Devoted to diagnostic and interventional spine imaging and therapeutics


Accuracy of detecting pedicle screw loosening using plain X rays 2008

General Spine

Fras Dakhil-Jerew, MRCS,
John Shepperd, FRCS, Non ASSR Member

Scientific Paper


In this study, we report interobserver reliability of X-ray for the interpretation of pedicle screw osteointegration based on the diagnosis of "Halo zone" surrounding the screw.
Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome.

Methods & Materials

Lumbar spine X-ray images of 50 patients in two views (AP and lateral) randomly selected from our cohort of 420 Dynesys patients. The images were deployed in a CD-ROM. The authors were asked to review the images and state whether or not each pedicle screw is loose (total of 258 pedicle screws).
Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.
Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.


Kappa index for Pedicle screw loosening among 3 Experts was
0.2198 for 95% confidence interval and CI (-0.0520, 0.4916). KI for all of the seven assessers; 3 Experts & 4 Specialist Registrars, it was 0.1462 for CI (0.0332, 0.2592).


Kappa Index among expert assessors was 0.2 which means X-ray is unreliable for the assessment of pedicle screw osteointegration. Validity of X-ray is not applicable as it is unreliable.
We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.


No financial issues or conflict of interest to disclose.