Interobserver and Intraobserver Variability in the Identification of the Lenke Classification Lumbar Modifier in Adolescent Idiopathic Scoliosis

STUDY DESIGN Interobserver and intraobserver reliability study for the identification of the Lenke classification lumbar modifier by a panel of experts compared with a computer algorithm. OBJECTIVES To measure the variability of the Lenke classification lumbar modifier and determine if computer assistance using 3-dimensional spine models can improve the reliability of classification. SUMMARY OF BACKGROUND DATA The lumbar modifier has been proposed to subclassify Lenke scoliotic curve types into A, B, and C on the basis of the relationship between the central sacral vertical line (CSVL) and the apical lumbar vertebra. Landmarks for identification of the CSVL have not been clearly defined, and the reliability of the actual CSVL position and lumbar modifier selection have never been tested independently. Therefore, the value of the lumbar modifier for curve classification remains unknown. METHODS The preoperative radiographs of 68 patients with adolescent idiopathic scoliosis presenting a Lenke type 1 curve were measured manually twice by 6 members of the Scoliosis Research Society 3-dimensional classification committee at 6 months interval. Intraobserver and interobserver reliability was quantified using the percentage of agreement and kappa statistics. In addition, the lumbar curve of all subjects was reconstructed in 3-dimension using a stereoradiographic technique and was submitted to a computer algorithm to infer the lumbar modifier according to measurements from the pedicles. RESULTS Interobserver rates for the first trial showed a mean kappa value of 0.56. Second trial rates were higher with a mean kappa value of 0.64. Intraobserver rates were evaluated at a mean kappa value of 0.69. The computer algorithm was successful in identifying the lumbar curve type and was in agreement with the observers by a proportion up to 93%. CONCLUSIONS Agreement between and within observers for the Lenke lumbar modifier is only moderate to substantial with manual methods. Computer assistance with 3-dimensional models of the spine has the potential to decrease this variability.