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Surgeon Reliability for the Assessment of Lumbar Spinal Stenosis on MRI: The Impact of Surgeon Experience

Satyajit V. Marawar, MBBS,1 Ian A. Madom, MD,2 Mark Palumbo, MD,3 Richard A. Tallarico, MD,2 Nathaniel R. Ordway, MS, PE,2 Umesh Metkar, MD,4 Dongliang Wang, PhD,5 Adam Green, BS,2 William F. Lavelle, MD2

1Syracuse Veterans Affairs Medical Center,  Syracuse, NY, 2Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY, 3Division of Spine Surgery, Warren Alpert School of Medicine at Brown University, Providence, RI, 4Carolina Pines Regional Medical Center, Hartsville, SC, 5Department of Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, NY



Treating surgeon's visual assessment of axial MRI images to ascertain the degree of stenosis has a critical impact on surgical decision-making. The purpose of this study was to prospectively analyze the impact of surgeon experience on inter-observer and intra-observer reliability of assessing severity of spinal stenosis on MRIs by spine surgeons directly involved in surgical decision-making. 


Seven fellowship trained spine surgeons reviewed MRI studies of 30 symptomatic patients with lumbar stenosis and graded the stenosis in the central canal, the lateral recess and the foramen at T12-L1 to L5-S1 as none, mild, moderate or severe. No specific instructions were provided to what constituted mild, moderate, or severe stenosis. Two surgeons were "senior" (>fifteen years of practice experience); two were "intermediate" (>four years of practice experience), and three "junior" (< one year of practice experience). The concordance correlation coefficient (CCC) was calculated to assess inter-observer reliability. Seven MRI studies were duplicated and randomly re-read to evaluate inter-observer reliability. 


Surgeon experience was found to be a strong predictor of inter-observer reliability. Senior inter-observer reliability was significantly higher assessing central(p<0.001), foraminal p=0.005 and lateral p=0.001 than "junior" group.Senior group also showed significantly higher inter-observer reliability that intermediate group assessing foraminal stenosis (p=0.036). In intra-observer reliability the results were contrary to that found in inter-observer reliability. 


Inter-observer reliability of assessing stenosis on MRIs increases with surgeon experience. Lower intra-observer reliability values among the senior group, although not clearly explained, may be due to the small number of MRIs evaluated and quality of MRI images.

Level of evidence: Level 3.

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Lumbar spinal stenosis, radiological grading, inter-observer reliability, intra-observer reliability, surgeon experience
Volume 11 Issue 5
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