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C OPYRIGHT Ó 2013 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Do Oblique Views Add Value in the Diagnosis

of Spondylolysis in Adolescents?
Nicholas A. Beck, BS, Robert Miller, BS, Keith Baldwin, MD, MSTP, MPH, X. Zhu, MS, David Spiegel, MD,
Denis Drummond, MD, Wudbhav N. Sankar, MD, and John M. Flynn, MD

Investigation performed at The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

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 ret-
rospectively 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 dem-
onstrated 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 sig-
nificant 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.
Level of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

L
ow back pain is common in adolescents and young
adults, with approximately 35% of patients experi-
encing these symptoms at some point in their life1.
While the most common cause of low back pain in adoles-
cents is muscular, many of these patients experience pain
secondary to a diagnosable abnormality2,3. Spondylolysis is of
particular importance because it represents the most com-
mon radiographically identifiable cause of low back pain in
adolescents between the ages of ten and eighteen years2.
Spondylolysis has an incidence of 4% to 8% in the general

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.

J Bone Joint Surg Am. 2013;95:e65(1-7) d http://dx.doi.org/10.2106/JBJS.L.00824

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TABLE I Summary of Test Characteristics for Radiographic Studies
Two-View*
Kappa 0.59 (0.41 to 0.67)
Accuracy 0.82 (0.73 to 0.85)
Sensitivity 0.59 (0.49 to 0.64)
Specificity 0.96 (0.89 to 0.99)
Positive predictive 0.91 (0.74 to 0.97)
value
Negative predictive 0.78 (0.70 to 0.81)
value
*The values in parentheses represent the 95% confidence interval.
pediatric population and represents a stress fracture of the
pars interarticularis4.
Imaging of the pars interarticularis is particularly diffi-
cult because of the oblique orientation of this structure5,6.
Previous studies have shown that the single best view for
identifying spondylolysis is the collimated lateral view; how-
ever, approximately 20% of pars defects can only be seen on
oblique views7,8. As result, the use of left oblique and right
oblique radiographs for the diagnosis of spondylolysis has long
been standard practice as the dogma is that they allow for better
visualization of the pars3,9-11.
This dogma has come into question in recent years with
the growing interest in limiting radiation exposure in patients,
particularly in children, whose cells are more sensitive to the
mutagenic effects of radiation12 and who have a higher lifetime
accumulation. It is predicted that 1.5% and 2% of future
cancers will be due to radiation from medical studies13. Radio-
graphs of the lumbar spine also expose the pelvis to radiation,
posing a risk to the pelvic bone marrow and intrapelvic organs.
The purpose of the present study was to evaluate the diagnostic
value of oblique radiographs in the diagnosis of spondylolysis
in adolescents and to contrast that value with the increased cost
and radiation exposure.
Materials and Methods
Radiographic Review
A fter institutional review board approval, we conducted a retrospective
cohort study of patients with back pain who were managed at our tertiary
care children’s hospital. The inclusion criteria were an age of ten to nineteen
years and a four-view lumbosacral radiographic study for the workup of back
pain. The exclusion criteria included a history of previous back surgery or
major trauma, spondylolisthesis, spondylolysis at a level other than L5, and
poor-quality radiographs. We searched our radiology database for patients who
were evaluated with the following radiographic studies: four-view, lumbosacral
computed tomographic scanning (CT), lumbar magnetic resonance imaging
(MRI), and bone scanning from January 1, 2000 to January 1, 2008. Addi-
tionally, we searched our outpatient billing database to identify patients with an
ICD-9 (International Classification of Diseases, Ninth Revision) code consis-
tent with back pain and spondylolysis over the same dates.
These lists were cross-referenced to generate two cohorts: patients
with a positive radiographic diagnosis of spondylolysis (spondylolysis group)
D O O B L I Q U E V I E W S A D D VA L U E I N T H E D I A G N O S I S
O F S P O N D Y L O LY S I S I N A D O L E S C E N T S ?
Four-View* P Value
0.51 (0.31 to 0.61) 0.43
0.78 (0.69 to 0.83) 0.40
0.53 (0.42 to 0.59) 0.33
0.94 (0.87 to 0.98) 0.60
0.85 (0.67 to 0.94) 0.53
0.76 (0.70 to 0.79) 0.75
and patients with a negative radiographic diagnosis of spondylolysis (control
group). Advanced imaging (MRI, CT, and bone scanning) was used as the
gold standard with which to compare radiographs. Patients in the spondy-
lolysis cohort had a positive four-view study or a subsequent positive MRI,
CT, or bone scan. Radiographs for the spondylolysis cohort were reviewed by
the senior author (J.M.F.) to determine which patients did not meet our
exclusion criteria. All patients in the control cohort had a negative four-view
radiographic study that was confirmed with negative MRI, CT, or bone
scanning.
Outpatient records were reviewed to obtain demographic informa-
tion. Radiology reports were reviewed for all four-view, MRI, CT, and bone
scanning studies. Initial four-view radiographs for each patient were arranged
into two sets of slides: one showing four views (anteroposterior, lateral, right
oblique, left oblique) and one showing two views (anteroposterior and lateral
only). The slides were presented to four attending pediatric spine surgeons in
a random reading sequence, with four-view slides being presented first, fol-
lowed by two-view slides. Each slide was graded as positive or negative for
spondylolysis. Twenty patients (ten who were graded as positive for spon-
dylolysis and ten who were graded as negative for spondylolysis) were
reevaluated six months after the initial reading for the calculation of intra-
observer agreement.
For the purpose of analysis, each slide was given an overall positive or
negative grading based on a consensus of the reviewer readings. For four-view
slides that had a tie (two positive and two negative readings), the reading by the
radiologist was used as the tie-breaker. For two-view slides that had a tie, the
reading by the senior author (J.M.F.) was used as the tie-breaker. This plan was
made a priori, before any analysis.
Statistical Methods
It was essential for our study to be adequately powered to show no difference
between four-view and two-view radiographic studies. A chi-square power
analysis was performed before patient selection. The power analysis was con-
ducted with a desired two-sided alpha of 0.05 and a desired power of 0.80.
Calculations demonstrated that a total sample size of eighty-seven patients
would be necessary. A chi-square test with Yates correction was used for binary
or categorical variables. The Student t test was used for normally distributed
continuous variables.
Interobserver and intraobserver agreement as well as agreement with
advanced imaging (the gold standard) was assessed by calculating intraclass
correlation coefficients (ICCs). An ICC of 1.0 represents perfect agreement,
and an ICC of 0 suggests that measurements are entirely random. Although
some authors have postulated that a certain range of values for the ICC
14
represents acceptable agreement, there is no set standard . In addition to
ICCs, the sensitivity, specificity, test accuracy, and positive and negative
predictive values were calculated and compared with advanced imaging. All
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TABLE II Radiation and Cost Data for Radiographic Studies
2-View
Effective dose (mSv) 0.72
Risk of exposure-induced death 43.5/million
Loss of life expectancy (hr) 8.4
Cost $365
statistics were calculated with SPSS software (processor version 16.0; SPSS,
Chicago, Illinois).
Radiation and Cost
Radiation effective doses were calculated for two-view and four-view radio-
graphs with the use of PCXMC software (STUK, Helsinki, Finland) on the basis
of age-specific computer radiography (CR) imaging techniques determined by
our radiology department. These values were input into the program for an-
teroposterior, lateral, left oblique, and right oblique projections. The two-view
total effective dose was determined by adding anteroposterior and lateral
values, and the four-view total effective dose was determined by adding an-
teroposterior, lateral, left oblique, and right oblique values. In addition, we used
the PCXMC software to estimate the risk of exposure-induced death values
with the weighting factors presented in ICRP (International Commission on
Radiological Protection) Publication 10312. The costs for two-view and four-
view studies were determined by means of a search of charges from our radi-
ology department.
Source of Funding
The authors received no funding for this study.
Results
S eventy-four consecutive patients with spondylolysis were
identified, and twenty-four met our exclusion criteria as
described previously. Fifty-four consecutive control patients
were identified, and four met our exclusion criteria. This
Fig. 1
Detailed diagram of patient selection. BS = bone scanning, CT = computed tomography, MRI = magnetic resonance imaging, and pts = patients.
D O O B L I Q U E V I E W S A D D VA L U E I N T H E D I A G N O S I S
O F S P O N D Y L O LY S I S I N A D O L E S C E N T S ?
4-View Difference
1.26 0.54
78.5/million 35/million
15.2 6.8
$510 $145
brought both cohorts to fifty patients, for a total of 100 patients
included in our study (Fig. 1). The average ages of the patients
in the two groups were similar (see Appendix).
In eighty-nine of the 100 cases, the consensus readings
were the same for both the two-view and four-view slides,
meaning that only eleven cases had different consensus read-
ings. The two-view readings were incorrect in five of those
eleven cases, with four false-negative readings and one false-
positive reading. The four-view readings were incorrect in six
of those cases, with four false-negative readings and two false-
positive readings. Sample slides are shown in Figures 2-A and
2-B.
ICCs were calculated for both two-view and four-view
studies (see Appendix). All ICC values fell within the ‘‘mod-
erate’’ range15. These data clearly showed that both two-view
and four-view radiographs were associated with moderate
interobserver agreement, moderate intraobserver (test-retest
agreement), and moderate agreement with advanced imag-
ing studies. There were no significant differences between
two-view and four-view studies in terms of any of the ICC
values.
A detailed analysis of the sensitivity, specificity, test ac-
curacy, and positive and negative predictive values was per-
formed, and the values were compared with those of advanced
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O F S P O N D Y L O LY S I S I N A D O L E S C E N T S ?

Fig. 2-A

Fig. 2-B
Figs. 2-A and 2-B Radiographs of the spine of a patient in the spondylolysis group. This patient was considered to have spondylolysis by all reviewers
on the basis of both the four-view and two-view slides. Fig. 2-A The bilateral pars defect is visible on the lateral view (upper right) and both oblique views
(bottom). Fig. 2-B The pars interarticularis defect is visible on the lateral view (right).

imaging, CT, bone scan, or MRI. These data showed that ra-
diographs had moderate agreement, relatively high accuracy,
poor sensitivity, and high specificity for the diagnosis of
spondylolysis (Table I). This finding suggests that radio-
graphs are a poor screening test because they are associated
with many false-negative results but are a good confirmatory
test because they are associated with few false-positive
results.
Radiation and cost data for two-view and four-view
studies were calculated (Table II). The calculated ionizing
radiation effective dose was increased 75% with the addition
of oblique views. Also, the cancer risk of exposure-induced
death from this radiation was 80% higher in association with
four-view studies. The model used in the PCXMC software
assumes a loss of approximately twenty-five years for each
cancer-induced death. When that time was extrapolated over
a sample population, there was a loss of life expectancy of 8.4
hours for two-view studies and 15.2 hours for four-view
studies for every study that a patient received. In addition to
the increased radiation, at our institution, each four-view
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study incurred $145 of additional cost compared with two-
view studies.
Discussion
T he value of oblique view lumbar spine radiographs for the
evaluation of a patient with back pain has been a topic of
debate. Several investigators who have directly compared four-
view studies with two-view studies have argued for the use of
oblique views because two-view studies missed the diagnosis of
spondylolysis in some cases. Amato et al., in a study of fifty-six
cases of spondylolysis, showed that the single best view for
detecting spondylolysis was the collimated lateral view, which
allowed the diagnosis to be determined in 84% of the cases7.
However, 19% of the cases were only detectible on the oblique
views. Gehweiler and Daffner, in a study of 500 adult patients,
found that oblique views were necessary for diagnosis in 12%
of the cases, including all twenty-two cases of spondylolysis16.
Libson et al., in a review of 1743 male soldiers, showed that
20% of the 165 cases of spondylolysis were only detectable on
oblique views17.
Other investigators have argued against the use of
oblique views. DeLuca and Rhea, in a study of 300 adult
patients who were followed prospectively, showed that
Fig. 3
Radiographs of the spine of a patient in the spondylolysis group who had an accurate positive four-view consensus reading and a false-negative two-view
consensus reading. The unilateral left-sided pars interarticularis defect was not visible on the lateral view (upper right) but was apparent on the left oblique
view (lower right) (arrow).
D O O B L I Q U E V I E W S A D D VA L U E I N T H E D I A G N O S I S
O F S P O N D Y L O LY S I S I N A D O L E S C E N T S ?
oblique views added no additional information18. Rhea et al., in
a study of 200 adult patients, showed that oblique views
changed the radiographic interpretation in only four cases
(2%)19.
Our appropriately powered study showed that there was
no significant difference in any of the test characteristics be-
tween two-view and four-view radiographs. This finding sug-
gests that there is no diagnostic benefit associated with oblique
views. However, oblique views were helpful for diagnosing
unilateral spondylolysis. Twenty patients (40%) in the spon-
dylolysis group had unilateral pars defects. Three (75%) of the
four patients with a false-negative consensus for the two-view
slide and an accurate positive consensus for the four-view slide
had unilateral defects (Fig. 3). Other authors have reported
similar findings. Roberts et al., in a study of 125 pediatric pa-
tients, found that oblique views increased diagnostic accuracy
by 5% over anteroposterior and lateral views20. However, all
of those abnormalities were cases of unilateral spondylolysis.
Scavone et al., in a study of 782 adult patients, found that two-
view studies missed 87% of the unilateral pars defects in the
sixty patients who had spondylolysis21. Frequently, unilateral
defects can be clinically diagnosed on the basis of the one-
legged hyperextension test and unilateral tenderness. Clinical
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suspicion of a unilateral lesion is high in cases in which pain is
recalcitrant despite the passage of time and the use of nonop-
erative treatment, and the use of oblique views may be indi-
cated in such cases.
In contrast, the oblique views contributed to a false-
negative reading for four patients in the spondylolysis group for
whom the two-view consensus was accurately read as positive
(Fig. 4). In these cases, the defects were visible on the lateral
view but not in the plane of the oblique views. Saifuddin et al.,
in an axial CT study of thirty-four patients with sixty-nine
defects, showed that there was wide variation of the orientation
of the angle of pars defects5. Only 32% of the defects were
within 15° of the 45° oblique plane, and only 10% were within
5° of the 45° oblique plane. In the present study, oblique views
failed to show defects in 8% (four) of the fifty patients in the
spondylolysis group.
The increased radiation and costs associated with the use
of oblique views are not outweighed by increased diagnostic
value. Ionizing radiation exposure resulting from imaging
studies should be minimized when possible, especially for pe-
diatric patients, in whom the risk of fatal cancer per sievert is
nearly double that in adults12,22.
A limitation of this study is its retrospective design. Al-
though all patients in the control group received advanced
Fig. 4
Radiographs of the spine of a patient who had an accurate positive two-view consensus reading and a false-negative four-view consensus reading. The pars
defect was visible on the lateral view (upper right) (arrow) but not on either of the oblique views (bottom).
D O O B L I Q U E V I E W S A D D VA L U E I N T H E D I A G N O S I S
O F S P O N D Y L O LY S I S I N A D O L E S C E N T S ?
imaging studies showing no pars defect, not all of the patients
spondylolysis group had a bone scan, CT, or MRI. Eighteen
(36%) of the fifty patients in the spondylolysis group did not
receive advanced imaging and were not included in calculations
comparing radiographs with advanced imaging. In addition, all
radiographs were presented to the reviewers as static images on
PowerPoint (Microsoft, Redmond, Washington) slides. The
reviewers stated that if they were able to control the brightness
and contrast of the images, they would be more confident in
their diagnosis.
It is also important to note that the value of any diag-
nostic test, including radiographs, can be influenced by the
clinical scenario in which the test is ordered. This clinical
‘‘prescreening’’ increases the prevalence of disease in the tested
population, thereby improving the operating characteristics of
a diagnostic test. While the present study suggests that four-
view studies do not add additional benefit for screening pur-
poses, oblique views may occasionally still be indicated for
certain patients, depending on the clinical findings.
In spite of these limitations, the present study demon-
strated that although oblique views have long been standard
practice, these additional views did not provide a diagnostic
benefit over two-view studies that outweighs concerns related
to radiation and cost.
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Appendix
Tables showing demographic data and a summary of
interclass correlation coefficients are available with
the online version of this article as a data supplement at
jbjs.org. n
Nicholas A. Beck, BS
Robert Miller, BS
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Keith Baldwin, MD, MSTP, MPH
X. Zhu, MS
David Spiegel, MD
Denis Drummond, MD
Wudbhav N. Sankar, MD
John M. Flynn, MD
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