5.4 Degenerative measures: 5.4.2 Spine Classifications and Severity Measures
Teija Lund
1 Introduction to grading degenerative disc disease: Is it feasible? Is it needed?
Why do some discs degenerate and others not? When does “normal aging” of the disc change into “degenerative disc disease”? Why are some discs painful and others not? What would be the ideal treatment for painful disc degeneration? These are just few of the questions that have intrigued researchers and clinicians during the past decades. However, despite extensive biochemical, biomechanical, epidemiological, and clinical research, several questions still remain unanswered. Indeed, we still lack an all-encompassing definition of the entity called ’degenerative disc disease’ itself.
2 Current classification systems for degenerative disc disease
For years our thinking on the progress of degenerative changes in the spine and their clinical consequences was dominated by the three-stage theory of Kirkaldy-Willis and Farfan [1]. This classification was mainly based on clinical and radiological observations, with little scientific basis. Later on the introduction of discography added information on the morphology of the injected disc, and displayed successive stages of disc degeneration [2]. Because of its invasiveness, however, discography, is a less than ideal method of gaining information on the severity of disc degeneration. During the last 20 years MRI has become the method of choice for the clinical assessment of intervertebral discs and spinal pathology. Abnormal disc signal intensity in T2-weighted MRI images has been shown to correlate with the degenerative changes seen on discography [3, 4].
With the evolving MRI technology we have the ability of gaining extremely detailed information on lumbar spine pathology. Low back pain and disc degeneration, however, challenge us with a specific problem: findings on x-rays and MRIs do not necessarily correlate with patients’ symptoms. In recent years, a fair bit of research has attempted to establish a connection between some specific MRI features, such as the high intensity zone (HIZ) [5] or Modic changes [6,7] and patients’ clinical symptoms. Aprill and Bogduk first reported a strong correlation between the annular HIZ and the result of provocative discography in low back pain patients [5]. Their findings were later confirmed by several authors [8–10], and contradicted by others [11–13]. Cross-sectional cohort studies have linked the presence of Modic changes, especially those of Modic type I, to low back pain [14, 15], but the correlation between Modic changes and pain provocation from the affected level on discography has proven variable [16–18].
3 Summary
Thus, the ideal classification for degenerative disc disease would include not only the morphological status of the disc, but also the clinical signs and symptoms affecting the patient’s everyday life, especially pain and functional disability. Developing such a disease severity measure will be a huge task. Nevertheless, it would be shortsighted to claim that a mere morphological grading of disc degeneration is clinically irrelevant. The introduction of such a grading system will hopefully help us to define which structural changes in the spine are associated with pain, and whether there are some prognostic signs to guide our treatment decisions. Furthermore, for both research and clinical purposes, we need a comprehensive standardized terminology to adequately compare data from different studies in a reliable way, and eventually to establish clinically relevant treatment outcome measures.
4 References
1. Kirkaldy-Willis WH, Farfan HF (1982) Instability of the lumbar spine. Clin Orthop Relat Res; 110–123. 2. Adams MA, Dolan P, Hutton WC (1986) The stages of disc degeneration as revealed by discograms. J Bone Joint Surg Br; 68:36–41. 3. Pfirrmann CW, Metzdorf A, Zanetti M, et al(2001) Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine; 26:1873–1878. 4. Schneiderman C, Flannigan B, Kingston S, et al(1987) Magnetic resonance imaging in the diagnosis of disc degeneration: correlation with discography. Spine; 12:276–281. 5. Aprill C, Bogduk N (1992) High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol; 65:361–369. 6. Modic MT, Steinberg PM, Ross JS, et al(1988) Degenerative disc disease: assessment of changes in vertebral body marrow with MR imaging. Radiology; 166:193–199. 7. Berns DH, Blaser SI, Modic MT (1989) Magnetic resonance imaging of the spine. Clin Orthop Relat Res; 78–100. 8. Schellhas KP, Pollei SR, Cundry CR, et al(1996) Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography. Spine; 21:79–86. 9. Ito M, Incorvaia KM, Yu SF, et al(1998) Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine; 23:1252–1258. 10. Lam KS, Carlin D, Mulholland RC (2000) Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source. Eur Spine J; 9:36–41. 11. Smith BM, Hurwitz EL, Solsberg D, et al(1998) Interobserver reliability of detecting lumbar intervertebral disc high-intensity zone on magnetic resonance imaging and association of high-intensity zone with pain and anular disruption. Spine; 23:2074–2080. 12. Carragee EJ, Paragioudakis SJ, Khurana S (2000) 2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Spine; 25:2987–2992. 13. Weishaupt D, Zanetti M, Hodler J, et al (2001) Painful Lumbar Disc Derangement: Relevance of Endplate Abnormalities at MR Imaging. Radiology; 218:420–427. 14. Kjaer P, Korsholm L, Bendix T, et al(2006) Modic changes and their associations with clinical findings. Eur Spine J; 15:1312–1319. 15. Kuisma M, Karppinen J, Niinimaki J, et al(2007) Modic changes in endplates of lumbar vertebral bodies: prevalence and association with low back and sciatic pain among middle-aged male workers. Spine; 32:1116–1122. 16. Braithwaite I, White J, Saifuddin A, et al(1998) Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur Spine J; 7:363–368. 17. Bram J, Zanetti M, Min K, et al(1998) MR abnormalities of the intervertebral disks and adjacent bone marrow as predictors of segmental instability of the lumbar spine. Acta Radiol; 39:18–23. 18. Sandhu HS, Sanchez-Caso LP, Parvataneni HK, et al(2000) Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI. J Spinal Disord; 13:438–443.1 Adams Stages of Disc Degeneration
Adams MA, Dolan P, Hutton WC (1986) The stages of disc degeneration as revealed by discograms. J Bone Joint Surg Br; 68:36–41.
SCALE DESCRIPTION
The five types of discogram morphology and the stages of disc degeneration they represent:
Cottonball—No signs of degeneration with soft white amorphous nucleus
Lobular—Mature disc with nucleus starting to coalesce into fibrous lumps
Irregular—Degenerative disc with fissures and clefts in the nucleus and inner annulus
Fissured—Degenerated disc with radial fissure leading to the outer edge of the annulus
Ruptured—Disc has complete radial fissure that allows injected fluid to escape
Interpretation:
The further the progression, the greater the severity. Progression listed in descending order of severity.
SCALE ILLUSTRATION
METHODOLOGY
No predictive validity studies were identified
Predictive validity
Population tested in | Outcome | Predictive validity |
Not tested |
Reliability
References:
Agorastides ID, Lam KS, Freeman BJ, et al (2002) The Adams classification for cadaveric discograms: inter- and intra-observer error in the clinical setting. Eur Spine J; 11:76–79.
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2 Carragee Lumbar Disc Herniation Classification
Carragee EJ, Han MY, Suen PW, et al (2003) Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. J Bone Joint Surg Am; 85—A:102–108.
SCALE DESCRIPTION
Disc herniations classified based on fragmentation:
Fragment-fissure Type—Disc herniation with a minimal anular defect and an extruded or sequestrated fragment
Fragment-defect Type—Disc herniation with a large or massive anular defect and an extruded or sequestrated fragment
Fragment-contained Type—Disc herniation with an intact annulus and one or more subanular detached fragments
No Fragment-contained Type—Disc herniation with an intact annulus and no subanular detached fragment
Interpretation:
Descriptive of herniation. One type not necessarily more severe than the next.
SCALE ILLUSTRATION
METHODOLOGY
Predictive validity
Reliability
References:
Carragee EJ, Han MY, Suen PW, et al (2003) Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. J Bone Joint Surg Am; 85—A:102–108.
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3 Ghiselli UCLA Grading System for Intervertebral Space Degeneration
Ghiselli G, Wang JC, Hsu WK, et al (2003) L5—S1 segment survivorship and clinical outcome analysis after L4-L5 isolated fusion. Spine; 28:1275–1280.
SCALE DESCRIPTION
Intervertebral space degeneration graded as follows:
Grade I—Absence of disc space narrowing, osteophytes and end plate sclerosis
Grade II—Presence of disc space narrowing and absence of both osteophytes and end plate sclerosis
Grade III—Presence or absence of disc space narrowing and osteophytes with absence of end plate sclerosis
Grade IV—Presence or absence of disc space narrowing and osteophytes with presence of end plate sclerosis
Interpretation:
The further the progression, the greater the severity. Progression listed in descending order of severity.
SCALE ILLUSTRATION
METHODOLOGY
No predictive validity studies were identified
Predictive validity
Population tested in | Outcome | Predictive validity |
Not tested |
Reliability
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4 Kellgren and Lawrence Osteoarthritis Severity Grade
Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis; 16:494–502.
SCALE DESCRIPTION
Using lateral view cervical disc degeneration graded according to the following:
Grade 1—Minimal anterior osteophytosis
Grade 2—Definite anterior osteophytosis with possible narrowing of the disc space and some sclerosis of vertebral plates
Grade 3—Moderate narrowing of the disc space with definite sclerosis of vertebral plates and osteophytosis
Grade 4—Severe narrowing of the disc space with definite sclerosis of vertebral plates and multiple large osteophytes
Interpretation:
The higher the grade, the greater the severity.
SCALE ILLUSTRATION
METHODOLOGY
No predictive validity studies were identified
Predictive validity
Population tested in | Outcome | Predictive validity |
Not tested |
Reliability
References:
1. Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis; 16:494–502. 2. Reijman M, Hazes JM, Koes BW, et al (2004) Validity, reliability, and applicability of seven defi nitions of hip osteoarthritis used in epidemiological studies: a systematic appraisal. Ann Rheum Dis; 63:226–232. 3. Kallman DA, Wigley FM, Scott WW, Jr., et al (1989) New radiographic grading scales for osteoarthritis of the hand. Reliability for determining prevalence and progression. Arthritis Rheum; 32:1584–1591. 4. Scott WW, Jr., Lethbridge-Cejku M, Reichle R, et al (1993) Reliability of grading scales for individual radiographic features of osteoarthritis of the knee. The Baltimore longitudinal study of aging atlas of knee osteoarthritis. Invest Radiol; 28:497–501. 5. Kessler S, Guenther KP, Puhl W (1998) Scoring prevalence and severity in gonarthritis: the suitability of the Kellgren & Lawrence scale. Clin Rheumatol; 17:205–209.CONTENT
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5 Kettler Cervical Spine Radiographic Grading System
Kettler A, Rohlmann F, Neidlinger-Wilke C, et al (2006) Validity and interobserver agreement of a new radiographic grading system for intervertebral disc degeneration: Part II. Cervical spine. Eur Spine J; 15:732–741.
SCALE DESCRIPTION
Using a radiographic grading system lumbar intervertebral disc degeneration can be graded according to the following variables:
Height loss—Anterior and posterior height loss with respect to the individual height before degerneration
Osteophyte formation—Sum of points of four edges:
No osteophytes—0 points
< 2 mm—1 point
> 2 mm, but less than 4 mm—2 points
> 4 mm—3 points
Diffuse sclerosis—Sum of points of both adjacent vertebral bodies:
No sclerosis—0 points
50% partially or completely affected—1 point
> 50% partially or completely affected—2 points
Interpretation:
Each variable is scored individually on a 0 to 3 point scale:
Height loss:
0–0%
1–< 33%
2–> 33%, but < 66%
3–< 66%
Osteophyte formation:
0–0 points
1–1–4 points
2–5–8 points
3–9–12 points
Diffuse sclerosis:
0–0 points
1–1 point
2–2 points
3–3–4 points
Overall “degree of degeneration” is the sum of points of all variables:
Grade 0–0 points (no degeneration)
Grade 1–1–3 points (mild degeneration)
Grade 2–4–6 points (moderate degeneration)
Grade 3–7–9 points (severe degeneration)
Related posts:
5.1 Spine Classifications and Severity Measures
5.3 Deformity severity measures: 5.3.2 Spine Classifications and Severity Measures
5.3 Deformity severity measures: 5.3.4 Deformity severity measures: spondylolisthesis
5.5 Osteoporosis severity measures
5.4 Degenerative measures: 5.4.1 Degenerative measures: cervical myelopathy
5.3 Deformity severity measures: 5.3.1 Spine Classifications and Severity Measures
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