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September 10, 2025Open Access

The Total Disc Replacement Osteolysis Grading Scale – a simple, reliable and quantifiable tool for assessing, managing and reporting osteolysis after cervical total disc replacement

Key Points

The TDR Osteolysis Grading Scale shows good reliability for measuring osteolytic cysts using imaging techniques.
Inter-rater reliability ranged from moderate to good, with sensitivity for high-grade osteolysis significantly higher in CT assessments.
Both CT and X-ray methods demonstrated varying reliability for assessing osteolysis grades and cyst measurements in participants.
Using this grading tool may assist in standardizing osteolysis reporting and support clinical decision-making regarding rehabilitation.

Abstract

Abstract Purpose Cervical Total Disc Replacement (CTDR) related periprosthetic osteolysis is inconsistently reported. The purpose of this study is to assess the previously published TDR Osteolysis Grading Scale, a quantitative classification system of CTDR-related osteolysis, and to assess its reliability and utility using Computer Tomography (CT) and X-ray imaging. Methods Participants were assigned to Groups A (CT, 20 participants, 27 implants) and B (X-ray, 20 participants, 26 implants). Four blinded raters independently measured osteolytic cysts and both vertebral endplates, calculated the percentage of osteolysis and assigned osteolysis grades: Grade 0, no osteolysis; Grade 1, < 50% of 1 endplate; Grade 2, < 50% of both endplates; Grade 3, ≥ 50% of 1 endplate; Grade 4, ≥ 50% of both endplates. Inter-rater reliability and sensitivity were assessed using intraclass correlation coefficients (ICC), Fleiss’ and Cohen’s Kappa statistics and sensitivity testing. Results Group A had good reliability for osteolytic cyst measurements (ICC = 0. 78–0. 79), poor reliability for endplate measurements (ICC = 0. 41–0. 45) and moderate reliability for osteolysis grades (-coefficient = 0. 42). Group B had moderate reliability for osteolytic cyst (ICC = 0. 55–0. 57) and endplate measurements (ICC = 0. 55–0. 64) and fair reliability for osteolysis grades (-coefficient = 0. 30). Reliability between reference grades and assigned grades was moderate for Group A (-coefficient = 0. 46–0. 60) and fair for Group B (-coefficient = 0. 08–0. 35). Sensitivity was greater for high grade osteolysis (grade 3 and 4) in Group A (0. 80–1) than Group B (0. 17–0. 50). Conclusion The TDR Osteolysis Grading Scale demonstrated good reliability and sensitivity amongst raters with CT. Implementing this tool may aid in standardising osteolysis reporting, monitoring osteolysis progression and clinical decision-making.

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