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    Digital subtraction imaging (DSI) decreases the risk of intravascular injection during cervical transforaminal epidural steroid injection (CTFESI); however, sequence acquisition and interpretation are operator-dependent skills. This study tests the reliability of a grading system to determine adequate DSI during CTFESI. Academic tertiary medical center. A grading scheme for adequate DSI quality during CTFESI was created by the study authors based on patient positioning, mask image, and volume of contrast injected. The inter-rater and intrarater reliability values of this grading scheme were tested using 50 DSI images evaluated by three raters during two distinct sessions separated by four weeks. Based on a power analysis, a sample of 50 scans was sufficient to detect significant correlations. Inter-rater reliability was determined by percent agreement between graders for dichotomized categories of "quality of DSI is adequate for safe C-TFESI" vs "quality of DSI is inadequate for safe C-TFESI." The percentage of agreement was reported, along with Gwet's agreement coefficient (AC). The intrarater (pre/post) correlation was assessed using Yule's Q statistics. Correlation coefficients were interpreted as follows: 0.00-0.19 "very weak," 0.20-0.39 "weak," 0.40-0.59 "moderate," 0.60-0.79 "strong," and 0.80-1.00 "very strong." Inter-rater reliability analyses demonstrated that the patient position category had "very strong" agreement, contrast volume had "strong" agreement, and mask image had "moderate" agreement. The overall inter-rater reliability was "moderate." All of the raters demonstrated "very strong" intrarater reliability. The proposed grading system for adequate-quality DSI during CTFESI showed overall "moderate" and "very strong" inter- and intrarater reliability, respectively. This scheme provides an objective measure of DSI quality for CTFESI. Refinement is needed to improve the reliability of this scheme. © The Author(s) 2020. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.All rights reserved. For permissions, please e-mail:


    Danielle Binler, L McLean House, Ryan Mattie, Mikhail Saltychev, Masato Nagao, Murat Pekmeczi, Lionel Metz, Conor O'Neil, Vinil Shah, Zachary L McCormick. The Reliability of a Grading System for Digital Subtraction Imaging Quality During Cervical Transforaminal Epidural Steroid Injection. Pain medicine (Malden, Mass.). 2020 Nov 01;21(11):3126-3132

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    PMID: 32167547

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