INTEROBSERVER AND INTRAOBSERVER RELIABILITY OF PELVIC INCIDENCE AS A PREDICTOR IN PROGRESSION OF SPONDYLOLISTHESIS

Abstract

The aim was to evaluate the Intraobserver and Interobserver reliability of Pelvic Incidence as a fundamental parameter of sagittal spino-pelvic balance in patients with spondylolisthesis compared to controls with Idiopathic Adolescent Scoliosis.

A blinded test retest study including multi-surgeon assessment of Pelvic Incidence in patients with spondylolisthesis and Idiopathic Adolescent Scoliosis was carried out. We assessed the agreement between the pelvic incidence measurements using the Bland and Altman method and mean differences (95% confidence interval) are reported.

Forty patients seen at Starship Children’s Hospital between 1992 – 2003 by two spinal surgeons were retrospectively identified. The main group had 20 patients with spondylolisthesis (Isthmic and/or Dysplastic types) and the control group consisted of 20 patients with Idiopathic Adolescent Scoliosis. Five observers with different levels of experience included the two orthopaedic surgeons, one fellow, one senior trainee and one non-trainee registrar. Prior to the initial test phase, a consensus-building session was carried out. All five observers arrived at a standardised method for measuring the Pelvic Incidence. In the test phase randomly ordered lateral lumbosacral radiographs were independently evaluated by the five observers and pelvic incidence was measured. Assessment of the Pelvic Incidence was repeated one week later in the re-test phase. The radiographs were presented in a randomly pre-assigned order. Bland and Altman plots were constructed and mean differences (95% confidence interval) reported to evaluate the agreement between the Pelvic Incidence measurements among the five independent observers. All analysis was performed on the statistical software package SAS. P-value of 0.05 was considered statistically significant.

The spondylolisthesis group had 11 (55%) males and 9 (45%) females with an average age of 14 ± 4.2. 2 patients had high-grade (Meyerding Class III, IV, V) and 16 had low-grade (Meyerding Class I, II) spondylolisthesis. 2 patients were post-reduction of spondylolisthesis. In the Scoliosis group there were 2 (10%) males and 18 (90%) females with an average age of 15 ± 2.9. There was no significant difference between male and females pelvic incidence measurement (60° ± 18.7° vs. 57° ± 14.6°, p=0.540) or age (15 ± 2.9 vs. 14 ± 3.8, p=0.181). There was no difference in pelvic incidence across the Meyerding groups, p=0.257. There was a significant difference between spondylolisthesis and scoliosis pelvic incidence measurements 65° ± 15.6° vs. 51° ± 12.8°, p=0.003. In the Spondylolisthesis Group the interobserver reliability between five clinicians, expressed as the mean difference in pelvic incidence measurement was 0.6° (95%CI −0.81, 1.91) and was not significantly different from zero p=0.423. The agreement limits were from −12.8° to 13.9°. The intraobserver reliability of pelvic incidence showed the mean difference ranging from −2.1° to 1.4° (p=0.129 and 0.333 with 95% CI). One had marginal evidence of a significant difference of 3.3° (95% CI 0.05° to 6.55°, p=0.047). In the Scoliosis Group the interobserver reliability was 0.3° (95% CI −0.81, 1.49) and was not significantly different from zero p=0.726. The agreement limits were from −11.0° to 11.6°. The intraobserver reliability among four observers ranged from −1.7° to 0.5° (p=0.178 and 0.661). One had a significant difference in readings of 4.1° (95% CI of 0.70° to 7.40°, p= 0.020).

Scoliosis patients had a significantly smaller pelvic incidence than spondylolisthesis patients. The interobserver reliability of the pelvic incidence measurement was excellent across both groups. The intraobserver reliability was good with only one observer in each group demonstrating a marginally significant difference. Pelvic incidence is therefore a reliable measurement which can be used as a predictor in progression of spondylolisthesis.