Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
J Bone Joint Surg Am. 2013 May 15;95(10):e65. doi: 10.2106/JBJS.L.00824.
Anteroposterior, lateral, and right and left oblique lumbar spine radiographs are often a standard part of the evaluation of children who are clinically suspected of having spondylolysis. Recent concerns regarding radiation exposure and costs have brought the value of oblique radiographs into question. The purpose of the present study was to determine the diagnostic value of oblique views in the diagnosis of spondylolysis.
Radiographs of fifty adolescents with L5 spondylolysis without spondylolisthesis and fifty controls were retrospectively reviewed. All controls were confirmed not to have spondylolysis on the basis of computed tomographic scanning, magnetic resonance imaging, or bone scanning. Anteroposterior, lateral, and right and left oblique radiographs of the lumbar spine were arranged into two sets of slides: one showing four views (anteroposterior, lateral, right oblique, and left oblique) and one showing two views (anteroposterior and lateral only). The slides were randomly presented to four pediatric spine surgeons for diagnosis, with four-view slides being presented first, followed by two-view slides. The slides for twenty random patients were later reanalyzed in order to calculate of intra-rater agreement. A power analysis demonstrated that this study was adequately powered. Inter-rater and intra-rater agreement were assessed on the basis of the percentage of overall agreement and intraclass correlation coefficients (ICCs). PCXMC software was used to generate effective radiation doses. Study charges were determined from radiology billing data.
There was no significant difference in sensitivity and specificity between four-view and two-view radiographs in the diagnosis of spondylolysis. The sensitivity was 0.59 for two-view studies and 0.53 for four-view studies (p = 0.33). The specificity was 0.96 for two-view studies and 0.94 for four-view studies (p = 0.60). Inter-rater agreement, intra-rater agreement, and agreement with gold-standard ICC values were in the moderate range and also demonstrated no significant differences. Percent overall agreement was 78% for four-view studies and 82% for two-view studies. The radiation effective dose was 1.26 mSv for four-view studies and 0.72 mSv for two-view studies (difference, 0.54 mSv). The charge for four-view studies was $145 more than that for two-view studies.
There is no difference in sensitivity and specificity between four-view and two-view studies. Although oblique views have long been considered standard practice by some, our data could not identify a diagnostic benefit that might outweigh the additional cost and radiation exposure.
前后位、侧位以及右左斜位腰椎 X 光片通常是临床怀疑有脊椎裂患儿评估的标准部分。最近对辐射暴露和成本的担忧使斜位 X 光片的价值受到质疑。本研究的目的是确定斜位 X 光片在诊断脊椎裂中的诊断价值。
回顾性分析 50 例无脊椎滑脱的 L5 脊椎裂青少年和 50 例对照者的 X 光片。所有对照者均通过 CT 扫描、磁共振成像或骨扫描证实无脊椎裂。将腰椎前后位、侧位和右左斜位 X 光片排列成两组幻灯片：一组显示四幅图像（前后位、侧位、右斜位和左斜位），另一组显示两幅图像（仅前后位和侧位）。将四视图幻灯片首先呈现给四位儿科脊柱外科医生进行诊断，然后呈现两视图幻灯片。为了计算内部评估者之间的一致性，对随机的 20 名患者的幻灯片进行了重新分析。功效分析表明，本研究具有足够的功效。基于整体一致性百分比和组内相关系数（ICCs）评估评估者间和内部评估者之间的一致性。使用 PCXMC 软件生成有效辐射剂量。研究费用根据放射科计费数据确定。
在诊断脊椎裂方面，四视图和两视图 X 光片之间的敏感性和特异性均无显著差异。两视图研究的敏感性为 0.59，四视图研究的敏感性为 0.53（p=0.33）。两视图研究的特异性为 0.96，四视图研究的特异性为 0.94（p=0.60）。评估者间、内部评估者之间和与金标准 ICC 值的一致性处于中等范围，也无显著差异。四视图研究的总体一致性百分比为 78%，两视图研究的总体一致性百分比为 82%。四视图研究的有效辐射剂量为 1.26mSv，两视图研究的有效辐射剂量为 0.72mSv（差异为 0.54mSv）。四视图研究的费用比两视图研究多 145 美元。
四视图和两视图研究之间的敏感性和特异性没有差异。尽管斜位 X 光片一直被一些人认为是标准做法，但我们的数据无法确定可能超过额外成本和辐射暴露的诊断优势。
