Eur Spine J (2016) 25:2728–2733
DOI 10.1007/s00586-016-4438-z
ORIGINAL ARTICLE
The Pfirrmann classification of lumbar intervertebral disc
degeneration: an independent inter- and intra-observer
agreement assessment
Julio Urrutia1 • Pablo Besa1 • Mauricio Campos1 • Pablo Cikutovic2
Mario Cabezon2 • Marcelo Molina1 • Juan Pablo Cruz2
Received: 13 September 2015 / Revised: 2 February 2016 / Accepted: 2 February 2016 / Published online: 15 February 2016
Ó Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose Grading inter-vertebral disc degeneration (IDD)
is important in the evaluation of many degenerative con-
ditions, including patients with low back pain. Magnetic
resonance imaging (MRI) is considered the best imaging
instrument to evaluate IDD. The Pfirrmann classification is
commonly used to grade IDD; the authors describing this
classification showed an adequate agreement using it;
however, there has been a paucity of independent agree-
ment studies using this grading system. The aim of this
study was to perform an independent inter- and intra-ob-
server agreement study using the Pfirrmann classification.
Methods T2-weighted sagittal images of 79 patients
consecutively studied with lumbar spine MRI were clas-
sified using the Pfirrmann grading system by six evaluators
(three spine surgeons and three radiologists). After a
6-week interval, the 79 cases were presented to the same
evaluators in a random sequence for repeat evaluation. The
intra-class correlation coefficient (ICC) and the weighted
kappa (wj) were used to determine the inter- and intra-
observer agreement.
Results The inter-observer agreement was excellent, with
an ICC = 0.94 (0.93–0.95) and wj = 0.83 (0.74–0.91).
There were no differences between spine surgeons and
radiologists. Likewise, there were no differences in
& Julio Urrutia
jurrutia@med.puc.cl
1 munication among physicians, but it should also stan-
Department of Orthopaedic Surgery, School of Medicine,
Pontificia Universidad Catolica de Chile, Marcoleta 352,
Santiago, Chile
2
Department of Radiology, School of Medicine, Pontificia
Universidad Catolica de Chile, Santiago, Chile
123
•
agreement evaluating the different lumbar discs. Most
differences among observers were only of one grade. Intra-
observer agreement was also excellent with ICC = 0.86
(0.83–0.89) and wj = 0.89 (0.85–0.93).
Conclusions In this independent study, the Pfirrmann
classification demonstrated an adequate agreement among
different observers and by the same observer on separate
occasions. Furthermore, it allows communication between
radiologists and spine surgeons.
Keywords Disc degeneration
Agreement study
Disc
degeneration classification
Magnetic resonance imaging

Lumbar spine
Introduction
Magnetic resonance imaging (MRI) is a very helpful tool in
the evaluation of patients with spinal symptoms since it
allows an accurate morphologic evaluation of the lumbar
spine. In fact, it is considered the best imaging instrument
to evaluate inter-vertebral disc degeneration (IDD),
because it not only shows disc morphology, but also disc
hydration. The most widely known classification of IDD
was developed by Pfirrmann et al. [1]; this MRI-based
grading system considers disc signal intensity, disc struc-
ture, distinction between nucleus and anulus, and disc
height in order to classify disc degeneration in five grades
[1].
An ideal grading system should not only allow com-
dardize research terminology, and guide treatment
decision-making in individual patients. The authors
describing this classification reported an adequate agree-
ment among observers using it [1]; however, there has been