Clinical Application Notes, April 2001

Assessment of Scoliosis with Ortelius 800TM

Preliminary Results
Dalia Dickman, Ph.D., Oren Caspi OrthoScan Technologies

Abstract: Accurate and non-invasive measurements are essential for deformity diagnosis and
assessment of curve progression. Although the standard procedure for diagnosis and follow-up of the
progression of scoliosis is the Cobb method of radiographic measurement, there is much concern
related to the multiple exposures to ionizing radiation. Ortelius 800TM is a unique device that allows
radiation-free, simple and accurate assessment of spinal deformities. Preliminary analysis of the
clinical value of Ortelius 800TM for analysis of spinal deformities was performed on patients with
scoliosis ranging from 10 to 46 degrees. Correspondence between Cobb angles measured on direct
radiographs and those calculated by Ortelius 800TM were estimated by Pearsons correlation
coefficient showing a significant correlation and a mean difference of 3.6 degrees. Preliminary results
are promising, implicating that the use of Ortelius 800TM is of clinical value and can reduce the
number of radiographs required in the monitoring of scoliosis patients.

Moreover, exposure to radiation occurs

during a period of life when growth is
rapid, potentially amplifying the deleterious
biologic effects (Natl Acad.Sci 1990). This
has raised concern regarding the effects of
this repeated exposure. A retrospective
cohort study conducted in 5573 female
patients with scoliosis found that women
with scoliosis or abnormal curvature of the
spine, who were exposed to multiple
diagnostic x-rays during childhood and
adolescence were found to have a 70%
higher risk of breast cancer as compared to
women of the general population (Doody
2000). Although more recent radiographic
techniques have lowered breast dose, there
is still a projected excess risk for breast
cancer using these radiographic techniques
and it has been recommended that all
efforts be made to further reduce exposures
(Doody 2000).

Children diagnosed with a spinal deformity

are assessed regularly in an outpatient clinic
and often undergo repeated radiographic
examinations. While this is the imaging
modality that is generally employed, there
are several problems regarding its
application to the spinal deformity. Curves
are described by their appearance on plain
films and quantified by the magnitude of
the Cobb angle derived from the
radiograph. This is the angle subtended
between lines drawn along the upper border
of the most tilted vertebrae above the
curves apex and the lower border of the
most tilted vertebrae below the apex (Cobb
1948). Interpretation of these results is
difficult as radiographs represent oblique
projections of the twisting spine and the
Cobb angle can be seen to vary widely
depending on the angle of the beam to the
patient (Dickson 1987). In addition to the
significant
inconsistency
of patient
positioning, leading to variable results,
intraobserver and interobserver errors have
been observed in calculation of the Cobb
angle as well (Pruijis 1994).

Modern technologies for assessing spinal

deformities are based on assessment of the
surface topography of the back in various
ways. Two basic types of technologies have
been implemented to assess the topography.
The technologies are either based on direct
measurement of the patients back or
reconstruction of surface shape (surface
topography) from scanned light or

Scoliosis patients typically undergo

numerous spinal radiographs (average of
25) during which they are exposed to
relatively high doses of ionizing radiation
(average of 10.8 cGy) (Doody 2000).

Clinical Application Notes, April 2001

photographic techniques (i.e., Moir

Contourgraphy,
Quantec)
(Oxborrow
1992). Position, body-build, and fat folds
contribute to the inaccuracies of surface
topography. Due to the clinical experience
acquired using this method, many authors
have concluded that there is poor
correlation between the observed body
asymmetry and the underlying scoliosis
(Adair 1977, Sahlstrand 1986, Prijs 1992)

equipped with sensors, a fusion of varied

technological elements. The scanner is
worn over the examiners index finger
while leaving the tip of the finger exposed.
This maintains the palpation at the bare
fingertip to enable accurate recognition and
recording of the verterbral spinous
processes (see figure 1 below). The
examination is extremely concise and the
system provides very accurate recording of
the spine coordinate. The recorded
positions are used to reconstruct the 3D
contour of the spine and to calculate the
location of each verterbra as well as
deformity angle, graphically presented by
the system on the LCD monitor in real time
(see figure 2 below).

A
system
providing
radiation-free
monitoring that is repeatable and reliable
would be of great clinical value. The
development of Ortelius 800TM addresses
this need. Ortelius 800TM is based on direct
measurement of the patients back with a
fingertip scanner. The fingertip scanner is

Figure 1: General overview of the Ortelius 800TM system ( site model) and examination setting.

Clinical Application Notes, April 2001

Figure 2: Scan analysis results. A 2D graphical reconstruction of the patients spine is presented after
examination of the patient with Ortelius 800TM. Location of deformity angle identified and deformity angle
is calculated automatically by the system with an option for manual measurements of any angle between
any other chosen vertebrae.

repeated three times for repeatability

studies as well as statistical analysis.
The time required for each examination is
less than two minutes for a trained
examiner. The data is then digitized and
stored and Ortelius 800TM provides a novel
method for plotting and analyzing the spine.
Details regarding the patient history and
examination results are stored in the patient
log for comparisons with follow-up visits
required for monitoring.

Materials and Methods

This study was designed to investigate the
correlation between the Ortelius 800TM
calculated deformity angle and radiographic
Cobb angles as well as to compare the
Ortelius 800TM spine plots directly with the
spine
contour
of
anterioposterior
radiographs.
Ortelius 800TM. The Ortelius 800TM system
is illustrated in figure 1 above. It consists of
a main console and fingertip scanner. The
examiner palpates the spinous processes of
the vertebrae with the help of his/her index
and middle fingers. The examiner begins
with C7 and records the positions of the
spinous processes along the length of the
spine. Other landmarks recorded are the
upper border of the gluteal cleft, left and
right posterior superior iliac spines, left and
right acroniom of the scapulae, and lastly,
the occipital tuberance. Each examination is

Patient selection. Inclusion criteria for

patients chosen for this study include
diagnosis with adolescent idiopathic
scoliosis with Cobb angles ranging from 10
to 50 degrees who could provide recent
standing
full-spine
posteroanterior
radiographs
.
X-ray analysis: Recent, standing full-spine
posteroanterior radiographs were obtained
for each patient. All radiographs were
analyzed with Ortelius 800 TM
and

Clinical Application Notes, April 2001

measurements
on
anterioposterior
radiographs by Pearsons correlation
coefficient. These 18 patients were a
consecutive series of patients and were
randomly chosen. Ortelius 800TM was
employed to calculate the deformity angle
directly on the radiograph and was
compared to Cobb angle measurements as
well. Pearsons correlation coefficient
between Cobb angle and Ortelius 800TM
deformity angle was 0.91 for direct
measurements on the radiograph with
Ortelius 800TM and 0.79 for patient
examination with Ortelius 800TM
(see
table 1 below).

deformity angles were compared to those

received by the traditional Cobb method.
Results
Correlation between Cobb and Ortelius
800TM calculated angles.
Nearly 100 patients have been examined
with Ortelius800TM for development of the
device in order to receive accurate results.
Development required changes regarding
collected data and parameters. After
standardizing these parameters, 18 patients
were analyzed in this preliminary study.
Ortelius 800TM-calculated deformity angles
were compared to manual Cobb angle

Mean Difference
(degrees)

Ortelius 800 TM x-ray measurement

deformity angle-Cobb angle

0.91

0.22

Ortelius 800 TM patient

measurement deformity angleCobb angle

0.79

3.64

Table 1. Comparison of Ortelius 800 TM deformity angles to Cobb angles by Pearsons correlation coefficient (r).

Correlation between Ortelius 800TM plot

of the spine contour from patient
examinations and spine contour from
anterioposterior
radiographs.
Spine
contour correlations were investigated by
superimposing Ortelius 800TM spine plots
directly on anterioposterior radiographs.
While comparing the Ortelius 800TM plot of
the spine contour from the patient
examinations to the anterioposterior
radiographs, an extremely high correlation
can be noted (see figures 3,4). Despite
minor variations in spinous process location
between the two, Ortelius 800 TM is capable
of identifying and taking these variations
into consideration, the final outcome being
highly correlated Ortelius 800 TM deformity
angle to Cobb angle.

Clinical Application Notes, April 2001

Figure 3: Ortelius 800TM deformity angle analysis of mild deformities. (a)Posterio-anterior spinal
radiograph of a patient with a major right thoracic curvature of 19. Ortelius 800TM graphic representation
of the scoliosis curvature of this patient is overlaid on the posterio-anterior spinal radiograph demonstrating
a deformity angle of 16 degrees as indicated above. (b) Posterio-anterior spinal radiograph of a patient with
left lumbar curvature of 11 degrees. Ortelius 800TM graphic representation of the scoliosis curvature of
this patient is overlaid on the posterio-anterior spinal radiograph demonstrating a left lumbar curve of 11
degrees as indicated above.

Clinical Application Notes, April 2001

Figure 4: Ortelius 800TM angle analysis of moderate deformities. (a)Posterio-anterior spinal radiograph of a patient
with a right lumbar curvature of 25 degrees. Ortelius 800TM graphic representation of the scoliosis curvature of this
patient is overlaid on the posterio-anterior spinal radiograph demonstrating a right lumbar deformity angle of 25
degrees as indicated above. (b) Posterio-anterior spinal radiograph of a patient with right thoracic and left lumbar
curvature of 46 and 32 respectively. Ortelius 800TM graphic representation of the scoliosis curvature of this patient
is overlaid on the posterio-anterior spinal radiograph demonstrating a right thoracic deformity angle of 42 degrees
and a left lumbar curve of 31 degrees as indicated above. (c) Posterio-anterior spinal radiograph of a patient with
right thoracic curvature of 40. Ortelius 800TM graphic representation of the scoliosis curvature of this patient is
overlaid on the posterio-anterior spinal radiograph demonstrating a right thoracic deformity angle of 36 degrees as
indicated above

Clinical Application Notes, April 2001

Morin Doody M, Lonstein JE, Stovall M, Hacker

DG, Luckyanov N, Land CE. Breast cancer mortality
after diagnostic radiography: findings from the
U.S.Scoliosis Cohort Study. Spine 2000 Aug
15;25(16):2052-63
National Academy of Sciences. Health Effects of
Exposure to Low Levels of Ionizing Radiation. BEIR
V. Committee on the Biological Effects of Ionizing
Radiations. Washington, DC: National Academy
Press, 1990.

Conclusion
This is a report of a preliminary study to
investigate the clinical value of Ortelius
800 TM for the diagnosis and monitoring of
scoliosis in a wide range of deformity
angles (ranging from 10-46 degrees). The
preliminary results reveal promising results
regarding both the deformity angle as well
as the spine contour reconstructed by
Ortelius 800 TM as compared to standard
posterioanterior radiographs. A large-scale
study, presently in progress, will allow
further validation of Ortelius 800 TM as a
tool for diagnosis and monitoring of spinal
deformities, as well as further establishment
and reduction of error margins.

Oxborrow NJ. Assesing the child with scoliosis:

the role of surface topography. Arch Dis Child
2000; 83:453-455.Marchesi DG, Transfeldt EE,
Bradford DS, Heithoff KB. Changes in
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Spine 1992; 17:775-780
Adair IV, Van Wijk MC, Armstrong GWMoire
topography in scoliosis screening. Clin Orthop
1977;(129): 165-71
Sahlstrand T. The clinical value of Moire topography
in the management of scoliosis. Spine 1986
Jun;11(5):409-17
Pruijs JEH et al. School screening for scoliosis
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References
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Dickson RA. Scoliosis: how big are you?
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