title: The "shadow sign":  a radiographic differentiation of stainless steel versus titanium spinal instrumentation in spine surgery.
abstract: BACKGROUND
  Stainless steel spinal instrumentation has been supplanted in recent years by titanium instrumentation. Knowing whether stainless steel or titanium was used in a previous surgery can guide clinical decision making processes, but frequently the clinician has no way to know what type of metal was used. We describe the radiographic "shadow sign," in which superimposed titanium rods and screws remain radiolucent enough that the contour of the underlying components can be seen on a lateral radiograph, whereas superimposed stainless steel rods and screws are completely radiopaque. This technique was evaluated using a retrospective, randomized, and blinded radiographic comparison of titanium and stainless steel spinal instrumentation. The objective was to determine whether the "shadow sign" can reliably differentiate titanium from stainless steel spinal instrumentation.
  
  
  METHODS
  Lateral radiographs from 16 cases of posterior spinal instrumentation (6 titanium, 6 stainless steel, and 2 replicates of each to assess intraobserver reliability) were randomly selected from a database of cases performed for pediatric scoliosis in a university setting from 2005 to 2009. The cases were randomized then shown to 19 orthopaedic surgery residents, 1 spine fellow, and 2 spine attendings. After the "shadow sign" was described, the surgeons were asked to determine what type of metal each implant was made of.
  
  
  RESULTS
  The κ value for both stainless steel and titanium versus the gold standard was 0.83 [standard error (SE) = 0.053], indicating excellent agreement. The κ value for agreement between raters was 0.71 (SE = 0.016) and the κ value for agreement within raters was 0.70 (SE = 0.016), both of which indicated substantial agreement.
  
  
  CONCLUSIONS
  The "shadow sign" can help a clinician differentiate titanium from stainless steel spinal instrumentation based on radiographic appearance alone. Furthermore, our study reveals that the level of experience in diagnosing spinal lateral radiographs also enhances the use of the "shadow sign" indicator.
  
  
  METHODS
  The method proposed to differentiate titanium from stainless steel falls within the diagnostic studies domain. As unaltered randomization was used to enroll radiographs and the procedure was systematic, this study may be classified in the Level II category.
authors.affiliation: Orthopaedic Surgery, University of Virginia, Charlottesville, VA 22903, USA.
authors.forename: Sean M
authors.initials: SM
authors.lastname: Jones-Quaidoo
authors.forename: Wendy
authors.initials: W
authors.lastname: Novicoff
authors.forename: Andrew
authors.initials: A
authors.lastname: Park
authors.forename: Vincent
authors.initials: V
authors.lastname: Arlet
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D016268:Internal Fixators; D008297:Male; D015203:Reproducibility of Results; D012600:Scoliosis / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000601:surgery*; D013123:Spinal Fusion / Q000295:instrumentation*; D013193:Stainless Steel / Q000145:classification; D014025:Titanium / Q000145:classification; D014057:Tomography, X-Ray Computed
chemical_list: D013193:Stainless Steel; D014025:Titanium