Cross-validation of ultrasound imaging in adolescent idiopathic scoliosis

Steven de Reuver, Rob C. Brink, Yong Ping Zheng, Frederik J.A. Beek, René M. Castelein, Tin Yan Lee

Research output: Journal article publicationJournal articleAcademic researchpeer-review

8 Citations (Scopus)


Purpose: Adolescent idiopathic scoliosis (AIS) patients are exposed to 9–10 times more radiation and a fivefold increased lifetime cancer risk. Radiation-free imaging alternatives are needed. Ultrasound imaging of spinal curvature was shown to be accurate, however, systematically underestimating the Cobb angle. The purpose of this study is to create and cross-validate an equation that calculates the expected Cobb angle using ultrasound spinal measurements of AIS patients. Methods: Seventy AIS patients with upright radiography and spinal ultrasound were split randomly in a 4:1 ratio to the equation creation (n = 54) or validation (n = 16) group. Ultrasound angles based on the spinous processes shadows were measured automatically by the ultrasound system (Scolioscan, Telefield, Hong Kong). For thoracic and lumbar curves separately, the equation: expected Cobb angle = regression coefficient × ultrasound angle, was created and subsequently cross-validated in the validation group. Results: Linear regression analysis between ultrasound angles and radiographic Cobb angles (thoracic: R2 = 0.968, lumbar: R2 = 0.923, p < 0.001) in the creation group resulted in the equations: thoracic Cobb angle = 1.43 × ultrasound angle and lumbar Cobb angle = 1.23 × ultrasound angle. With these equations, expected Cobb angles in the validation group were calculated and showed an excellent correlation with the radiographic Cobb angles (thoracic: R2 = 0.959, lumbar: R2 = 0.936, p < 0.001). The mean absolute differences were 6.5°–7.3°. Bland–Altman plots showed good accuracy and no proportional bias. Conclusion: The equations from ultrasound measurements to Cobb angles were valid and accurate. This supports the implementation of ultrasound imaging, possibly leading to less frequent radiography and reducing ionizing radiation in AIS patients.

Original languageEnglish
Pages (from-to)628-633
Number of pages6
JournalEuropean Spine Journal
Issue number3
Publication statusPublished - Mar 2021


  • Adolescent idiopathic scoliosis
  • Cobb angle
  • Radiation-free alternative
  • Ultrasound imaging
  • Validation

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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