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The “Shadow Sign”: A Radiographic Differentiation of Stainless Steel Versus Titanium Spinal Instrumentation in Spine Surgery

Jones-Quaidoo, Sean M. MD; Novicoff, Wendy PhD; Park, Andrew MSc; Arlet, Vincent MD

Journal of Pediatric Orthopaedics: December 2011 - Volume 31 - Issue 8 - p 875–877
doi: 10.1097/BPO.0b013e31822e024a

Background: Stainless steel spinal instrumentation has been supplanted in recent years by titanium instrumentation. Knowing whether stainless steel or titanium was used in a previous surgery can guide clinical decision making processes, but frequently the clinician has no way to know what type of metal was used. We describe the radiographic “shadow sign,” in which superimposed titanium rods and screws remain radiolucent enough that the contour of the underlying components can be seen on a lateral radiograph, whereas superimposed stainless steel rods and screws are completely radiopaque. This technique was evaluated using a retrospective, randomized, and blinded radiographic comparison of titanium and stainless steel spinal instrumentation. The objective was to determine whether the “shadow sign” can reliably differentiate titanium from stainless steel spinal instrumentation.

Methods: Lateral radiographs from 16 cases of posterior spinal instrumentation (6 titanium, 6 stainless steel, and 2 replicates of each to assess intraobserver reliability) were randomly selected from a database of cases performed for pediatric scoliosis in a university setting from 2005 to 2009. The cases were randomized then shown to 19 orthopaedic surgery residents, 1 spine fellow, and 2 spine attendings. After the “shadow sign” was described, the surgeons were asked to determine what type of metal each implant was made of.

Results: The


value for both stainless steel and titanium versus the gold standard was 0.83 [standard error (SE)=0.053], indicating excellent agreement. The


value for agreement between raters was 0.71 (SE=0.016) and the


value for agreement within raters was 0.70 (SE=0.016), both of which indicated substantial agreement.

Conclusions: The “shadow sign” can help a clinician differentiate titanium from stainless steel spinal instrumentation based on radiographic appearance alone. Furthermore, our study reveals that the level of experience in diagnosing spinal lateral radiographs also enhances the use of the “shadow sign” indicator.

Level of Evidence: The method proposed to differentiate titanium from stainless steel falls within the diagnostic studies domain. As unaltered randomization was used to enroll radiographs and the procedure was systematic, this study may be classified in the Level II category.

Orthopaedic Surgery, University of Virginia, Charlottesville, VA

University of Virginia IRB exemption status has been obtained for this study.

The authors declare no conflicts of interest.

Reprints: Vincent Arlet, MD, Warren G. Stamp Professor of Orthopaedic Surgery, Professor of Neurosurgery, Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive Suite 330, Charlottesville, VA 22903, E-mail:

© 2011 Lippincott Williams & Wilkins, Inc.