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Improved accuracy in Risser sign grading with lateral spinal radiography

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Abstract

Development of the ossification of the iliac crest is used to assess the remaining spinal growth. The clinical value of the Risser sign has been questioned because of its inaccuracy in grades 3 and 4. Estimation of the Risser sign based on the lateral spinal radiograph has not been reported. The aim of the study was to evaluate the course of ossification of the iliac apophysis along its full extension and to investigate relevance of the lateral spinal radiograph for more accurate Risser sign grading. Cross sectional analysis of spinal frontal and lateral long cassette standing spinal radiographs of 201 girls aged from 10.2 to 20.0 years were done. On the lateral spinal view, the ossification of the posterior part of the iliac apophysis was quantified at four grades: absent (A), partial (B), complete (C) or fused (D). The position of the posterior superior iliac spine was studied on both views as well as in pelvic specimens. The results showed that the posterior one-third portion of the iliac apophysis was sagittally oriented and obscured on the frontal radiograph by the sacroiliac junction. It could be studied on the lateral radiograph and revealed a different grading of the apophysis excursion in 58 of 201 (29%) patients, comparing to the frontal view. Both advanced or delayed ossification was observed and assessed with Lateral Risser Modifiers. Twenty-five percent of the patients at Risser 0 or 1 or 2 demonstrated a simultaneous ossification of the most anterior and the most posterior part of the iliac crest. The Risser grades of capping or fusion could be more precisely diagnosed using lateral radiograph in complement to the frontal one. The conclusions drawn from this study were: (1) Currently used Risser sign grading does not consider the actual excursion of the iliac apophysis, because one-third of the apophysis cannot be observed on the frontal radiograph. (2) Iliac apophysis full excursion or fusion can be more accurately estimated when the lateral spinal radiograph is analyzed with Lateral Risser Modifiers.

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Acknowledgments

To Prof. J. Piontek for availability of pelvic specimens. To Dr. M. Walczak, Dr. M. Idzior and Dr. M. Tomaszewski for participation in the inter-observer study. To Prof. M. Hawes and Mr. J. O’Brien for substantial and language assistance.

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  1. Department of Pediatric Orthopedics and Traumatology, Klinika Ortopedii Dzieciecej, University of Medical Sciences, Ul. 28 Czerwca 1956 roku nr 135, 61-545, Poznan, Poland

    Tomasz Kotwicki

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Correspondence to Tomasz Kotwicki.

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586_2008_794_MOESM1_ESM.tif

Fig. 1 PSIS on the top view (left) and lateral view (right) of the pelvis specimen. The position of the posterior superior iliac spine is marked as PSIS while the position apparently taken for the PSIS on standard frontal radiograph is marked as aPSIS. In this case the distance from PSIS to aPSIS covers 28% of the total length of the iliac crest. This part can be seen on the lateral radiograph exclusively (TIFF 1413 kb)

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Fig. 2 White arrow indicates the apparent location of the PSIS reproduced in figures in orthopedic manuals. Red-and-white arrow indicates the actual location of the PSIS. Red line indicates the portion of the iliac apophysis which can be studied on the standard AP or PA radiograph. Green line indicates the portion of the iliac apophysis which cannot be studied on standard AP or PA radiographs but can be seen on lateral radiograph (TIFF 680 kb)

Fig. 3 Risser sign staging according to A.A. DeSmet: Radiology of spinal curvatures. Mosby 1985: page 45(TIFF 203 kb)

Fig. 4 Risser sign staging according to M. Tachdjian: Pediatric Orthopedics. Saunders 1990, page 2290 (TIFF 319 kb)

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Fig. 5 Risser sign staging according to A.G. Martinez-Lozano: Embriology, Growth and Maturation [in:] Weinstein (ed.) The Pediatric Spine. Principles and Practice. Raven Press 1994, page 1864 (TIFF 390 kb)

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Fig. 6 D CT reconstruction of the pelvis exposed in Boston Museum of Science. aPSIS indicates the point taken for posterior iliac spine on the frontal radiograph. PSIS indicates the actual posterior superior iliac spine. max. indicates posterior maximum of the thickness of the iliac crest (TIFF 1175 kb)

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Fig. 7 CT scan passing through the anterior and posterior iliac spines demonstrates non-fused iliac apophysis. The PSIS is situated at the level of S1 vertebra (TIFF 657 kb)

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Kotwicki, T. Improved accuracy in Risser sign grading with lateral spinal radiography. Eur Spine J 17, 1676–1685 (2008). https://doi.org/10.1007/s00586-008-0794-7

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