Interobserver agreement using Schlapbach graded scale for diffuse idiopathic skeletal hyperostosis (DISH): can we reduce the cut-off point of vertebral affection?

  • Stefanie Francesca Pini
  • Valentina Acosta-Ramón
  • Marian Tobalina-Segura
  • Emilio Pariente-Rodrigo
  • Javier Rueda-Gotor
  • José Manuel Olmos-Martínez
  • José Luis Hernández-HernándezEmail author
Original Article


Resnick-Niwayama criteria for diagnosing DISH depict an advanced stage, and a new reduced cut-off point with three contiguous vertebrae affected (two bone bridges) has been proposed. The aim has been to know the interobserver agreement by using a graded scale of DISH in which grade II matches with the new proposed cut-off point and grade III matches with the first criterion of Resnick-Niwayama. Males ≥ 50 years and postmenopausal women included in a population-based prospective study (the Camargo Cohort) were analyzed. Sample size was obtained according to an expected kappa of 0.95 and an accuracy of ± 8%. Three physicians applied independently Schlapbach graded scale (ranged from grade 0, no ossification, to grade III, ≥ 3 consecutive bone bridges) on the lateral radiographs of thoracic and lumbar spine of participants. We calculated inter- and intra-observer agreement and correlation. One hundred and fifty eight radiographs (79 patients, 68 ± 9 years) were assessed. Kappa values (95% confidence interval) for grades 0, I, II, and III were 0.63 (0.50–0.77), 0.49 (0.37–0.62), 0.32 (0.17–0.47), and 0.69 (0.60–0.77), respectively. Weighted kappa for the three pairs of raters were 0.87 (0.82–0.93), 0.84 (0.77–0.91), and 0.81 (0.72–0.90). Grade III was the image that generated greater agreement, while a significant decrease was noted in grade II, the new proposed criterion. The simultaneous presence of an incomplete DISH and osteoarthritis, in a thoracic spinal segment with peculiar anatomical characteristics (reduced disk spaces, kyphotic curve), is thought to be a major cause of variability in the results.


Diffuse idiopathic skeletal hyperostosis Forestier-Rotes disease Interobserver variability Spine X-ray diagnosis 



The study has been funded in part by the Health Institute Carlos III (PI15/00521), Ministerio de Economía y Competitividad, Spain, which includes FEDER funds from the European Union.

Compliance with ethical standards




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Copyright information

© International League of Associations for Rheumatology (ILAR) 2018

Authors and Affiliations

  • Stefanie Francesca Pini
    • 1
  • Valentina Acosta-Ramón
    • 1
  • Marian Tobalina-Segura
    • 1
  • Emilio Pariente-Rodrigo
    • 2
  • Javier Rueda-Gotor
    • 3
  • José Manuel Olmos-Martínez
    • 4
  • José Luis Hernández-Hernández
    • 4
    Email author return OK on get
  1. 1.Camargo Primary Health Care CentreMuriedasSpain
  2. 2.Camargo Primary Health Care Centre and University of CantabriaMuriedasSpain
  3. 3.Musculoskeletal Unit. Department of RheumatologyUniversity Hospital Marqués de ValdecillaSantanderSpain
  4. 4.Bone Metabolism Unit. Department of Internal MedicineUniversity Hospital Marqués de Valdecilla-IDIVAL and University of CantabriaSantanderSpain

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