title: Interobserver reproducibility of criteria for vertebral body exclusion.
abstract: We studied reproducibility of the ISCD vertebral exclusion criteria among four interpreters. Surprisingly, agreement among interpreters was only moderate, because of differences in threshold for diagnosing focal structural defects and choice of which vertebra among a pair discordant for T-score, area, or BMC to exclude. Our results suggest that reproducibility may be improved by specifically addressing the sources of interobserver disagreement.
  
  
  BACKGROUND
  Although DXA is widely used to measure vertebral BMD, its interpretation is subject to multiple confounders including osteoarthritis, aortic calcification, and scoliosis. In an attempt to standardize interpretation and minimize the impact of artifacts, the International Society for Clinical Densitometry (ISCD) established criteria for vertebral exclusion, including the presence of a focal structural defect (FSD), discrepancy of >1 SD in T-score between adjacent vertebrae, and a lack of increase in BMC or area from L1 to L4. Whereas the efforts of the ISCD represent an important advance in BMD interpretation, the interobserver reproducibility with application of these criteria is unknown. We hypothesized that there would be substantial agreement among four interpreters regarding application of the exclusion criteria and the final lumbar spine T-score.
  
  
  METHODS
  Each interpreter read a set of 200 lumbar DXA scans obtained on male veterans, applying the ISCD vertebral body exclusion criteria.
  
  
  RESULTS
  Surprisingly, agreement among interpreters was only moderate. Differences in interpretation resulted from differing thresholds for recognition of FSD and the choice of excluding the upper or lower vertebral body for the criteria requiring comparison between adjacent vertebrae.
  
  
  CONCLUSIONS
  Despite their apparent simplicity, the ISCD vertebral exclusion criteria are difficult to apply consistently. In principle, appropriate refinement of the exclusion criteria may significantly improve interobserver agreement.
authors.affiliation: Rheumatology Section, Department of Medicine, University of Wisconsin, William S. Middleton Veterans Hospital, Madison, Wisconsin, USA. keh@medicine.wisc.edu
authors.forename: Karen E
authors.initials: KE
authors.lastname: Hansen
authors.forename: Neil
authors.initials: N
authors.lastname: Binkley
authors.forename: Rose
authors.initials: R
authors.lastname: Christian
authors.forename: Nellie
authors.initials: N
authors.lastname: Vallarta-Ast
authors.forename: Diane
authors.initials: D
authors.lastname: Krueger
authors.forename: Marc K
authors.initials: MK
authors.lastname: Drezner
authors.forename: Robert D
authors.initials: RD
authors.lastname: Blank
mesh_terms: D015502:Absorptiometry, Photon / Q000592:standards; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015519:Bone Density; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010024:Osteoporosis / Q000175:diagnosis*; D013131:Spine / Q000000981:diagnostic imaging*