Skip to main content
SpringerLink
Log in

Review of existing grading systems for cervical or lumbar disc and facet joint degeneration

  • Review
  • Published:
European Spine Journal Aims and scope Submit manuscript

An Erratum to this article was published on 03 May 2006

Abstract

The aim of this literature review was to present and to evaluate all grading systems for cervical and lumbar disc and facet joint degeneration, which are accessible from the MEDLINE database. A MEDLINE search was conducted to select all articles presenting own grading systems for cervical or lumbar disc or facet joint degeneration. To give an overview, these grading systems were listed systematically depending on the spinal region they refer to and the methodology used for grading. All systems were checked for reliability tests and those recommended for use having an interobserver Kappa or Intraclass Correlation Coefficient >0.60 if disc degeneration was graded and >0.40 if facet joint degeneration was graded. MEDLINE search revealed 42 different grading systems. Thirty of these were used to grade lumbar spine degeneration, ten were used to grade cervical spine degeneration and two were used to grade both. Thus, the grading systems for the lumbar spine represented the vast majority of all 42 grading systems. Interobserver reliability tests were found for 12 grading systems. Based on their Kappa or Intraclass Correlation Coefficients nine of these could be recommended for use and three could not. All other systems could neither be recommended nor not be recommended since reliability tests were missing. These systems should therefore first be tested before use. The design of the grading systems varied considerably. Five grading systems were beginning with the lowest degree of degeneration, 37, however, with the normal, not degenerated state. A 5-grade scale was used in six systems, a 4-grade scale in 24, a 3-grade scale in eight and a 2-grade scale in three systems. In 15 cases the normal, not degenerated state was assigned to “grade 0”, in another 15 cases, however, this state was assigned to “grade 1”. This wide variety in the design of the grading systems makes comparisons difficult and may easily lead to confusion. We would therefore recommend to define certain standards. Our suggestion would be to use a scale of three to five grades, to begin the scale with the not degenerated state and to assign this state to “grade 0”.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Adams MA, Dolan P, Hutton WC (1986) The stages of disc degeneration as revealed by discograms. J Bone Joint Surg Br 68(1):36–41

    PubMed  Google Scholar 

  2. Adams MA, McNally DS, Dolan P (1996) ’Stress’ distributions inside intervertebral discs. The effects of age and degeneration. J Bone Joint Surg Br 78(6):965–972

    Article  PubMed  Google Scholar 

  3. Berlemann U, Gries NC, Moore RJ (1998) The relationship between height, shape and histological changes in early degeneration of the lower lumbar discs. Eur Spine J 7(3):212–217

    Article  PubMed  Google Scholar 

  4. Boos N, Nerlich AG, Wiest I, von der Mark K, Aebi M (1997) Immunolocalization of type X collagen in human lumbar intervertebral discs during ageing and degeneration. Histochem Cell Biol 108(6):471–480

    Article  PubMed  Google Scholar 

  5. Boos N, Wallin A, Schmucker T, Aebi M, Boesch C (1994) Quantitative MR imaging of lumbar intervertebral disc and vertebral bodies: methodology, reproducibility, and preliminary results. Magn Reson Imaging 12(4):577–587

    Article  PubMed  Google Scholar 

  6. Boos N, Weissbach S, Rohrbach H, Weiler C, Spratt KF, Nerlich AG (2002) Classification of age-related changes in lumbar intervertebral discs: 2002 Volvo Award in basic science. Spine 27(23):2631–2644

    Article  PubMed  Google Scholar 

  7. Brant-Zawadzki MN, Jensen MC, Obuchowski N, Ross JS, Modic MT (1995) Interobserver and intraobserver variability in interpretation of lumbar disc abnormalities. A comparison of two nomenclatures (discussion 1264). Spine 20(11):1257–1263

    PubMed  Google Scholar 

  8. Brooker AE, Barter RW (1965) Cervical spondylosis. A clinical study with comparative radiology. Brain 88(5):925–936

    PubMed  Google Scholar 

  9. Buckwalter JA (1995) Aging and degeneration of the human intervertebral disc. Spine 20(11):1307–1314

    PubMed  Google Scholar 

  10. Butler D, Trafimow JH, Andersson GB, McNeill TW, Huckman MS (1990) Discs degenerate before facets. Spine 15(2):111–113

    PubMed  Google Scholar 

  11. Carrera GF, Haughton VM, Syvertsen A, Williams AL (1980) Computed tomography of the lumbar facet joints. Radiology 134(1):145–148

    PubMed  Google Scholar 

  12. Cohen J (1968) Weighted kappa: nominal scale agreement with provision for scaled disagreement or partial credit. Psychol Bull 70:213–220

    Google Scholar 

  13. Collins DH (1949) The pathology of articular and spinal diseases. Edward Arnold & Co, London

    Google Scholar 

  14. Coste J, Judet O, Barre O, Siaud JR, Cohen de Lara A, Paolaggi JB (1994) Inter- and intraobserver variability in the interpretation of computed tomography of the lumbar spine. J Clin Epidemiol 47(4):375–381

    Article  PubMed  Google Scholar 

  15. Cote P, Cassidy JD, Yong-Hing K, Sibley J, Loewy J (1997) Apophysial joint degeneration, disc degeneration, and sagittal curve of the cervical spine. Can they be measured reliably on radiographs? Spine 22(8):859–864

    Article  PubMed  Google Scholar 

  16. Coventry MB (1945) The intervertebral disc: Its macroscopic anatomy and pathology: Part III. Pathological changes in the intervertebral disc lesion. J Bone Joint Surg [Am] 27:460–473

    Google Scholar 

  17. Coventry MB (1945) The intervertebral disc: Its microscopic anatomy and pathology: Part I. Anatomy, development and pathology. J Bone Joint Surg [Am] 27:105–112

    Google Scholar 

  18. Coventry MB (1945) The intervertebral disc: Its microscopic anatomy and pathology: Part II. Changes in the intervertebral disc concomitant with age. J Bone Joint Surg [Am] 27:233–247

    Google Scholar 

  19. Demaerel P, Wilms G, Goffin J, Baert AL (1992) Osteoarthritis of the facet joints and its role in low-back pain: evaluation with conventional tomography. J Belge Radiol 75(2):81–86

    PubMed  Google Scholar 

  20. Eisenstein SM, Parry CR (1987) The lumbar facet arthrosis syndrome. Clinical presentation and articular surface changes. J Bone Joint Surg Br 69(1):3–7

    PubMed  Google Scholar 

  21. Fleiss JL (1981) Statistical methods for rates and proportions, 2nd edn. Wiley, New York

    Google Scholar 

  22. Fletcher G, Haughton VM, Ho KC, Yu SW (1990) Age-related changes in the cervical facet joints: studies with cryomicrotomy, MR, and CT. AJR Am J Roentgenol 154(4):817–820

    PubMed  Google Scholar 

  23. Fraser RD, Osti OL, Vernon-Roberts B (1993) Intervertebral disc degeneration. Eur Spine J 1:205–213

    Article  Google Scholar 

  24. Friberg S, Hirsch C (1949) Anatomical and clinical studies on lumbar disc degeneration. Acta Orthop Scand 19:222–242

    PubMed  Google Scholar 

  25. Friedenberg ZB, Miller WT (1963) Degenerative disc disease of the cervical spine. J Bone Joint Surg Am 45:1171–8

    PubMed  Google Scholar 

  26. Galante JO (1967) Tensile properties of the human lumbar annulus fibrosus. Acta Orthop Scand (Suppl100):1–91

    Google Scholar 

  27. Gibson MJ, Buckley J, Mawhinney R, Mulholland RC, Worthington BS (1986) Magnetic resonance imaging and discography in the diagnosis of disc degeneration. A comparative study of 50 discs. J Bone Joint Surg Br 68(3):369–373

    PubMed  Google Scholar 

  28. Gordon SJ, Yang KH, Mayer PJ, Mace AH Jr, Kish VL, Radin EL (1991) Mechanism of disc rupture. A preliminary report. Spine 16(4):450–456

    PubMed  Google Scholar 

  29. Gries NC, Berlemann U, Moore RJ, Vernon-Roberts B (2000) Early histologic changes in lower lumbar discs and facet joints and their correlation. Eur Spine J 9(1):23–29

    Article  PubMed  Google Scholar 

  30. Grogan J, Nowicki BH, Schmidt TA, Haughton VM (1997) Lumbar facet joint tropism does not accelerate degeneration of the facet joints. AJNR Am J Neuroradiol 18(7):1325–1329

    Google Scholar 

  31. Gunzburg R, Parkinson R, Moore R et al (1992) A cadaveric study comparing discography, magnetic resonance imaging, histology, and mechanical behavior of the human lumbar disc. Spine 17(4):417–426

    PubMed  Google Scholar 

  32. Hendry NG (1958) The hydration of the nucleus pulposus and its relation to intervertebral disc derangement. J Bone Joint Surg Br 40B(1):132–144

    Google Scholar 

  33. Hirsch C (1972) Some morphological changes in the cervical spine during ageing. In: Hirsch C, Zotterman Y (eds) Cervical pain. Pergamon Press, New York, pp 21–32

    Google Scholar 

  34. Kellgren JH, Jeffrey MR, Ball J (1963) The epidemiology of chronic rheumatism. vol II: Atlas of standard radiographs of arthritis. Blackwell Scientific Publications, Oxford, pp 14–19

    Google Scholar 

  35. Kellgren JH, Lawrence JS (1952) Rheumatism in miners. II. X-ray study. Br J Ind Med 9(3):197–207

    PubMed  Google Scholar 

  36. Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16(4):494–502

    PubMed  Google Scholar 

  37. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174

    PubMed  Google Scholar 

  38. Lane NE, Nevitt MC, Genant HK, Hochberg MC (1993) Reliability of new indices of radiographic osteoarthritis of the hand and hip and lumbar disc degeneration. J Rheumatol 20(11):1911–1918

    PubMed  Google Scholar 

  39. Lehto IJ, Tertti MO, Komu ME, Paajanen HE, Tuominen J, Kormano MJ (1994) Age-related MRI changes at 0.1 T in cervical discs in asymptomatic subjects. Neuroradiology 36(1):49–53

    Article  PubMed  Google Scholar 

  40. Lindblom K (1944) Protrusions of discs and nerve compression in the lumbar region. Acta Radiol 25:195

    Google Scholar 

  41. Lindblom K (1951) Backache and its relation to ruptures of the intravertebral disks. Radiology 57(5):710–719

    PubMed  Google Scholar 

  42. Lindblom K (1951) Discography of dissecting transosseous ruptures of intervertebral discs in the lumbar region. Acta Radiol 36(1):12–16

    PubMed  Google Scholar 

  43. Macnab I (1975) Cervical spondylosis. Clin Orthop (109):69–77

    Google Scholar 

  44. Madan SS, Rai A, Harley JM (2003) Interobserver error in interpretation of the radiographs for degeneration of the lumbar spine. Iowa Orthop J 23:51–56

    PubMed  Google Scholar 

  45. Masaryk TJ, Ross JS, Modic MT, Boumphrey F, Bohlman H, Wilber G (1988) High-resolution MR imaging of sequestered lumbar intervertebral disks. AJR Am J Roentgenol 150(5):1155–1162

    PubMed  Google Scholar 

  46. Milgram J (1990) Intervertebral disc disease and degenerative arthritis of the spine. In: Milgram J (ed) Radiologic and histologic pathology of nontumorous dieseases of bone and joints. Northbrook Publishing Company, pp 519–588

  47. Mimura M, Panjabi MM, Oxland TR, Crisco JJ, Yamamoto I, Vasavada A (1994) Disc degeneration affects the multidirectional flexibility of the lumbar spine. Spine 19(12):1371–1380

    PubMed  Google Scholar 

  48. Nachemson A (1960) Lumbar Intradiscal Pressure. Experimental studies on post-mortem material. Acta Orthop Scand Suppl 43:43

    Google Scholar 

  49. Naylor A, Smare DL (1953) Fluid content of the nucleus pulposus as a factor in the disk syndrome; preliminary report. Br Med J 4843:975–976

    PubMed  Google Scholar 

  50. Nerlich AG, Schleicher ED, Boos N (1997) 1997 Volvo Award winner in basic science studies. Immunohistologic markers for age-related changes of human lumbar intervertebral discs. Spine 22(24):2781–2795

    Article  PubMed  Google Scholar 

  51. Osti OL, Vernon-Roberts B, Fraser RD (1990) 1990 Volvo Award in experimental studies. Anulus tears and intervertebral disc degeneration. An experimental study using an animal model. Spine 15(8):762–767

    PubMed  Google Scholar 

  52. Pathria M, Sartoris DJ, Resnick D (1987) Osteoarthritis of the facet joints: accuracy of oblique radiographic assessment. Radiology 164(1):227–230

    PubMed  Google Scholar 

  53. Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N (2001) Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine 26(17):1873–1878

    Article  PubMed  Google Scholar 

  54. Resnick D (1985) Degenerative diseases of the vertebral column. Radiology 156(1):3–14

    Google Scholar 

  55. Schellhas KP, Smith MD, Gundry CR, Pollei SR (1996) Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers (discussion 311–312). Spine 21(3):300–311

    Article  PubMed  Google Scholar 

  56. Schneiderman G, Flannigan B, Kingston S, Thomas J, Dillin WH, Watkins RG (1987) Magnetic resonance imaging in the diagnosis of disc degeneration: correlation with discography. Spine 12(3):276–281

    PubMed  Google Scholar 

  57. Shrout PE, Fleiss J (1979) Intraclass correlations: Uses in Assessing Rater Reliability. Psychol Bull 86(2):420–428

    Article  Google Scholar 

  58. Silberstein CE (1965) The Evolution of Degenerative Changes in the Cervical Spine and an Investigation into the “Joints of Luschka”. Clin Orthop 40:184–204

    PubMed  Google Scholar 

  59. Streiner DL, Norman GL (1989) Health measurement scales: a practical guide to their development and use. Oxford University Press, Oxford

    Google Scholar 

  60. Swanepoel MW, Adams LM, Smeathers JE (1995) Human lumbar apophyseal joint damage and intervertebral disc degeneration. Ann Rheum Dis 54(3):182–188

    PubMed  Google Scholar 

  61. Tanno I, Oguma H, Murakami G, Sato S, Yamashita T (2003) Which portion in a facet is specifically affected by articular cartilage degeneration with aging in the human lumbar zygapophysial joint? Okajimas Folia Anat Jpn 80(1):29–34

    PubMed  Google Scholar 

  62. Tertti M, Paajanen H, Laato M, Aho H, Komu M, Kormano M (1991) Disc degeneration in magnetic resonance imaging. A comparative biochemical, histologic, and radiologic study in cadaver spines. Spine 16(6):629–634

    PubMed  Google Scholar 

  63. Thompson JP, Pearce RH, Schechter MT, Adams ME, Tsang IK, Bishop PB (1990) Preliminary evaluation of a scheme for grading the gross morphology of the human intervertebral disc. Spine 15(5):411–415

    PubMed  Google Scholar 

  64. Töndury G (1972) The behaviour of the cervical discs during life. In: Hirsch C, Zotterman Y (eds) Cervical pain. Pergamon Press, New York, pp 59–66

    Google Scholar 

  65. Vernon-Roberts B (1987) Pathology of intervertebral discs and apophyseal joints. The lumbar spine and back pain. Churchill-Livingstone, London, pp 37–55

    Google Scholar 

  66. Vernon-Roberts B, Pirie CJ (1977) Degenerative changes in the intervertebral discs of the lumbar spine and their sequelae. Rheumatol Rehabil 16(1):13–21

    PubMed  Google Scholar 

  67. Viikari-Juntura E, Raininko R, Videman T, Porkka L (1989) Evaluation of cervical disc degeneration with ultralow field MRI and discography. An experimental study on cadavers. Spine 14(6):616–619

    PubMed  Google Scholar 

  68. Virgin WJ (1951) Experimental investigations into the physical properties of the intervertebral disc. J Bone Joint Surg Br 33B(4):607–611

    PubMed  Google Scholar 

  69. Virgin WJ (1958) Anatomical and pathological aspects of the intervertebral disc. Indian J Surg 20:113

    Google Scholar 

  70. Weishaupt D, Zanetti M, Boos N, Hodler J (1999) MR imaging and CT in osteoarthritis of the lumbar facet joints. Skeletal Radiol 28(4):215–219

    Article  PubMed  Google Scholar 

  71. Wybier M (2001) Imaging of lumbar degenerative changes involving structures other than disk space. Radiol Clin North Am 39(1):101–114

    Article  PubMed  Google Scholar 

  72. Yasuma T, Koh S, Okamura T, Yamauchi Y (1990) Histological changes in aging lumbar intervertebral discs. Their role in protrusions and prolapses. J Bone Joint Surg Am 72(2):220–229

    PubMed  Google Scholar 

  73. Yu S, Haughton VM, Sether LA, Ho KC, Wagner M (1989) Criteria for classifying normal and degenerated lumbar intervertebral disks. Radiology 170(2):523–536

    PubMed  Google Scholar 

  74. Ziv I, Maroudas C, Robin G, Maroudas A (1993) Human facet cartilage: swelling and some physicochemical characteristics as a function of age. Part 2: age changes in some biophysical parameters of human facet joint cartilage. Spine 18(1):136–146

    Google Scholar 

Download references

Acknowledgements

The authors would specially like to thank the Deutsche Arthrose-Hilfe e.V. and the German Research Council (DFG, WI 1352/6-1) for financial support.

Author information

Authors and Affiliations

  1. Institute of Orthopaedic Research and Biomechanics, University of Ulm, Ulm, Germany

    Annette Kettler & Hans-Joachim Wilke

Authors
  1. Annette Kettler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hans-Joachim Wilke
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hans-Joachim Wilke.

Additional information

An erratum to this article can be found at http://dx.doi.org/10.1007/s00586-006-1077-9

Appendix

Appendix

Grading systems for lumbar disc degeneration

Macroscopic anatomy

Table 9 Macroscopic grading of lumbar disc degeneration on transverse sections described by Nachemson 1960 [48]
Full size table
Table 10 Macroscopic grading of lumbar disc degeneration on sagittal sections proposed by Thompson et al. [63]
Full size table

Histology

Table 11 Histologic grading of lumbar disc degeneration on sagittal paraffin sections stained with haematoxylin and eosin, Masson–Goldner and Alcian blue-PAS proposed by Boos et al. [6]
Full size table

Plain radiography

Table 12 Radiographic grading of lumbar disc degeneration on lateral and antero-posterior views described by Mimura et al. [47]
Full size table
Table 13 Radiographic grading of lumbar disc degeneration on lateral views described by Lane et al. 1993 [38]
Full size table

Magnetic resonance imaging

Table 14 Grading of lumbar disc degeneration on T2-weighted sagittal MRI-scans proposed by Pfirrmann et al. [53]
Full size table

Discography

Table 15 Discographic grading of lumbar disc degeneration in the sagittal plane proposed by Adams et al. [1]
Full size table

Grading systems for cervical disc degeneration

Plain radiography

Table 16 Radiographic grading of cervical disc degeneration on lateral views described by Kellgren et al. [34]
Full size table

Grading systems for lumbar facet joint degeneration

Computed tomography

Table 17 Grading of lumbar facet joint degeneration on oblique conventional radiographs and CT scans described by Pathria et al. [52]
Full size table

Magnetic resonance imaging

Table 18 Grading of lumbar facet joint degeneration using computed tomography and magnetic resonance imaging described by Weishaupt et al. [70]
Full size table

Grading systems for cervical facet joint degeneration

Plain radiography

Table 19 Radiographic grading of cervical facet joint degeneration on lateral views described by Kellgren et al. [34]
Full size table

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kettler, A., Wilke, HJ. Review of existing grading systems for cervical or lumbar disc and facet joint degeneration. Eur Spine J 15, 705–718 (2006). https://doi.org/10.1007/s00586-005-0954-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-005-0954-y

Keywords

Search

Navigation