Flexion-Extension Radiograph Imaging Protocol Reliability Study

September 10, 2025 updated by: Rijnstate Hospital

Evaluating the Test-retest Reliability of a Standardized Flexion - Extension Radiograph Imaging Protocol for the Lumbar Spine.

Orthopedic surgeons often face the dilemma of whether to add fusion to a decompression procedure of the spine. Their decision mainly relies on personal experience to determine if a level is unstable preoperatively or if a specific decompression procedure might destabilize the spine. Lumbar spine flexion-extension radiographs aim to provide clinicians with images to assess the dynamism of a vertebral level, which crucial for evaluating spinal instability. However, the lack of a standardized imaging protocol for taking such flexion-extension radiographs leads to wide variability in their quality. This impacts the efficacy of radiographic measurements of angular and translational motion used for diagnosis. To effectively and reliably diagnose instability, it is crucial to control and standardize the flexion-extension radiograph protocols to promote the repeatability of intervertebral motion that characterizes a patient's full range of motion. The objective of this study is to evaluate the test-retest reliability of a standardized flexion - extension radiograph imaging protocol for the lumbar spine. This is an exploratory reliability study. A non-probability purposive sample of 45 patients with back pain from two tertiary care hospitals in The Netherlands is used. There is bo intervention. The main study parameter/endpoint is the agreement between the participants' first ("test") and second ("retest") kinematic results from their lumbar flexion-extension radiographs.

Study Overview

Status

Active, not recruiting

Conditions

Intervention / Treatment

Detailed Description

Lumbar spinal stenosis, a narrowing of the spinal canal in the lower part of the back, is a relatively common medical problem, but optimal treatment for the condition is poorly understood. Lumbar spinal stenosis is commonly treated with decompression surgery (providing more space for the compressed nerve roots) with or without additional lumbar fusion surgery (connecting two or more vertebrae to eliminate instability). Orthopaedic surgeons are currently faced with the dilemma of whether or not to add fusion to a decompression procedure. To decide between these two surgical options, surgeons rely mostly on their personal experience. They have to subjectively gauge whether a level is unstable preoperatively or if a specific decompression procedure is likely to destabilize the spine. A valid and reliable test for spinal instability would facilitate research to determine whether spinal instability measurements can be used to choose the optimal surgical treatment for each level.

A reliable diagnostic assessment for spinal instability would ideally be validated using an existing "gold standard" test. Such a test should have a very high sensitivity and specificity and must be supported by clearly developed rationale and high-quality evidence. Unfortunately, such a test does not currently exist for spinal instability. However, abnormalities in intervertebral motion are often a hallmark for spinal instability. A commonly accepted way to examine intervertebral motion is by analyzing the patient's flexion-extension radiographs. Using these two radiographs, the spine's sagittal plane intervertebral motion can be measured. The relative motion between the two images can be measured at all relevant levels either through manual measurement or computer assisted methods. Ideally, a standardized flexion-extension radiograph imaging protocol accomplishes the following: the patient sufficiently stresses the spine in order to assess the integrity of intervertebral motion restraints (ligaments, annulus, facet capsule, etc.), it is easily implemented into the clinical work flow, and it is reliable and repeatable across subjects and clinicians.

A myriad of patient positioning protocols for the flexion-extension radiograph imaging procedure have been tested and deployed, although generally without well-validated success criteria. Despite the large amount of studies on the topic, no one flexion-extension radiograph imaging protocol has been widely accepted. This suggests that 1) the studies were not appropriately powered to influence change, 2) some protocols (methods, equipment, instructions, etc.) are not easily implemented or practical in routine clinical workflows, 3) acquiring radiograph images of the lumbar spine in sufficiently stressed positions is not widely accepted as clinically important, or 4) most ordering clinicians do not realize how often a patient fails to adequately stress the spine while undergoing a standard of care flexion-extension radiograph. One factor that can often cast doubt on the efficacy of the flexion-extension radiograph procedure is the level of patient effort or range of spinal motion achieved by the patient. For standing flexion-extension radiographs, more patient effort leads to more intervertebral motion. This is a fairly simple and intuitive concept. However, achieving maximum patient effort is not a simple task. It could be argued that symptomatic patients should not be expected to exert maximum effort because it can be painful or uncomfortable. This argument can be supplemented with evidence that fear avoidance can limit motion and intervertertebral motion is substantially increased after analgesic injections.

Despite some of the arguments that can be used against the implementation of standardized flexion-extension radiograph imaging protocols in assessing spinal instability, there is ample data that good patient effort can be obtained in symptomatic patients. In one large multi-site study of lumbar stenosis with the exact same patient inclusion/exclusion criteria, a large amount of variance can be seen in the average level of intervertebral rotation. This suggests that differences in the flexion-extension radiograph protocol could be the driving factor in this high amount of variance seen between sites. It is also possible that the physician and/or radiology technician helped to quell patient's fear of motion by explaining that the maximum flexion and extension will not injure their back and will provide the best data for a reliable diagnosis.

With this in mind, the need for a standardized flexion-extension radiograph imaging protocol to assess for spinal instability is evident. Such standardized protocols can influence the amount of intervertebral motion, both translational and rotational. Since intervertebral motion is often used as evidence for spinal instability, inadequate effort likely leads to false negatives for spinal instability. Thus, developing a standardized imaging protocol to reliably measure intervertebral motion during a flexion-extension exam is clinically significant, as it often influences the diagnosis of a patient.

Study Type

Observational

Enrollment (Estimated)

45

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Netherlands
      • Amsterdam, Netherlands
        • OLVG
    • Gelderland
      • Arnhem, Gelderland, Netherlands, 6800 WC
        • Rijnstate Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

Yes

Sampling Method

Non-Probability Sample

Study Population

A non-probability purposive sample of 45 patients will be recruited.

Description

Inclusion Criteria:

  • referral to the orthopaedic surgeon because of pain in the back or leg and requiring lumbar spine radiographs so the orthopaedic surgeon is able to diagnose the probable cause of the pain.
  • over the age of 18 years
  • ability to flex and extend the spine sufficiently to facilitate acceptable flexion and extension radiographs.

Exclusion Criteria:

  • any form of spine-related traumatic injury
  • prior lumbar spinal surgery
  • lateral spondylolisthesis or coronal plane curvature in the lumbar spine of >10°
  • the presence of involuntary back muscle spasms
  • the presence of significant changes in pain during the day
  • inability to understand and sign the study Informed Consent form
  • inability to follow oral instructions

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Observational Models: Cohort
  • Time Perspectives: Cross-Sectional

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Agreement between the participants' first ("test") and second ("retest") kinematic results: intervertebral translation, intervertebral rotation and a value derived form the latter: translation-per-degree-of-rotation.
Time Frame: One hour after taking both sets of the flexion-extension radiographs
Test-retest reliability.
One hour after taking both sets of the flexion-extension radiographs

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Rijnstate Hospital

Collaborators

Medical Metrics Diagnostics, Inc

Investigators

  • Principal Investigator: Job LC van Susante, Dr. PhD., Department of orthopedics, Rijnstate Hospital

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

November 27, 2024

Primary Completion (Actual)

August 25, 2025

Study Completion (Estimated)

July 1, 2026

Study Registration Dates

First Submitted

November 10, 2022

First Submitted That Met QC Criteria

November 21, 2022

First Posted (Actual)

December 1, 2022

Study Record Updates

Last Update Posted (Estimated)

September 11, 2025

Last Update Submitted That Met QC Criteria

September 10, 2025

Last Verified

September 1, 2025

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • NL82684.091.22

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

UNDECIDED

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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