[Harrison]

Everyone, thanks for making this an interesting and helpful post. Though I am pooped and getting up in a few hours, I spent some time reviewing PubMed on the issue of facet disease and grading systems (big mistake, but good validation of the misdirection of our tax dollars and the NIH).

I am sorry to say this (again), but the spine societies need to get their act together to compensate for this problem that effects TENS of MILLIONS of people in America (TConner: right on!). Though this article is dated, it speaks volumes about the nature and depths of some of the problems we are touching upon in this topic.

Complaints aside, imaging for disease assessments is not part of the current clinical picture. There are a handful of small startups that have some powerful image enhancement software to aid diagnosticians, but IMHO, disease should be left for the pathologists. That is, the geeks that are smart about microscopy, disease pathology, immunohistopathology, hematology. They are conspicuously absent from the diagnostic process of spine patients – both pre and post-op surgery. And that is so wrong!
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Annette Kettler1 and Hans-Joachim Wilke
Institute of Orthopaedic Research and Biomechanics, University of Ulm, Ulm, Germany

Received: 13 October 2004 Revised: 4 April 2005 Accepted: 14 April 2005 Published online: 20 September 2005

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 .

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