Intra-rater agreement of the anorectal exam and classification of injury severity in children with spinal cord injury

Study design: Intra-rater reliability study, cross-sectional design. Objectives: To report on the intra-rater agreement of the anorectal examinations and classification of injury severity in children with spinal cord injury (SCI). Setting: Two, non-profit children's hospitals specializing in pediatric SCI. Methods: 180 subjects had at least two trials of the anorectal examinations as defined by the International Standards for Neurological Classification of Spinal Cord Injury. Intraclass correlation coefficients (ICC) and 95% confidence intervals (CI) were used to evaluate the agreement. ICC > 0.90 = high agreement; ICC between 0.75-0.89 = moderate agreement; ICC < 0.75 = poor agreement. Results: When evaluated for the entire sample, agreement was moderate-high for anal sensation and contraction and injury classification. When evaluated as a function of age at examination and type of injury, agreement for anal sensation was poor for subjects with tetraplegia in the 12-15-year age group (ICC = 0.56) and 16-21-year age group (ICC = 0.70) and for subjects with paraplegia in the 6-11-year age group (ICC = 0.69). Agreement for anal contraction was moderate for subjects with tetraplegia in the 16-21-year age group (ICC = 0.81) and subjects with paraplegia in the 12-15-year age group (ICC = 0.78) and poor for subjects with paraplegia in the 6-11-year age group (ICC = 0.67). Agreement for injury classification was poor for subjects with tetraplegia in the 12-15-year group (ICC = 0.56) and 16-21-year group (ICC = 0.74) and paraplegia in the 6-11-year group (ICC = 0.11) and 12-15-year group (ICC = 0.63). Anorectal responses had high agreement in subjects with tetraplegia in the 6-11year group and moderate to high agreement in subjects with paraplegia in the 16-21-year group. Conclusion: The data do not fully support the use of anorectal examination in children. Further work is warranted to establish the validity of anorectal examination. Spinal Cord (2009) 47, 687-691; doi:10.1038/sc.2008.180; published online 3 February 2009