title: Do oblique views add value in the diagnosis of spondylolysis in adolescents?
abstract: BACKGROUND
  Anteroposterior, lateral, and right and left oblique lumbar spine radiographs are often a standard part of the evaluation of children who are clinically suspected of having spondylolysis. Recent concerns regarding radiation exposure and costs have brought the value of oblique radiographs into question. The purpose of the present study was to determine the diagnostic value of oblique views in the diagnosis of spondylolysis.
  
  
  METHODS
  Radiographs of fifty adolescents with L5 spondylolysis without spondylolisthesis and fifty controls were retrospectively reviewed. All controls were confirmed not to have spondylolysis on the basis of computed tomographic scanning, magnetic resonance imaging, or bone scanning. Anteroposterior, lateral, and right and left oblique radiographs of the lumbar spine were arranged into two sets of slides: one showing four views (anteroposterior, lateral, right oblique, and left oblique) and one showing two views (anteroposterior and lateral only). The slides were randomly presented to four pediatric spine surgeons for diagnosis, with four-view slides being presented first, followed by two-view slides. The slides for twenty random patients were later reanalyzed in order to calculate of intra-rater agreement. A power analysis demonstrated that this study was adequately powered. Inter-rater and intra-rater agreement were assessed on the basis of the percentage of overall agreement and intraclass correlation coefficients (ICCs). PCXMC software was used to generate effective radiation doses. Study charges were determined from radiology billing data.
  
  
  RESULTS
  There was no significant difference in sensitivity and specificity between four-view and two-view radiographs in the diagnosis of spondylolysis. The sensitivity was 0.59 for two-view studies and 0.53 for four-view studies (p = 0.33). The specificity was 0.96 for two-view studies and 0.94 for four-view studies (p = 0.60). Inter-rater agreement, intra-rater agreement, and agreement with gold-standard ICC values were in the moderate range and also demonstrated no significant differences. Percent overall agreement was 78% for four-view studies and 82% for two-view studies. The radiation effective dose was 1.26 mSv for four-view studies and 0.72 mSv for two-view studies (difference, 0.54 mSv). The charge for four-view studies was $145 more than that for two-view studies.
  
  
  CONCLUSIONS
  There is no difference in sensitivity and specificity between four-view and two-view studies. Although oblique views have long been considered standard practice by some, our data could not identify a diagnostic benefit that might outweigh the additional cost and radiation exposure.
authors.affiliation: Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
authors.forename: Nicholas A
authors.initials: NA
authors.lastname: Beck
authors.forename: Robert
authors.initials: R
authors.lastname: Miller
authors.forename: Keith
authors.initials: K
authors.lastname: Baldwin
authors.forename: X
authors.initials: X
authors.lastname: Zhu
authors.forename: David
authors.initials: D
authors.lastname: Spiegel
authors.forename: Denis
authors.initials: D
authors.lastname: Drummond
authors.forename: Wudbhav N
authors.initials: WN
authors.lastname: Sankar
authors.forename: John M
authors.initials: JM
authors.lastname: Flynn
mesh_terms: D000293:Adolescent; D016022:Case-Control Studies; D015331:Cohort Studies; D017721:Hospital Costs; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging*; D015588:Observer Variation; D015143:Philadelphia; D011829:Radiation Dosage; D011859:Radiography; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013169:Spondylolysis / Q000000981:diagnostic imaging* / Q000191:economics