Clinical and radiographic degenerative spondylolisthesis (CARDS) classification.
BACKGROUND
Lumbar degenerative spondylolisthesis (DS) is a common, acquired condition leading to disabling back and/or leg pain. Although surgery is common used to treat patients with severe symptoms, there are no universally accepted treatment guidelines. Wide variation in vertebral translation, disc collapse, sagittal alignment, and vertebral mobility suggests this is a heterogeneous disease. A classification scheme would be useful to differentiate homogenous subgroups that may benefit from different treatment strategies.


OBJECTIVE
To develop and test the reliability of a simple, clinically useful classification scheme for lumbar DS.


METHODS
Retrospective case series.


METHODS
One hundred twenty-six patients.


METHODS
Proposed radiographic classification system.


METHODS
A classification system is proposed that considers disc space height, sagittal alignment and translation, and the absence or presence of unilateral or bilateral leg pain. Test cases were graded by six observers to establish interobserver reliability and regraded in a different order 1 month later to establish intraobserver reliability using Kappa analysis. To establish the relative prevalence of each subtype, a series of 100 consecutive patients presenting with L4-L5 DS were classified.


RESULTS
Four radiographic subtypes were identified: Type A: advanced Disc space collapse without kyphosis; Type B: disc partially preserved with translation of 5 mm or less; Type C: disc partially preserved with translation of more than 5 mm; and Type D: kyphotic alignment. The leg pain modifier 0 denotes no leg pain, 1 denotes unilateral leg pain, and 2 represents bilateral leg pain. The Kappa value describing interobserver reliability was 0.82, representing near-perfect agreement. Intraobserver reliability analysis demonstrated Kappa=0.83, representing near-perfect agreement. Grading of the consecutive series of 100 patients revealed the following distribution: 16% Type A, 37% Type B, 33% Type C, and 14% Type D.


CONCLUSIONS
A new radiographic and clinical classification scheme for lumbar DS with high inter- and intraobserver reliabilites is proposed. Use of this classification scheme should facilitate communication to enhance the quality of outcomes research on DS.
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA. Electronic address: chris.kepler@gmail.com.
Christopher K
CK
Kepler
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA.
Alan S
AS
Hilibrand
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA.
Amir
A
Sayadipour
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA.
John D
JD
Koerner
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA.
Jeffrey A
JA
Rihn
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA.
Kristen E
KE
Radcliff
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA.
Alexander R
AR
Vaccaro
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA.
Todd J
TJ
Albert
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA.
D Greg
DG
Anderson
D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010146:Pain / Q000209:etiology; D011859:Radiography; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013168:Spondylolisthesis / Q000145:classification* / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000601:surgery
Classification system; Degenerative spondylolisthesis; Iatrogenic destabilization; Lumbar degenerative spondylolisthesis; Lumbar spinal fusion; Spondylolisthesis