Does Community Spine X-Ray Misinterpretation Contribute to Delays in Treatment for Adolescent Idiopathic Scoliosis Patients?

BACKGROUND

A substantial proportion of adolescent idiopathic scoliosis (AIS) patients present late at initial visit. Before orthopaedic consultation, community radiology is frequently used. Results inform primary care physicians to determine when an orthopaedic referral is indicated and guide the triage decisions in tertiary care. The utility and accuracy of community spine radiology for AIS patients is suboptimal; however, its impact on timely presentation is unknown. This study quantifies the impact of inaccurate measurements of the major coronal curve by community radiologists on late AIS presentation.

METHODS

This is a retrospective review of AIS patients seen for initial consultation with community-acquired index imaging. Available index spine x-rays (n=119) were independently remeasured by 2 blinded raters. Agreement in measurements of the major coronal curve using the Cobb method between community radiology and spine specialists was computed, then compared with readings of the reference standard, which were 3-foot standing spine x-rays obtained at initial consultation. Logistic regression was used to estimate the odds of late presentation from the discrepancy in measurements of the major coronal curve between index and reference standard evaluation when images were obtained within 90 days (n=111). Late presentation was defined as those who were likely surgical candidates at initial consultation. Discrepancies were defined as differences in major coronal curve measurements >5 degrees between index and reference standard evaluation.

RESULTS

Discrepancies in measurements of the major coronal curve ranged from 6 to 29 degrees (mean=12 deg., SD=6 deg.). Over half (n=28, 56%) of these inaccuracies were differences of 10 degrees or more. Agreement in measurements of the major coronal curve on the index x-ray between community radiologists and spine specialists was moderate (ICC=0.78 95% CI: 0.66-0.86, SEM=6 deg.; ICC=0.74 95% CI: 0.65-0.81, SEM=7 deg.). Comparatively, agreement between spine specialists on both index image and reference standard was excellent (ICC=0.96, 95% CI: 0.89-0.98, SEM=3 deg.; ICC=0.97, 95% CI: 0.95-0.98, SEM=3 deg.). The proportion of AIS patients who presented late was 34%. The odds of late referral increased with inaccuracies in community measurements (OR=3.55, 95% CI: 1.91-6.59).

CONCLUSIONS

Inaccuracies in measurements of the major coronal curve by community radiology may impact timely AIS presentation, potentially increasing the number of avoidable spine surgeries due to missed opportunities for nonoperative treatment.

LEVEL OF EVIDENCE: Level III.