic scoliosis in adolescents. Spine (Phila Pa 1976) 35(13):1285–1293. doi:10.1097/BRS.0b013e3181dc48f4

    Google Scholar 

  4. 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 Am 72(3):320–327

    PubMed  CAS  Google Scholar 

  5. Carman DL, Browne RH, Birch JG (1990) Measurement of scoliosis and kyphosis radiographs. Intraobserver and interobserver variation. J Bone Joint Surg Am 72(3):328–333

    PubMed  CAS  Google Scholar 

  6. Srinivasalu S, Modi HN, Smehta S, Suh SW, Chen T, Murun T (2008) Cobb angle measurement of scoliosis using computer measurement of digitally acquired radiographs-intraobserver and interobserver variability. Asian Spine J 2(2):90–93. doi:10.4184/asj.2008.2.2.90

    PubMed  Article  CAS  Google Scholar 

  7. Corona J, Sanders JO, Luhmann SJ, Diab M, Vitale MG (2012) Reliability of radiographic measures for infantile idiopathic scoliosis. J Bone Joint Surg Am 94(12):e861–e868. doi:10.2106/JBJS.K.00311

    Google Scholar 

  8. Jones JK, Krow A, Hariharan S, Weekes L (2008) Measuring angles on digitalized radiographic images using Microsoft PowerPoint. West Indian Med J 57(1):14–19

    PubMed  CAS  Google Scholar 

  9. Tanure MC, Pinheiro AP, Oliveira AS (2010) Reliability assessment of Cobb angle measurements using manual and digital methods. Spine J 10(9):769–774. doi:10.1016/j.spinee.2010.02.020

    PubMed  Article  Google Scholar 

  10. Shea KG, Stevens PM, Nelson M, Smith JT, Masters KS, Yandow S (1998) A comparison of manual versus computer-assisted radiographic measurement. Intraobserver measurement variability for Cobb angles. Spine (Phila Pa 1976) 23(5):551–555

    Article  CAS  Google Scholar 

  11. Cheung J, Wever DJ, Veldhuizen AG, Klein JP, Verdonck B, Nijlunsing R, Cool JC, Van Horn JR (2002) The reliability of quantitative analysis on digital images of the scoliotic spine. Eur Spine J 11(6):535–542. doi:10.1007/s00586-001-0381-7

    PubMed  Article  Google Scholar 

  12. Chockalingam N, Dangerfield PH, Giakas G, Cochrane T, Dorgan JC (2002) Computer-assisted Cobb measurement of scoliosis. Eur Spine J 11(4):353–357. doi:10.1007/s00586-002-0386-x

    PubMed  Article  Google Scholar 

  13. Allen S, Parent E, Khorasani M, Hill DL, Lou E, Raso JV (2008) Validity and reliability of active shape models for the estimation of cobb angle in patients with adolescent idiopathic scoliosis. J Digit Imaging 21(2):208–218. doi:10.1007/s10278-007-9026-7

    PubMed  Article  Google Scholar 

  14. Zhang J, Lou E, Hill DL, Raso JV, Wang Y, Le LH, Shi X (2010) Computer-aided assessment of scoliosis on posteroanterior radiographs. Med Biol Eng Comput 48(2):185–195. doi:10.1007/s11517-009-0556-7

    PubMed  Article  Google Scholar 

  15. Shaw M, Adam CJ, Izatt MT, Licina P, Askin GN (2012) Use of the iPhone for Cobb angle measurement in scoliosis. Eur Spine J 21(6):1062–1068. doi:10.1007/s00586-011-2059-0

    PubMed  Article  Google Scholar 

  16. Qiao J, Liu Z, Xu L, Wu T, Zheng X, Zhu Z, Zhu F, Qian B, Qiu Y (2012) Reliability analysis of a smartphone-aided measurement method for the Cobb angle of scoliosis. J Spinal Disord Tech 25(4):E88–E92. doi:10.1097/BSD.0b013e3182463964

    PubMed  Article  Google Scholar 

  17. de Vet HC, Terwee CB, Knol DL, Bouter LM (2006) When to use agreement versus reliability measures. J Clin Epidemiol 59(10):1033–1039. doi:10.1016/j.jclinepi.2005.10.015

    PubMed  Article  Google Scholar 

  18. Bartlett JW, Frost C (2008) Reliability, repeatability and reproducibility: analysis of measurement errors in continuous variables. Ultrasound Obstet Gynecol 31(4):466–475. doi:10.1002/uog.5256

    PubMed  Article  CAS  Google Scholar 

  19. Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86(2):420–428

    PubMed  Article  CAS  Google Scholar 

  20. Streiner DL, Norman GR (2008) Health measurement scales a practical guide to their development and use, vol 4. Oxford University Press, Oxford

    Google Scholar 

  21. Whiting P, Rutjes AW, Dinnes J, Reitsma J, Bossuyt PM, Kleijnen J (2004) Development and validation of methods for assessing the quality of diagnostic accuracy studies. Health Technol Assess 8(25):1–234 (pii: 98-27-99)

    Google Scholar 

  22. Lucas NP, Macaskill P, Irwig L, Bogduk N (2010) The development of a quality appraisal tool for studies of diagnostic reliability (QAREL). J Clin Epidemiol 63(8):854–861. doi:10.1016/j.jclinepi.2009.10.002

    PubMed  Article  Google Scholar 

  23. Zhang J, Lou E, Le LH, Hill DL, Raso JV, Wang Y (2009) Automatic Cobb measurement of scoliosis based on fuzzy Hough transform with vertebral shape prior. J Digit Imaging 22(5):463–472. doi:10.1007/s10278-008-9127-y

    PubMed  Article  Google Scholar 

  24. Zhang J, Lou E, Shi X, Wang Y, Hill DL, Raso JV, Le LH, Lv L (2010) A computer-aided Cobb angle measurement method and its reliability. J Spinal Disord Tech 23(6):383–387. doi:10.1097/BSD.0b013e3181bb9a3c

    PubMed  Article  Google Scholar 

  25. Goldberg MS, Poitras B, Mayo NE, Labelle H, Bourassa R, Cloutier R (1988) Observer variation in assessing spinal curvature and skeletal development in adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 13(12):1371–1377

    Article  CAS  Google Scholar 

  26. Lonstein JE, Carlson JM (1984) The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am 66(7):1061–1071

    PubMed  CAS  Google Scholar 

  27. Pruijs JE, Hageman MA, Keessen W, van der Meer R, van Wieringen JC (1994) Variation in Cobb angle measurements in scoliosis. Skeletal Radiol 23(7):517–520

    PubMed  Article  CAS  Google Scholar 

  28. Bland JM, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1(8476):307–310

    PubMed  Article  CAS  Google Scholar 

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Conflict of interest

None.

Author information

Affiliations

  1. Unireha, Paediatric Rehabilitation, University of Cologne, Lindenburger Allee 44, 50931, Cologne, Germany

    S. Langensiepen

  2. Children’s Hospital, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany

    O. Semler, O. Fricke & E. Schönau

  3. Center for Orthopaedic and Trauma Surgery, Department of Orthopaedics, Medizinisches Zentrum StädteRegion Aachen, Mauerfeldchen 25, 52146, Würselen, Germany

    R. Sobottke

  4. Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany

    J. Franklin

  5. Department of Orthopaedic and Trauma Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany

    P. Eysel

Authors
  1. S. Langensiepen
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  2. O. Semler
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  3. R. Sobottke
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  4. O. Fricke
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  5. J. Franklin
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  6. E. Schönau
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  7. P. Eysel
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Correspondence to S. Langensiepen.

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Langensiepen, S., Semler, O., Sobottke, R. et al. Measuring procedures to determine the Cobb angle in idiopathic scoliosis: a systematic review. Eur Spine J 22, 2360–2371 (2013). https://doi.org/10.1007/s00586-013-2693-9

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  • DOI: https://doi.org/10.1007/s00586-013-2693-9

Keywords

  • Cobb angle
  • Idiopathic scoliosis
  • Systematic review
  • Reproducibility
  • Measuring methods
  • Computer-assisted measuring