Send to

Choose Destination
Chiropr Man Therap. 2019 May 1;27:20. doi: 10.1186/s12998-019-0241-3. eCollection 2019.

European guidelines on quality criteria for diagnostic radiographic images of the lumbar spine - an intra- and inter-observer reproducibility study.

Author information

1Research Unit of Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5250 Odense M, Denmark.
Private chiropractic practice, Back Center Midwestern Jutland, Dalgas Allé 2A, 7400 Herning, Denmark.
4Nordic Institute of Chiropractic and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark.
Private chiropractic practice, Reykjavik, Iceland.
5Institute of Clinical Medicine, University of Southern Denmark, Odense, Denmark.
6Orthopedic Department, Odense University Hospital, Odense, Denmark.



The Commission of the European Communities has published guidelines to be used as a gold standard for quality assessment of diagnostic radiographic images. Image quality and radiation dose must be monitored and optimally balanced for diagnostic purposes on patients. The objective of the current study was to assess intra- and inter-observer reproducibility in less experienced observers using the proposed European Guidelines on Quality Criteria for Diagnostic Radiographic Images in a quality assessment of lumbar spine radiographs in primary chiropractic practice in Denmark.


Two observers initially evaluated lumbar spine radiographs randomly selected from fifty chiropractic clinics, all connected to the national PACS server (KirPACS) in Denmark. All evaluations were performed twice by both observers using a four-week interval and for compliance with the European Quality Criteria for Diagnostic Radiographic Images. Inter- and intra-observer reproducibility was calculated using kappa statistics. In the interpretation of the kappa coefficient, the standards for strength of agreement reported by Landis and Koch were followed.


The strength of the inter-observer agreement of general image quality at baseline ranged from moderate agreement (k = 0.47) to substantial agreement (k = 0.68). After four weeks, the inter-observer agreement still ranged from moderate agreement (k = 0.59) to substantial agreement (k = 0.71), but with increased agreement for both kappa coefficients. In relation to intra-observer agreement of general image quality, the strength for observer A ranged from moderate (k = 0.58) to substantial (k = 0.72) and the strength for observer B overall was substantial (k = 0.63-0.75).


The European Guidelines on Quality Criteria for Diagnostic Radiographic Images are considered a gold-standard and used in a method for quality assurance within the Danish chiropractic profession. The inter-rater and intra-rater agreements in this study, using the CEC-criteria, were found mostly acceptable. With appropriate attention to clear understanding of the individual criteria and sufficient training, this method is found to be reliable, even using less experienced observers, to carry out Diagnostic Radiographic Image Quality-assurance in primary care settings.


Agreement; Chiropractor; EU-guidelines; EU-quality criteria; Imaging; Lumbar spine; Primary care; Primary practice; Radiographs; Radiography; Reliability; Reproducibility; X-rays

Conflict of interest statement

Information on authors qualifications and affiliations is found on the first page of this article.Not applicable. This study was done in conjunction with quality assurance procedures required by Danish law [6] and all personal data were blinded for the observers. Only documentation of image quality was performed, with no possible correlation to patients. The procedures are mandatory and has no consequences for diagnoses and treatment of patients.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplemental Content

Full text links

Icon for BioMed Central Icon for PubMed Central
Loading ...
Support Center