Eur Spine J (1995) 4:34-38
r.opean .
M e a s u r e m e n t of vertebral rotation: Perdriolle versus R a i m o n d i
H.-R. Weiss
Katharina-Schroth-Spinal Deformities Rehabilitation Center, Leinenbornerweg 44, D-55566 Sobernheim, Germany
S u m m a r y . The measurement of vertebral rotation accord-
ing to Perdriolle is widely used in the French-speaking
and Anglo-American countries. Even in this measurement
technique there may be a relatively high estimation error
because of the not very accurate grading in steps of 5 ~.
The measurement according to Raimondi seems to be eas-
ier to use and is more accurate, with 2 ~ steps. The purpose
of our study was to determine the technical error of both
measuring methods. The apex vertebra of 40 curves on 20
anteroposterior (AP) radiographs were measured by using
the Perdriolle torsion meter and the Regolo Raimondi. In-
terrater and intrarater reliability were computed. The tho-
racic Cobb angle was 43 ~ the lumbar Cobb angle 36 ~
The average rotation according to Perdriolle was" 19.1 ~
thoracic (SD 11.14), 12.7 ~ lumbar (11.21). Measurement
of vertebral rotation according to Raimondi showed an
average rotation of 20.25 ~ in the thoracic region (11.40)
and 13.4 ~ lumbar (10.92). The intrarater reliability was
r = 0.991 (Perdriolle) and r = 0.997 (Raimondi). The av-
erage intrarater error was 1.025 ~ in the Perdriolle mea-
surement and 0.4 ~ in the Raimondi measurement. Inter-
rater error was on average 3.112 ~ for the Perdriolle mea-
surement and 3.630 ~ for the Raimondi measurement. This
shows that both methods are useful tools for the follow-up
of vertebral rotation as projected on standard X-rays for
the experienced clinicial. The Raimondi ruler is easier to
use and is slightly more reliable.
K e y w o r d s : Scoliosis - Vertebral rotation - Torsion
meter
In the management and follow-up of scoliosis, the Cobb
angle is mainly used [5]. As the sole criterion for the fol-
low-up of scoliosis patients, it can only be recommended
with reservation, because it is measured only in one plane
and so does not enable us to describe the three-dimen-
sional deformity of scoliosis.
The importance of vertebral rotation was recognized as
early as 1865. Adams [2] showed that a lordosis rotating
to one side produces scoliosis as a secondary phenomenon.
Received: 7 January 1994
Revised: 25 May 1994
Accepted: 25 May 1994
pme lournat
9 Springer-Verlag 1995
Various methods have been developed and used clini-
cally to measure vertebral rotation. In 1948, Cobb graded
vertebral rotation based on the dislocation of the tip of the
spinous process in relation to the underlying vertebral
body as seen radiographically in the frontal plane. Nash
and Moe [12] published a practical procedure for the de-
termination of vertebral rotation from the projection of the
pedicle in frontal radiographs. This measurements tech-
nique may not be very accuarte due to the fact that there is
only a four-step grading.
The Perdriolle torsion meter is a template to measure
the amount of vertebral rotation on spinal radiographs. The
vertebral pedicle shadow offset and the edges of the verte-
bral bodies are marked and then measured with the torsion
meter as described by Richards [15]. Here we have a grad-
ing in 5 ~ intervals, which also may lead to measuring er-
rors.
The use of the Regolo Raimondi (Marrapese Editore -
Demi S.r.1., Rome, see Fig. 1) is very similar to the Perdri-
oUe torsion meter. With this template, the vertebral pedi-
cle shadow offset is measured in millimeters, as is the
width of the vertebral body (Figs. 2 and 3). The width of
the vertebra is determined on the anteroposterior (AP)
roentgenogram at the most narrow spot, the so-called ver-
tebral waist. Contrary to the Perdriolle torsion meter mea-
surements, there isno need to mark these measuring points.
It is sufficient to position the metric ruler and read the
width. Only the convex-sided pedicle must be marked. As
also during the Perdriolle procedure, the convex-sided
pedicle is bisected longitudinally by a line. For the deter-
mination of the pedicular offset, the distance of this bi-
secting line to the convex-sided waist of the vertebral body
is evaluated. After the measurement, the width of the ver-
tebra (in mm) is set in a window, and the pedicular offset
(in mm as well) will be found right next to the degree of
rotation on this template, where there are gradings in 2 ~
steps. There is no need to mark the edges of the verte-
bral body using the Raimondi template. Barsanti et al. [3]
demonstrated that the torsion meter may be an effective
way to measure vertebral rotation. In their study, 144 er-
rors were made in 351 measurements, of which more than
92% were within 5 ~. In this study, nine thoracic vertebra
were individually rotated to an arch of 0-60 ~ and mea-
sured with a torsion meter by three investigators. Per-
driolle [13] himself states that the error coefficient for
rotation angles between 5 ~ and 35 ~ should be small.

Fig. 1. The Regolo Raimondi
Fig. 2. The vertebral pedicle shadow offset is measured in millimeters as is the
width of the vertebral body
Drerup [7] s h o w e d that m e a s u r e m e n t o f vertebral rota-
tion is i n d e p e n d e n t o f lateral tilting and f o r w a r d - b a c k -
ward inclination. H e also introduced an i m p r o v e d m e t h o d
for m e a s u r i n g vertebral rotation [8]. This m e t h o d differs
from the N a s h and M o e m e t h o d b y localization o f the
m e a s u r e m e n t points on the inner edge of the p e d i c l e s and
the m e a s u r e m e n t o f their position.
A a r o and D a h l b o r n [1] introduced estimation o f verte-
bral rotation b y c o m p u t e r t o m o g r a p h y (CT). A s it is not
n e c e s s a r y for e v e r y scoliosis patient to undergo a CT
investigation and b e c a u s e C T scans m a y not be a v a i l a b l e
e v e r y w h e r e , the m e a s u r e m e n t o f vertebral rotation on
standing r a d i o g r a p h s m a y b e o f great v a l u e in e v e r y d a y
use.
Materials and methods
Rotation of the apex vertebra of 40 curvatures on 20 standing X-rays
was measured with the Perdriolle torsion meter and the Regolo
Raimondi by two experienced physicians. The average Cobb angle
was 43.65 ~ (SD 22.17) thoracic and 36.45 ~ (18.00) lumbar.
The average rotation according to Perdriolle was 19.1 ~ thoracic
(11.14) and 12.7 ~ lumbar (11.21). Measurement of vertebral rotation
using the Raimondi ruler showed an average rotation of 20.25 ~ in
the thoracic region (11.40) and 13.4 ~ lumbar (10.92).
Investigator 1 measured all 40 apex vertebral twice with the
Regolo Raimondi and twice with the Perdriolle torsion meter with-
out regard to previous measurements. The intratester reliability
was computed for the Regolo Raimondi and for the Perdriolle tor-
sion meter measurements.
35
Investigator 2 measured all 40 apex vertebral once with the Re-
golo Raimondi and once with the Perdriolle torsion meter. In every
new series of measurements, all marks previously made on the X-
rays were removed.
For estimation of accuracy, we computed correlations between
the first and second series of measurements of investigator 1 for
the Perdriolle torsion meter and the Regolo Raimondi. Addition-
ally, we computed correlations between the first series of measure-
ments done by investigator 1 with the series of measurements done
by investigator 2, also for the Perdriolle torsion meter and the Re-
golo Raimondi. The average error was also computed.
Results
The intertester correlation for all 40 apex vertebra showed
an accuracy o f r = 0.991 using the Perdriolle t o r s i o n m e t e r
and r = 0.997 using the R e g o l o R a i m o n d i . The intratester
correlation s h o w e d an accuracy o f r = 0.937 in the Perdri-
olle m e a s u r e m e n t s and r = 0.927 in the R a i m o n d i m e a -
surements. T h e a v e r a g e repetition error was 1.025 ~ in the
Perdriolle m e a s u r e m e n t s and 0.4 ~ in the R a i m o n d i m e a -
surements, done b y the s a m e investigator. T h e inter-ob-
server error was 3 ~ for the P e r d r i o l l e and 3.6 ~ for the Rai-
m o n d i measurements.
The a v e r a g e m e a s u r e m e n t error was also c o m p u t e d for
l u m b a r and for thoracic curves and is shown in Table 1.
O f the i n t r a t e s t e r m e a s u r e m e n t s 8 7 . 5 % w e r e w i t h i n
2 ~ u s i n g the P e r d r i o l l e t o r s i o n m e t e r a n d 9 7 . 5 % u s i n g
the R a i m o n d i t e m p l a t e . O f the intertester m e a s u r e m e n t s
36
:4:
:2Z
2~
":: o (see also Fig. 2)
Table 1. Average interobserver and intraob- Perdriolle Raimondi Perdriolle th Perdriolle 1 Raimondi th Raimondi 1
server error using the Perdriolle torsion me- (n = 40) (n = 40)
ter and the Regolo Raimondi
Intraobserver
error 1.025
Interobserver
error 3.112
1, Lumbar; th, thoracic
82.5% was within 5 ~ using the f o r m e r and 72.5% using
the latter.
Discussion
Richards [15] found a l a c k o f accuracy in the a s s e s s m e n t
o f vertebral rotation using the Perdriolle torsion meter. He
c o m p a r e d the rotation o f h u m a n c a d a v e r i c v e r t e b r a pro-
j e c t e d on A P r a d i o g r a p h s and m e a s u r e d with the Perdri-
olle torsion m e t e r the true rotation o f frozen c a d a v e r i c
spines. H e even found a high intraobserver error when
c o m p a r i n g Perdriolle m e a s u r e m e n t s with true rotation
value. F o r clinical use, it is not necessary to have a high
correlation with the true rotation. F o r f o l l o w - u p o f rota-
tion, the p r o j e c t e d rotation on A P r a d i o g r a p h s m a y be eas-
ily m e a s u r e d and seems to be reliable as can be seen in
our results. H o w e v e r , as H a l l b a u e r et al. [9] p o i n t e d out, if
vertebral rotation exceeds 45 ~ the pedicle shadow cannot
clearly be identified. In this case the p e d i c l e shadow is of-
ten c o n f o u n d e d with the articular portion o f the vertebra,
leading to a high m e a s u r e m e n t error. In daily routine rota-
tion usually does not exceed 30 or 40 ~ so most of the X-
rays can be m e a s u r e d with g o o d reliability. If m o r e than
30 ~ is measured, the m e a s u r e m e n t s m a y b e not valid
when m a d e with the Perdriolle or R a i m o n d i template.
Benson et al. [4] looked at cadaver vertebra with roation
ranging f r o m 15 to 45 ~ and noted the f o l l o w i n g sources o f
error:
- Single vertebra differ m a r k e d l y
- Different spines have different offsets for the s a m e de-
gree o f rotation
Fig. 3. The width of the verte-
bra in millimeters is set in the
window of the Raimondi ruler
and the degree of rotation
found next to the pedicular
offset, which also is measured
in millimeters. In this exam-
ple, we have a rotation of 24 ~
(n = 20) (n = 20) (n = 20) (n = 20)
0.400 1.050 1.000 0.150 0.650
3.630 3.000 3.225 4.660 2.600
- Changes in sagittal and frontal inclinations o f single
vertebral alter the offset in the s a m e m a n n e r as changes
in rotation
F o r f o l l o w - u p using A P radiographs, these sources o f er-
ror s e e m not to be important when the s a m e vertebra is
m e a s u r e d as in the first radiograph. Additionally, Drerup
[7] clearly demonstrates that tilting does not change the
projection o f the p e d i c l e offset at all. N e i t h e r will verte-
bral rotation b e affected b y translation. D r e r u p d e m o n -
strates that the conclusion drawn b y B e n s o n m a y be the
result of different definitions. Benson rotated the tilted and
inclined vertebra around a vertical axis, whereas Drerup de-
fines vertebral rotation about the true vertebral axis.
Richards states that an error o f 2 m m in identifying a
p e d i c l e w o u l d result in a difference o f apparant rotation o f
approximately 5 ~ An identification error of 2 m m seems to
be very large when the width o f the p e d i c l e s h a d o w is 4 - 6
mm. Identification errors that high are due to a lack of
exactness.
H o et al. [10] c o m p a r e d m e a s u r e m e n t s o f vertebral ro-
tation done on CT scans with the m e a s u r e m e n t s on A P ra-
diographs. M a r c h e s i et al. [11] also used the a s s e s s m e n t of
vertebral rotation introduced b y A a r o and D a h l b o r n [1]
for the f o l l o w - u p o f vertebral rotation o f the Harrington
and L u q u e instrumentation. D a n g e r f i e l d at al. [6] p o i n t e d
out that there m a y b e changes o f vertebral rotation and
C o b b angle due to different b o d y positions. C T m e a s u r e -
ments m e a s u r e vertebral rotation o f the r e c u m b e n t spine,
and on A P radiographs, w e m e a s u r e vertebral rotation in
the standing position.
F o r clinical use o f the Perdriolle torsion m e t e r or the
R e g o l o R a i m o n d i , one can easily m i n i m i z e the m e a s u r e -

ment error which may arise from an unstandardized X-ray
position. If the patient as a whole is rotated to one side the
rotation of the apex vertebra on one curve will increase,
while the rotation of the apex vertebra on the counter-
curve will decrease. If, during follow-ups, the sum of the
main curve and counter-curve rotation remains the same,
there may be no change of vertebral rotation. If vertebral
rotation increases or decreases in both curvatures, there is
a true change. Thus, measurement of only one apex verte-
bra for follow-up is not useful. For accurate determination
it is always necessary to measure a second apex vertebra
or reference vertebra to minimize measurement errors due
to wrong patient positioning in front of the radiograph.
As pointed out by Vaysse et al. [17], the Raimondi val-
ues are a little higher than measured by the Perdriolle tor-
sion meter. This agrees with my results here.
The measuring technique according to Raimondi showed
a higher measuring accuracy concerning intratester relia-
bility. The apparently worse reliability of the Raimondi
measuring technique in the intertester comparison results
from the fact that in the case of a thoracic curvature, the
articular portion was confused with the pedicle, which
was difficult to project. This resulted in a deviation of the
more than 10 ~ with otherwise good correlation. On the
whole it showed that both measuring techniques are capa-
ble of measuring very exactly the virtual rotation of verte-
bral bodies and thus can also be used for following up ro-
tation. Difficulties appeared especially in major scolioses
and greater rotation, where there was a superposition of
the vertebral arch over the edges of the concave-sided ver-
tebral bodies. Thus, sometimes an exact determination of
the edges of the concave-sided vertebral bodies was often
not possible without making errors. In some cases the
edges of the vertebral bodies had first to be reconstructed
by following the edges of the vertebral bodies of adjacent
vertebra, before it was possible to measure rotation. It is
therefore striking that both techniques showed a high mea-
suring accuracy in the thoracic region. If the vertebral arch
is superimposed on the edges of the vertebral bodies, it is
recommended to reconstruct the edges of the concave-
sided vertebral bodies with a pencil in order to increase
measuring accuracy.
I now use the measuring technique according to Rai-
mondi, because of its higher measuring accuracy and eas-
ier application. One must be aware of the fact that the real
rotation is not measured with the Regolo Raimondi or the
Perdriolle torsion meter. What is measured is only the
projected rotation, which can be determined with the help
of an AP X-ray. This had already been shown by Benson et
al. [4] in 1976. Also, a more recent study of Skalli et al. [16]
demonstrates with the help of a numerical geometric
model of a vertebra that the rotation measured in a bidi-
mensional manner (standard X-rays) differs from the real
three-dimensional rotation. By using their geometric
model, the authors showed very impressively that pro-
jected axial rotation depends on the vertebral tilt in the
frontal and sagittal planes. When measuring with different
pedicle offset methods, these errors, however, are of mi-
nor importance as here the apical vertebra is measured,
which in relation ot the other vertebrae of a curvature is
the one least tilted. For this reason, the measurement of
37
this vertebra is probably the most accurate one. If the api-
cal vertebra evidences a small inclination, the minor error
does not play any role in the follow-up of vertebral rota-
tion by 2D measurements, as it may be expected that the
apical vertebra presents the same inclination in the fol-
low-up X-ray as on the first one. In such a case of a sys-
tematic error in all follow-up measurements, significant
changes of the rotation may be determined by 2D meth-
ods. Further, Skalli et al. [16] stated that, if the measured
vertebra is tilted only slightly in the frontal or sagittal
planes, the expected error in the rotation measurement
compared with the true rotation value is small.
Conclusion
There is a high reliability for the measurement of projected
vertebral rotation using the Perdriolle torsion meter or the
Regolo Raimondi for rotation measurements up to 30 ~
When following up patients with scoliosis, the measure-
ment should be done by the same person to minimize
measurement error. The Raimondi ruler seems to be easier
to use and is slightly more reliable, so we think it is more
useful than the Perdriolle torsion meter. The criticism of
2D measurement methods [4, 16] lacks any practical rele-
vance, as the hypothetical measurement errors arising from
vertebral tilting in the frontal and sagittal planes is practi-
cally without importance when measuring the apical ver-
tebra. Even if we do not necessarily measure the real rota-
tion with 2D methods, especially with higher degrees of
vertebral rotation, we gain very useful and reliable infor-
mation in the follow-up of patients with idiopathic scolio-
sis.
Acknowledgement. I am thankful to Sigrun Fuchs for her measure-
ments.
References
1. Aaro S, Dahlbom M (1981) Estimation of vertebral rotation
and the spinal and rib cage deformity in scoliosis by computer
tomography. Spine 6 : 461-467
2. Adams W (1865) Lectures on the pathology and treatment of
lateral and other forms of curvature of the spine. Churchill and
Sons, London
3. Barsanti CM, deBari A, Covino BM (1990) The torsion meter:
a critical review. J Pediatr Orthop 10:527-531
4. Benson DR, Schultz AB, DeWald RL (1976) Roentgenographic
evaluation of vertebral rotation. J Bone Joint Surg [Am] 58 :
1125-1129
5. Cobb JR (1948) Outline for the study of scoliosis (AOS Instruc-
tional Course Lectures 5) American Academy of Orthopaedic
Surgeons, Ann Arbor, pp 261-275
6. Dangerfield PH, Scutt D, Dorgan JC, Li Y, Pearson JD, Brodie
DA (1992) The effect of body position on the three-dimen-
sional surface deformity of scoliosis. Proceedings of the Inter-
national Symposium on 3-D Scoliotic Deformities joined with
the VIIth International Symposium on Spinal Deformity and
Surface Topography, Montreal, Canada, June 1992. Editions
de l'Ecole Polytechnique de Montr6al, Gustav Fischer Verlag,
pp 139-147
7. Drerup B (1984) Principles of measurement of vertebral rota-
tion from frontal projections of the pedicles. J Biomechan 17 :
923-935
38
8. Drerup B (1985) Improvements in measuring vertebral rotation
from the projections of the pedicles. J Biomechan 18:369-378
9. Hallbauer T, Deimling U von, Schumpe G, Schmitt O (1992)
R6ntgenologische Aspekte der Skoliosediagnostik. Presented
at the 41st annual meeting of the Norddeutsche Orthop~iden-
vereinigung, Cologne, Germany, June 28
10. Ho EKW, Upadhyay SS, Ferris L, Bacon-Shone J, Chan FL,
Hsu LCS, Leong JCY (1992) A comparative study of com-
puted tomographic and plain radiographic methods to measure
vertebral rotation in adolescent idiopathic, Spine 17:771-774
11. Marchesi DG, Transfeldt EE, Bradford DS, Heithoff KB (1992)
Changes in vertebral rotation after Harrington and Luque in-
strumentation for idiopathic scoliosis. Spine 17:775-780
12. Nash CL, Moe JH (1969) A study of vertebral rotation. J Bone
Joint Surg [Am] 51 : 223-229
13. Perdriolle R (1991) Letter to the editor. J Pediatr Orthop 11:
789
14. Perdriolle R, Vidal J (1985) Thoracic idiopathic scoliosis curve
evolution and prognosis. Spine 9 : 785-791
15. Richards SB (1992) Measurement error in assessment of verte-
bral rotation using the Perdriolle torsion meter. Spine 17:513-
517
16. Skalli W, LaVaste F, DesCrimes JL (1993) Quantification of 3D
vertebral rotations in scoliosis: what are the true values? Pro-
ceedings of the Scoliosis Research Society meeting, Dublin, pp
200-201
17. Vaysse C, Neiger H, Bruandet JM (1991) Psoas et rotation vert&
brale dans la scoliose lombaire. In: Ducong6 P (ed) Vingts an-
n~es de recherches et d'exp~rimentation. Montpellier, Sauramps
M6dical, pp 97-104
18. Weiss HR (1992) Die Messung der Wirbeltorsion mit dem 'Re-
golo Raimondi' Presented at the 41st annual meeting of the
Norddeutsche Orthop~idenvereinigung, Cologne, Germany, June
29