Abstract
Background: The Cobb angle measurement of the spine is an important parameter for assessing patients with scoliosis in terms of diagnosis, treatment planning, follow-up for severity and disease progression. This angle can be obtained from a plain X-ray film in an upright posteroanterior view or can be measured from digital images. A 5° curve progression is considered clinically significant.
 Objective: This study aimed to compare the accuracy and difference of the Cobb angle measurements between manual and digital methods among 5 military hospitals located in the 1st area of command having orthopedic services and using different Picture Archiving and Communication (PACS).
 Methods: Using plain X- ray films of patients diagnosed with scoliosis, a comparative study of the Cobb angle measurement was conducted. A total of 120 images were recorded in a compact disc in the Digital Imaging and Communications in Medicine (DICOM) system and was used to install in computer systems of 5 military hospitals (Hospitals A, B, C, D, and E), and then was interpreted using each hospital digital PACS. The mean difference of 5° is considered clinically significant. The validity of measurements was analyzed using paired t- test for the mean equivalence. The reliability of one time measurement was also performed using Intraclass Correlation Coefficient (ICC).
 Results: Both one time and an average of three times of digital measurements among Hospitals A, B, C, D and E revealed significant differences when compared with the manual measurement (p < 0.01). However, no clinical significance of both one time and the averaged three measurements were observed when the mean difference was less than 5°. In the combined process group (Hospitals C, D and E), a significant difference of the manual and digital measurements was observed (p<0.01). However, no clinical significance using both one time and averaged three time measurements was found when the mean difference was less than 5°. The data of one time digital measurements were reliable (ICC= 0.9).
 Conclusion: The use of digital Cobb angle measurement is a convenient practice. A significant difference using manual and digital methods was found using both one and combined processes; however, no clinical significance was observed. One time digital measurement revealed validity as those found in three time averaged measurements.
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