Please use this identifier to cite or link to this item: http://hdl.handle.net/10397/91275
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Title: 3D ultrasound imaging provides reliable angle measurement with validity comparable to X-ray in patients with adolescent idiopathic scoliosis
Authors: Lee, TTY 
Lai, KKL 
Cheng, JCY
Castelein, RM
Lam, TP
Zheng, YP 
Issue Date: Jul-2021
Source: Journal of orthopaedic translation, July 2021, v. 29, p. 51-59
Abstract: Background & Objective: The application of ultrasound imaging for spine evaluation could minimize radiation exposure for patients with adolescence idiopathic scoliosis (AIS). A customized three-dimensional (3D) ultrasound imaging system has been demonstrated to provide reliable and valid coronal curvature measurements. However, these measurements were using the spinous processes as anatomical reference, leading to a predictable underestimation of the traditionally used Cobb angles. An alternative 3D ultrasound image reconstruction method was applied to create coronal images with more lateral features for angle measurement. The objective of this study was to test the reliability and the validity of this angle, the ultrasound curve angle (UCA), and compare the UCA with the Cobb angles on X-ray images of patients with AIS.
Materials and methods: This study was divided into: 1) Investigation of intra- and inter-reliability between two raters for measuring the UCA and two operators for acquiring ultrasound images; 2) Investigation of the validity between the radiographic Cobb angle and the UCA. Fifty patients and 164 patients with AIS, were included in the two stages, respectively. Patients underwent bi-planar X-ray and 3D ultrasound scanning on the same day. The proposed UCA was used to measure the coronal curvature from the ultrasound coronal images, which were formed using a newly customized volume projection imaging (VPI) method. The intra-rater/operator and inter-rater and operator reliability of the UCA were tested by intra-class correlation coefficient (ICC) (3,1) and (2,1), respectively. The validity of UCA measurements as compared to radiographic Cobb angles was tested by inter-method ICC (2,1), mean absolute difference (MAD), standard error of measurement (SEM), Pearson correlation coefficient and Bland–Altman statistics. The level of significance was set as 0.05.
Results: Excellent intra-rater and intra-operator (ICC (3,1)≥0.973) and excellent inter-rater and inter-operator reliability (ICC (2,1)≥0.925) for UCA measurement, with overall MAD and SEM no more than 3.5° and 1.7° were demonstrated for both main thoracic and (thoraco)lumbar curvatures. Very good correlations were observed between UCA and Cobb angle for main thoracic (R2=0.893) and (thoraco)lumbar (R2=0.884) curves. The mean (SD) measurements in terms of radiographic Cobb and UCA were 27.2 ​± ​11.6° and 26.3 ​± ​11.4° for main thoracic curves; and 26.2 ​± ​11.4° and 24.8 ​± ​9.7° for (thoraco)lumbar curve respectively. One hundred sixty-four subjects (33 male and 131 female subjects; 11–18 years of age, mean of 15.1 ​± ​1.9 years) were included for the validity session. Excellent inter-method variations (ICC (2,K) ≥0.933) with overall MAD and SEM no more than 3.0° and 1.5° were demonstrated for both main thoracic and (thoraco)lumbar curvatures. In addition, Bland–Altman plots demonstrated an acceptable agreement between ultrasound and radiographic Cobb measurements.
Conclusion: In this study, very good correlations and agreement were demonstrated between the ultrasound and X-ray measurements of the scoliotic curvature. Judging from the promising results of this study, patients with AIS with different severity of curves can be evaluated and monitored by ultrasound imaging, reducing the usage of radiation during follow-ups. This method could also be used for scoliosis screening. The Translational potential of this article: Ultrasound curve angle (UCA) obtained from 3D ultrasound imaging system can provide reliable and valid evaluation on coronal curvature for patients with AIS, without the need of radiation.
Keywords: Curve angles
Reliability
Scoliosis
Three-dimensional ultrasound imaging
Validity
Publisher: Elsevier
Journal: Journal of orthopaedic translation 
ISSN: 2214-031X
DOI: 10.1016/j.jot.2021.04.007
Rights: © 2021 The Authors. Published by Elsevier (Singapore) Pte Ltd on behalf of Chinese Speaking Orthopaedic Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
The following publication Lee, T. T. Y., Lai, K. K. L., Cheng, J. C. Y., Castelein, R. M., Lam, T. P., & Zheng, Y. P. (2021). 3D ultrasound imaging provides reliable angle measurement with validity comparable to X-ray in patients with adolescent idiopathic scoliosis. Journal of Orthopaedic Translation, 29, 51-59 is available at https://doi.org/10.1016/j.jot.2021.04.007
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